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Hospitals and Nursing Homes: Do Not Resuscitate Notices

Volume 806: debated on Thursday 1 October 2020


Asked by

To ask Her Majesty’s Government what assessment they have made of the use of Do Not Resuscitate notices in hospitals and nursing homes since March.

My Lords, I beg leave to ask the Question standing in my name on the Order Paper and refer to my interests in the register.

My Lords, the department is very clear that the blanket use of DNACPR and DNR is unacceptable. An agreement to a DNACPR is an individual decision and should involve the person concerned or, where the person lacks capacity, their family, carer, guardian or any other legally recognised advocate. I can inform the House that the Minister for Patient Safety and Mental Health will be writing to the Care Quality Commission requesting that it investigates and reports on DNACPR issues.

I am grateful to my noble friend and am aware of the letters written in respect of people with learning disabilities and autism during the first phase of the Covid-19 outbreak. However, with the second wave looking as though it is on its way, my noble friend will be aware that there is still concern from charities such as Mencap and the National Autistic Society, not least because of the attitude in some areas that people who have social care support needs are rather lesser human beings than the rest of us. How will the Care Quality Commission carry out this assessment as the second wave increases?

My Lords, it is completely unacceptable for any group of people to have blanket DNACPR provisions apply to them. The adult social care winter plan published on 18 September reiterates that and makes the position crystal clear. The General Medical Council is providing additional support and guidance to clinicians on how to meet the needs of patients and relatives, and the Resuscitation Council UK is creating a large amount of resources to provide training. The CQC is monitoring the situation extremely carefully.

My Lords, the distressing circumstances of the pandemic have once again highlighted the difficult and sometimes controversial issues about end-of-life treatment in general and individual choices. Will the Government set up a long-proposed review to examine all these issues, particularly to improve real patient choice?

The noble Baroness is entirely right. The Covid epidemic has shone a spotlight on the awful arrangements around end of life at a time when contagious disease presents a threat to all those present in a nursing home or hospital. Our thoughts and prayers go out to all those who have lived through such an experience or will face one in the near future. I note the noble Baroness’s call for a review. There is no current plan for one but I will carry the idea back to the department.

My Lords, I sympathise with the medical profession engaged in saving lives at all costs. However, many people will have spent a great deal of time in thought and consultation with relatives before deciding not to be resuscitated, should they become desperately ill, especially with Covid, with possible permanent physical or mental impairment. It is inconceivable that their wishes should be overturned by medical professionals who do not know or understand their background. What are the Government doing to ensure that that does not happen?

My Lords, I completely agree with the noble Baroness’s sentiments—so does the department and so do the Government. We have noted what happened during the Covid epidemic. The CQC is investigating potential lapses at that time. We have reinforced guidance in the winter plan and the CQC continues to review the situation. New training and guidance provisions are being put in place. We take the situation extremely seriously and are putting in the procedures and investment necessary to ensure the right outcome.

What training is being given to physicians and healthcare workers for when they discuss DNR with patients and next of kin?

The department is aware of the Queen’s Nursing Institute report on training and, although the majority of responses were positive, it raised questions about the training of, in particular, care home staff on the instruction to change resuscitation orders for patients without discussion. We are looking at that report very carefully. We cannot comment on individual cases but the report raises important questions. In the meantime, the General Medical Council is providing additional support and guidance to clinicians and the Resuscitation Council is creating a large range of resources for clinicians to help guide them and provide training.

I am pleased that the Minister has recognised that, although DNR is a medical decision and not something that requires a patient’s consent, not consulting with the patient and their family is an unlawful breach of human rights. We should be grateful that the scandal was exposed by Turning Point and other charities during the pandemic. Does the Minister have plans to review the DNR decisions that were made during the pandemic and does he know, or perhaps he can find out, how many DNRs were issued in excess of what one might have expected during the pandemic?

My Lords, NHSE&I is currently engaged with stakeholders, including people with lived experience, to develop better information for patients and to understand whether procedures need to be changed. I reassure the noble Baroness that DNRs are not issued, they are agreed with families and relevant loved ones. On no account should DNRs be unilaterally issued. They are for a joint decision; that kind of blanket application is something that we are extremely concerned about and seeking to avoid.

My Lords, when someone who has a DNACPR is well enough to leave hospital, can the Minister assure me that the notice will be reviewed as a matter of course after consultation with the patient and their carers?

The noble Baroness makes a fair point. Of course, someone who walks healthy from a hospital need not have such a notice left on their clinical records. I will admit that I do not know the precise arrangements for how that is conducted but I will be happy to write to the noble Baroness and explain the procedure.

My Lords, the Minister has already said that he quite understands that there will be people, particularly the elderly, who do not wish to be resuscitated. One easy way of ensuring that resuscitation does not happen is for people to have a living will. Will the Minister undertake to try to encourage GPs to ensure that all their patients understand this and that they have the potential to have a living will?

My Lords, the benefits of living wills are enormous, both for those entering the last stages of their life and their loved ones. It is something that we are keen to encourage. I do not know the precise arrangements for how GPs play a role in that, but I will be glad to write to the noble Baroness and explain what provisions are in place for encouraging the use of living wills.

My Lords, I commend my noble friend for his balanced comments on this extremely fraught situation—I think everything has just about been said. Every life is, of course, to be valued but many of us as we get older—dare I say, we are quite a lot older in this House than the average population—will be looking at whether we want a do not resuscitate order in our living will. That is why I commend the idea from the noble Baroness, Lady Wheatcroft, of spreading this information around.

My noble friend puts it all very well. It is my birthday today, so I am feeling a little bit older and thoughtful on these subjects. On a serious point, living wills have enormous benefits and give peace of mind to those who enter nursing homes and hospitals, and their loved ones. We will look carefully at this important point and I will share my correspondence with the noble Baroness, Lady Wheatcroft, with my noble friend.

Happy birthday to the Minister. Given the dangers of the shortcut abbreviation of DNR, which can result in essential care decreasing, has the Department of Health considered adopting NHS Wales’s concept of a natural, anticipated and accepted death—NAAD? In five years, this has had no problems reported and gently and sensitively leads to DNACPR conversations with patients and those who love them.

My Lords, I welcome the testimony of the noble Baroness. We often keep track of Wales’s use of innovative health measures and, while I am not aware of this concept in particular, I will be glad to take the advice back to the department, recommend it and return to the noble Baroness with a response on how we are going to take it forward.