Coronavirus: Investigation launched into blanket use of ‘Do not resuscitate’ orders during pandemic

Multiple reports of GPs imposing blanket DNR orders without assessment of each patient during earlier stages of Covid-19 crisis

The alleged blanket use of ‘Do not resuscitate’ orders on vulnerable patients during the pandemic is to be investigated by England’s health care watchdog.

Throughout the earlier stages of the Covid-19 outbreak there were multiple reports of GPs imposing blanket DNR orders on care home residents, the elderly and the disabled without an assessment of each patient.

In July, following the threat of a judicial review, ministers agreed to make the rules clearer for doctors and patients. Legally, the orders must be made on a case-by-case basis and patients should be included in the discussion.

Now, the Care Quality Commission (CQC) has said it is proceeding “at pace” with its probe into the use of Do Not Attempt Resuscitation (DNAR) and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders during the pandemic.

Health Minister Lord Bethell first announced the investigation in the House of Lords on 1 October.

"The Department is very clear that the blanket use of DNACPR and DNR is unacceptable,” he said. “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."

Dr Rosie Benneyworth, chief inspector of primary medical services and integrated care at the CQC, said: "We welcome this commission from Department of Health and Social Care and are taking it forward at pace.

"This builds on the concerns we reported earlier in the year and we are pleased that they are being given closer attention."

The Independent revealed in June that a number of national charities had successfully challenged more than a dozen unlawful DNRs that were put in place because of the patient’s disability, rather than due to any serious underlying health risk.

Turning Point said it had learned of 19 inappropriate DNRs from families, while Learning Disability England said almost one-fifth of its members had reported DNRs placed in people’s medical records without consultation during March and April.

Compassion in Dying also announced in May that it would support legal action against health secretary Matt Hancock and his initial refusal to intervene in the use of DNRs, as first reported by The Independent.

In one example, a man in his 50s with sight loss was admitted to hospital after a choking episode and was incorrectly diagnosed with coronavirus. He was discharged the next day with a DNR form giving the reason as his “blindness and severe learning disabilities”.

Marie-Anne Peters, whose brother Alistair has epilepsy but no other health conditions, later overturned a DNR on her brother which included instructions for him not to be taken to hospital.

Dr Benneyworth said that it was “unacceptable” for advance care plans concerning DNR orders to be applied to “groups of people of any description”.

"These decisions must continue to be made on an individual basis according to need,” she added.

"Through this review we will look to identify and share best practice in this complex area, as well as identifying where decisions may not have been patient-centred and ensuring mistakes are not repeated."

Fiona Carragher, director of research and influencing at Alzheimer’s Society, said it was “vital” that DNR orders are never inappropriately implemented again.

“Let’s be clear – it’s appalling to hear that a blanket DNAR approach was ever taken, effectively denying people their right to life, without permission appropriately obtained,” she said.

“These orders must only ever be applied to people on an individual basis, with all the correct checks in place. It’s vital that the CQC investigation ensures this never happens again, correcting any cases where it may have been inappropriately applied.”

Health leaders in England wrote to medics across the country on 7 April reminding them not to impose blanket DNR orders.

England’s chief nurse Ruth May and NHS England’s medical director Stephen Powis warned “blanket policies are inappropriate whether due to medical condition, disability, or age. This is particularly important in regard to do not attempt cardiopulmonary resuscitation orders.”

They added: “The key principle is that each person is an individual whose needs and preferences must be taken account of individually.”

The letter followed a joint statement from the CQC, the British Medical Association, the Care Provider Alliance and the Royal College of GPs, reminding medics it is "essential" that these decisions are made on an individual basis.

Polling from Compassion in Dying has shown that understanding of DNRs is limited within the public sphere.

A survey of 2026 people found that most did not know that a DNR decision is made if a clinician thinks that attempting CPR will do more harm than good (51 per cent), or that a patient will still continue to receive other care if a DNR decision is made (51 per cent).

A doctor does not need the patient’s consent for a DNR order, but they are required to consult the patient or their family. Not doing so is a breach of human rights.