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Do Not Attempt Resuscitation Orders: Guidelines

Volume 699: debated on Wednesday 21 July 2021

Given the extreme heat, both in London and here in the Boothroyd Room, if Members want to speak or intervene without their jackets, that is permitted. I am sure the public will have sympathy. I have also advised the Doorkeepers that they may take their jackets off. Members will also be aware that social distancing is no longer in operation, but I remind them that Mr Speaker has encouraged us to wear masks between speeches and interventions.

I beg to move,

That this House has considered guidelines for Do Not Attempt Resuscitation orders.

It is a pleasure to take part in this debate under your chairmanship, Ms Bardell. I will be fairly brief. I welcome the fact that hon. Friends have come along, and I am very happy to take interventions from them.

I requested this debate to raise the important matter of the use of do not attempt cardiopulmonary resuscitation and do not attempt resuscitation orders, which have been widely reported as being overused in recent years, particularly over the course of the covid-19 pandemic. I do not have a science or medical background. I am generally happy to defer to the opinions of the experts, who are far more qualified than me to speak about a patient’s condition. However, we have had a year of frequent and extremely worrying cases, some of which were highlighted by an article by Camilla Tominey in The Daily Telegraph on 12 June. I thank Ms Tominey for providing me with other articles. As a result of reading them, I felt compelled to raise this matter in the House today.

As a result of those reports, there are many people who have real concerns about this issue. Will they be consulted? I do not doubt that the medical professionals involved feel that they are doing their best and that they are acting in the best interests of their patients, but decisions of this kind must be made only after discussions with the patient or, if the circumstances demand it, their next of kin.

The Care Quality Commission published a report on 18 March following concerns raised at the beginning of the pandemic about the use of blanket DNACPR decisions across groups of potentially vulnerable people. It found that almost 10% of DNACPR decisions had been made and communicated inappropriately, involving potential breaches of the individual’s human rights.

Concerns have been raised by other Members during questions to the Prime Minister, the Leader of the House and the Health Secretary. Indeed, last week, when I questioned my right hon. Friend the Health Secretary, he said that a ministerial oversight group had been established to follow through on the CQC recommendations. I hope the Minister will be able to give more details about the work of that group. Many colleagues will have heard and read deeply saddening stories from constituents and citizens across the UK who have been impacted by this seemingly widespread approach.

I congratulate the hon. Gentleman on bringing this issue forward. When I saw it on the agenda for Westminster Hall, I just knew that I had to be here. As light is spread, Members like me had the same idea. That is why I wanted to be here. During the first wave of the pandemic, there were ongoing issues with DNAR orders. It has been stated that human rights may have been violated in over 500 cases. That is an enormous amount. Every one of us knows people who have found themselves in those difficult positions. The hon. Gentleman made a critical point: when decisions are made for DNAR orders, full protocol must be followed. Most importantly, the next of kin, who really need to know what is going on, have been ignored. That cannot happen again.

The hon. Gentleman makes some powerful points, particularly, as I just mentioned, about the involvement if not of the patient themselves, certainly of the next of kin.

There have been examples of elderly people who reported that they felt pressured into signing these orders against their will. On 16 June, the Daily Mail reported that research carried out by the University of Sheffield found that 31% of the patients in its study who were admitted to hospital for covid were issued with do not resuscitate orders. That is unacceptable. Decisions of that nature are for the individual. They have the right to make their decisions without feeling unduly pressurised.

There have also been reports of care home residents having these orders imposed without consent and some reports speak of “blanket use”, which again is completely unacceptable.

Another report was of a 76-year-old man being issued a DNAR order following a heart attack, from which he made a full recovery. The order had not been discussed beforehand, but when his wife protested, she was reportedly told to “let him go with dignity.” The situation was only put right after the intervention of a more understanding member of staff and the order was revoked.

Throughout the pandemic, there have also been distressing reports of disabled people being denied vital medical treatment. According to the charity Mencap, a number of disabled people have died prematurely when intervention could have saved their lives. However, such intervention was denied owing to DNAR orders that should not have been in place.

