Do Not Attempt Resuscitation Orders: Guidelines

(Limited Text - Ministerial Extracts only)

Wednesday 21st July 2021 Westminster Hall

[The Minister for Patient Safety, Suicide Prevention and Mental Health (Ms Nadine Dorries)]

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 gov.uk 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 england.nhs.uk. 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.