Policy recommendations

Prompted by concerns raised about DNACPR during the pandemic, the Care Quality Commission [CQC] carried out an investigation into their use in care homes. The investigation revealed a number of problematic practices, and the CQC issued a call for new standards, guidance and training. In response to the CQC, and in light of Autonomy Project research, we made a number of policy recommendations. We provide a summary of these below.

Individualised vs. blanket use of DNACPRsNew standards, guidance and training should make clear that DNACPR recommendations must be made on an individual basis, and that it is unlawful to make a DNACPR recommendation for a whole group of people merely on the basis of a shared characteristic, such as age or disability. We suggest that new guidance and training should include case studies to illustrate this distinction.

Consultation: New standards, guidance and training should make clear that consultation is always required unless it would cause physical or psychological harm. The distinction between DNACPR recommendations made on a narrowly clinical basis, and those based on the balance of benefits and burdens must be made clearer, and the nature of the consultation required in each case clarified. Again, case studies should be used to illustrate this. There should also be clearer guidance around what to do if a DNACPR form does not show evidence of the requisite consultation.

The legal status of DNACPR recommendations: The distinction between DNACPR recommendations and Advance Refusals of Treatment should be made clearer. The term ‘DNACPR orders’ should be avoided, since it might convey the false impression that DNACPR recommendations are legally binding.

The use of DNACPR recommendations: New standards, guidance and training should make clear that DNACPR recommendations must not influence care or treatment other than the administration of CPR. Current guidance from the General Medical Council might suggest that the presence of a DNACPR recommendation might play a role in decisions about whether to transfer a patient to hospital. This guidance should therefore be amended.

DNACPR forms: A number of changes to existing DNACPR forms would reinforce good practice in the above areas, as well as provide a means of challenging problematic DNACPR recommendations. In particular, the forms should include an indicative list of grounds on which a review of a DNACPR recommendation may be required.

What happens when a DNACPR decision is not in place?