Cardiopulmonary Resuscitation in the Pandemic

Danny Kruger Excerpts

Tuesday 13th April 2021 Commons Chamber

[Danny Kruger (Devizes) (Con)]

I rise to speak about the use of “Do not attempt cardiopulmonary resuscitation” notices during the pandemic. Last year, the health service was hit by the worst crisis in its history. The whole country was told to stay at home for one simple reason: to save the NHS. That meant not overwhelming the system with too much demand—too many people needing care. We faced a real nightmare scenario of the NHS not being able to treat people who were sick and dying. The horrific idea emerged of doctors or local health managers or the NHS itself having to play God to decide who should live and who should die by deciding who should get treatment and who should not. Thankfully, the NHS was not overwhelmed. This, of course, was mostly due to the heroic work of frontline staff. It is also because every measure possible was put in place to reduce pressure on hospitals. That included people staying at home, building new hospitals at record speed and getting people out of hospital as fast as possible, including to care homes. This is where the occasion for the DNACPR notices came about.

Care homes found themselves under enormous pressure, too. Stories emerged last spring of blanket DNACPR policies being put in place in care settings. They were for people with certain characteristics—people with learning disabilities, people with certain complex needs, and people with life-limiting illnesses. This was done, the report said, without consultation with patients themselves or with families. All this was quite wrong and against all the guidance. Indeed, in April last year, the Care Quality Commission issued a joint statement with the British Medical Association, the Care Provider Alliance and the Royal College of GPs, reminding all providers that it is unacceptable for advanced care plans with or without DNAR notices to be applied to groups of people of any description. I am pleased that they did it. I am particularly pleased that the Department of Health and Social Care— I understand that the Minister herself was responsible—asked the CQC to investigate these reports and to review how DNAR orders were used during the pandemic. I will come to its findings in a moment.

I want to make it clear that DNACPR orders are an appropriate part of our health and care system and can be a right and proper part of an individual’s care plan. We need to distinguish between what might be called beneficial and futile uses of CPR. An obvious example of beneficial CPR is for young people with neuro-degenerative conditions. Respiratory arrest is common for these patients, but with CPR they have an almost 100% survival rate. For them, it is essential and necessary. If a patient’s other vital organs are shutting down—if they are dying—CPR can do little.

[Jim Shannon (Strangford) (DUP)]

The hon. Gentleman and I share a very common cause, and I appreciate him bringing this debate forward. Does he not agree that for families such as mine who, last year, lost a loved one—my mother-in-law—we would like to believe that any and every measure was taken to save life. The stories that we have heard and that he has referred to are certainly heartbreaking. I very much share his concern.

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[Danny Kruger]

I thank the hon. Gentleman for his intervention and I extend my condolences to him and his family for the loss that they have suffered. I absolutely agree with him. The value of this debate is perhaps to help communicate the expectation that all patients receive the care that they need right up until the moment of death.

CPR can greatly distress the patient and their family in the last moments. CPR involves a team rushing to the bedside, shoving aside any family members who are gathered around and using what is basically a violent procedure, sometimes involving the breaking of ribs to try to restart the heart. As one doctor interviewed about CPR described it, it can be chaotic, traumatic and brutal. That is not what any of us would wish when our death is imminent, even if it extends life for a few minutes or hours. I have every sympathy with doctors and care home staff who want patients who are approaching death and their families to consider using DNACPR notices, but we have to be really careful about how they are used. That is not just because of the obvious immorality of a blanket policy that effectively judges some people as worth saving and some people as better off dead without consideration for their circumstances or their wishes, but because having a DNACPR notice influences the care people get more generally. There is anecdotal evidence from care homes that patients who have requested they are not resuscitated are not cared for as well as others. They might miss out on antibiotics for a chest infection, for example, or some other treatment for a reversible condition.

The essence of the responsibility of doctors and care staff is that care should persist for all, whatever their condition or capacity. That responsibility is well established in law and guidance, and I particularly value the principles in the Mental Capacity Act 2005, which seeks fundamentally to honour the dignity of the individual, no matter their capacity or condition. The 2005 Act also sets out guidance on best interests, which is the test that should be used to determine medical treatment in the event of the individual being unable to decide for themselves. Crucially, a best interests consideration requires decision makers to take a view as if they were the patient. It is not about what they think is best, but what they think the patient would want, and that is vital.

The CQC review concluded in February, and I am greatly relieved by some of its findings and very concerned by others. I am relieved that it did not find evidence of blanket DNACPR policies being applied as official practice by any health or care provider. It also found evidence of really good care being provided, including with the use of DNACPR orders on an individual case-by-case basis, with proper consultation and consideration of the patient’s best interests.

The CQC report also causes me concern that de facto blanket policies may have been in operation largely because we simply cannot tell everything that has been going on. The report highlights some very serious failings. Of the 166 care records that the CQC reviewed, 103 should have included a best interests assessment. In only 33 of these cases is there evidence of an assessment being carried out. Talking to patients and their families, the CQC found that 30% of patients with a DNACPR decision and 43% of families and carers did not feel that the patient’s best interests were fully considered. I am glad to say that the opinion of people with learning disabilities and their families was more positive about best interests considerations in their DNACPR decisions.

I do not believe that providers have been applying blanket policies, but what I am concerned about is the potential for such a thing. I am concerned that not all health and care providers are properly applying best interests considerations in the advance care planning they do with patients.

As the CQC said, we need to take a number of essential steps to prevent the possibility of abuse. There are three main practical recommendations, and I hope the Minister can confirm that her Department is working to implement all of them. The first is that we need a more consistent national approach to the use of these notices. That emphatically does not mean a blanket policy for which patients should receive them, but the opposite: a process to ensure that all patients are treated as individuals. The CQC report particularly highlighted the recommended summary plan for emergency care and treatment—or ReSPECT—process, which helps everyone involved to make informed decisions about an individual’s future care and treatment.

Secondly, we need to enable these conversations through proper investment in the training and support of the staff who will have them. Thirdly, and crucially, we need proper oversight and assurance that the decisions made have proper record-keeping. It really is scandalous that that was not in place already last year. We need comprehensive records of conversations and decisions. Integrated care systems should be responsible for monitoring the use of DNACPR notices, and the CQC should be responsible for investigating anomalies, such as particularly high or low numbers of orders in particular places.

I conclude with a final and more general observation about what we need, which goes beyond these vital but ultimately technical remedies to the potential for abuse. We need a moral framework that honours the dignity of sick, disabled, elderly or dying people. That is not something that the CQC or the DHSC or this Parliament can simply draw up on a piece of paper. Indeed, I am nervous about the idea of over-regulating end-of-life care and reducing it to a process, because at the end of that road lies the awful scenario we are trying to avoid—a blanket rule on who should live and who should die.

We are never going to be able to write the rules of life and death and every attempt to do so is ultimately dystopian. That is why the ultimate locus of decision making should be in the conversations between doctors and patients, and those who know and love them. We cannot regulate for good conversations, but we can certainly do our best to facilitate them, and the CQC recommendations will help that. The only way to ensure good conversations is to ensure that doctors and families have at heart the best interests of patients. We in this place can encourage good conversations and the right decisions by stating as clearly as we can that human life is infinitely precious, right until the end.