Suffice it to say that some of the stories I have heard are frankly sickening, especially those involving the disabled or those suffering from mental illness. Having said that, I do not want to identify individuals in specific cases, although one widely reported case referred to a former Member of the European Parliament, which is sort of halfway to identifying the person involved. However, as I say, that case has been public for some time. She was admitted to hospital in Oxford for an operation on a broken pelvis. After being discharged, she was, of course, shocked to discover that a DNAR order had been in place, without her knowledge or consultation. In the event, her heart stopped during the procedure, supposedly owing to the fact that she suffers from Parkinson’s disease.

I am sorry to say that, as a result of reports I have read, I am able to come to no other conclusion than that clinicians are making assumptions regarding their patients’ quality of life and chances of survival that frequently are harsh and unnecessary. It is evident that a robust response is required from the Department of Health and Social Care. Any delay is unacceptable.

Ministers from the Department have rightly offered reassurance. However, it is time we saw action. Best practice guidelines are already in place, having been set by the Resuscitation Council UK. However, the examples I have given clearly show that the guidance does not appear to have been adhered to by some clinicians.

I congratulate my hon. Friend on securing this debate. Does he agree that when a loved one is admitted to hospital or a care home, whatever their age, when DNAR is discussed with their friends or relatives it has to be handled very carefully, because it could be a great shock? Also, was he aware that a former colleague of ours has said, following my raising this subject at business questions two weeks ago, that her husband had a DNAR order placed upon him without her express consent?

My hon. Friend makes some important points. I was unaware of the particular case that he mentions, but it is yet another example of what is happening without the approval of the patient or their family.

As I say, Ministers from the Department of Health and Social Care have quite rightly offered reassurance, but clearly some clinicians appear—I say “appear”—to be treating the guidance merely as a tick-box exercise. However, we are talking about life and death decisions.

Decisions regarding our own mortality can be uncomfortable, obviously for ourselves but also for our loved ones. This issue highlights the need for a cultural shift to ensure that everyone feels supported to hold open and honest conversations about what they would like to happen at the end. These conversations need to take place as early as possible, as we approach old age or learn that we have significant health problems. It is only by doing so that we can be sure that our wishes and those of our loved ones are honoured, as well as reducing the distress of the relatives of patients who have chosen to have DNACPR orders in place.

I would be interested to hear from the Minister what she proposes to do to support health and care clinicians, professionals and workers in holding conversations about these orders, and the importance of their involving patients and their families.

Earlier, I referred to the ministerial oversight group. Will the Minister confirm that the Government are thinking about that recommendation? I stress that the group must include health and social care providers, including those in the palliative and end-of-life sector, as well as those involved in local government and voluntary and community organisations. I would be grateful if the Minister confirmed that.

To conclude, the overuse of these orders over the course of the pandemic is a national scandal. Reports suggest that there are people who are not with us today who otherwise would have been. Likewise, some of the lucky ones who have made a full recovery did so despite having one of those orders attached to them. We all recognise that our medical professionals face extremely difficult decisions. This issue deals with profound matters: the relationship between doctor and patient, and for many like me, who regard human like as sacred, the orders go against our deepest religious and spiritual beliefs and cannot be dealt with in a matter-of-fact way. I know that the Minister and her colleagues will take this matter extremely seriously and will want to provide the reassurance and confirmation that it will not be allowed to go on.

It is a pleasure to serve under your chairmanship, Ms Bardell. I thank my hon. Friend the Member for Cleethorpes (Martin Vickers) for bringing this extremely important topic to our attention.

I am well aware that the issue is highly emotive. Conversations around end of life and DNACPRs are some of the most challenging conversations that a clinician can have. It is important that they are approached in a compassionate and meaningful way that takes fully into account the wishes of the patient. I have had such conversations myself, both in the distant past in my professional capacity as a nurse, and recently in a more personal capacity, so I share and understand the concerns raised by my hon. Friend. I understand how difficult those conversations are, particularly if the person with whom a clinician is attempting to have the conversation does not want to have it.

I reassure my hon. Friend that the Department remains crystal clear that standards and quality of care should be maintained even in pressurised circumstances. Failure to consult people and their families on individual decisions on CPR causes significant distress. It is essential that such conversations are held in a sensitive and compassionate way, and that that is consistent across the health and care system.

There is already commendable joint guidance for clinicians on DNACPRs from the British Medical Association, the Resuscitation Council UK and the Royal College of Nursing. That guidance reflects that the agreement to a DNACPR is an individual decision and should involve the person concerned or, where the person lacks capacity, their families, carers, guardians and other legally recognised advocates.

In addition, significant work has been done over the last 16 months by the Department and clinical leaders to support practitioners in understanding best practice guidance. Clear messages around the use of DNACPR decisions were reinforced in our adult social care winter plan in September 2020, making clear that any advanced care decisions, including DNACPR decisions, should be fully discussed with the individual and their family where possible and appropriate, and signed by the clinician responsible for the individual’s care. Those guidelines were reinforced as recently as September 2020.

It has been well reported, however, that the pandemic shone a necessary but critical light on the application of DNACPR decisions, and highlighted how, in some cases, conversations were not always held in a patient-centred way. We heard particularly worrying reports about the inappropriate or blanket application across groups of people, including our most vulnerable.

To ensure that we could take early learnings on what was happening across the system, in October 2020 I commissioned the Care Quality Commission to review how DNACPR decisions were being made in the early stages of the pandemic. Its report, which was published on 18 March, highlighted examples of what good conversations around DNACPR look like. However, it also drew a worrying picture of the reasons why some of these conversations fell short of the high-quality personalised care people deserve. Of the three key areas for improvement the report identified, the application and adherence to guidance across the system was an area of concern. The report found a greater need for information, training and support for health and care professionals, to enable them to hold good, meaningful conversations. It is integral, therefore, that the training practitioners receive reflects that, to ensure that people’s needs and rights are met. It is critical that all staff have the knowledge, skills and confidence to speak with people about, and support them in making, appropriate DNACPR decisions, as well as feeling empowered to speak up when they do not feel the decision is right.

That is why I established a ministerial oversight group. The first meeting was held on 8 June and it brought together key organisations responsible for driving forward system-wide improvements, and provided an opportunity to set up their commitments. I found it encouraging to see a shared commitment to improve the use of DNACPR orders. I heard first hand of the ongoing work to improve knowledge and understanding of these issues, and the work being done to support colleagues across health and social care, to maintain and champion personalised approaches to care treatment. I believe that the terms of reference for the ministerial oversight group have gone live today on the website, so that my hon. Friend the Member for Cleethorpes can see the issues that we have decided we need to address in order to improve the use and application of orders.

Although I mentioned that a considerable amount of excellent guidance and support around DNACPRs already exists, with meaningful conversations taking place every day, it is clear that improvements are needed on consistency, training and implementation. It is a difficult conversation for clinicians to have. A priority of the ministerial oversight group will be to ensure that there is better awareness, understanding and use of the guidance and resources available across the system, so that everybody can practise these conversations to the same degree of effectiveness and the same standards.

We are also working closely with our stakeholders across health and care to ensure that that happens. Clearly, this is a work in progress and training should remain under constant review, both in the wider workforce and to ensure that staff understand the training that they receive. We must also ensure that people feel equal partners in their care, and are well equipped for conversations around the end of life.

NHS England has published public-facing guidance on DNACPR decisions, along with the release today of the terms of reference of my ministerial oversight group. NHS England has also published where people can get support if they are concerned about a DNACPR decision, on If anyone is concerned, they can find the guidance and know what they can do and say to challenge decisions.

Sensitive and well communicated DNACPRs can and should be an important part of patient care and end-of-life experience. We are committed to taking continued action—that is the point of the ministerial oversight group—to ensure guidance on DNACPR decisions is adhered to, that the training is in place, that the guidance is adhered to and that clinicians have the appropriate support to hold those difficult conversations.

Question put and agreed to.

Sitting suspended.