Covid-19: Resuscitation Orders

Question

Asked by

To ask Her Majesty’s Government what assessment they have made of the report by the Care Quality Commission Protect, respect, connect—decisions about living and dying well during COVID-19, published on 18 March, on decisions about the use of ‘do not attempt cardiopulmonary resuscitation’ orders for (1) care home residents, and (2) people with learning disabilities, during the pandemic.

My Lords, the department warmly welcomes the publication of the CQC report on the use of DNACPR decisions taken during the Covid-19 pandemic. We are pleased to see examples of good practice detailed in the report across both health and social care, but this was not true everywhere, particularly for our most vulnerable people. That is why the department is committed to driving forward the delivery of the report’s recommendations and ultimately ensuring that everyone experiences the compassionate care that they deserve.

My Lords, this report from the Care Quality Commission highlights that

“unprecedented pressure on care providers”

and the rapidly developing guidance has led to blanket “do not attempt cardiopulmonary resuscitation” orders being imposed at a local level, particularly affecting care home residents and people with learning disabilities. Failure to consult people about their care betrays a lack of decency and compassion, but it is also a human rights violation. I am very grateful to the Minister for his reassurance about the recommendations, but may I press him, in particular, to assure the House that the recommendation of a ministerial oversight group will be implemented?

My Lords, I can absolutely reassure the right reverend Prelate that the Minister with responsibility for patient safety and mental health care will be heading the ministerial oversight group to drive forward progress. The group will bring together a range of stakeholders across both health and care to ensure that the recommendations are implemented.

My Lords, given the significantly higher number of excess deaths among people with learning disabilities last year, will the Minister commit to finding out what proportion of those deaths were associated with DNACPRs? Does he agree that the use of blanket DNACPRs for people with learning disabilities is an indication of the extent of the lack of confidence and competence among healthcare staff to accommodate their needs, and adds to the urgent need to introduce the Oliver McGowan mandatory training currently being piloted? A timetable for the widespread introduction of that training would be very welcome.

My Lords, I am afraid that we are having questions that are far too long. Can people please keep their questions brief?

My Lords, we will address the audit points made by the noble Baroness. I completely endorse the importance of training; that is at the heart of the report and we acknowledge its importance. We are concerned about the number of people with learning disabilities who have died during the pandemic, and there will be a report on what the connections are.

My Lords, we know that it is unlawful for DNACPRs to be imposed, and I wonder why the research has not sought to identify why physicians and care workers continue to impose them in the way that they have. Does the Minister agree that the solution must lie in completely clear, unambiguous policy to advance care planning and DNACPR decisions, and a consistent use of accessible language, communication and guidance to enable clear understanding by commissioners, providers and the public?

I will gently push back against the noble Baroness: the policy is absolutely crystal clear. Blanket DNACPR is not the policy of this Government, as was repeated time and time again in our communications, which I would list if I had more time. Training is the issue: we need to give the front-line workforce the skills it needs to apply these very delicate but critical interactions. That is the recommendation of the report, and that is where we are focused on applying the lessons.

My Lords, does the Minister agree with Age UK that the report is the tip of the iceberg and requires the Government to bring forward proposals as part of a complete overhaul of the advance care planning system?

No, my Lords, I do not accept that the report is simply the tip of the iceberg; it is very thorough and goes into the matter extremely carefully. However, there are important lessons on training to be learned and they will be driven by the ministerial oversight group.

My Lords, the Care Quality Commission wrote up its findings at the time of the outbreak of Covid-19, which may have made them less reliable. A number of factors have served to raise exposure to decisions on whether or not to accept DNACPRs, and these were taken for groups rather than individually. Such groups included individuals suffering with dementia and learning disabilities who needed briefings that they could understand. The Care Quality Commission report is about how hospitals, care homes and doctors should support people to make decisions properly about how to restart. Are the Government satisfied that the decisions in this territory are now being taken properly?

My Lords, the report is crystal clear that we accept that more training is needed. Front-line care support workers need to be given more support in their interactions, and we will be putting that in place.

My Lords, I draw attention to my interests in the register, in particular the fact that I am a nurse involved with the Outcomes First Group, which supports people with learning disabilities. In order to increase the population’s awareness of care planning in relation to living and dying well, will the Government, in addition to training, consider incentivising healthcare workers to ensure that they have sufficient time to undertake proper assessment of individuals with cognitive impairment and learning difficulties as part of their routine care planning, which should be recorded and reviewed at least biannually?

The noble Baroness makes a very fair point; such care needs to be in the work plan particularly of those with learning difficulties, but of all those in care. We absolutely endorse the approach taken by the Resuscitation Council, which has extremely good guidance in this area.

My Lords, no one doubts the events described by the right reverend Prelate and noble Lords. By when can we be confident that the same could not happen again?

My Lords, we could not be moving more quickly. We got the report out before the end of the pandemic; we have acknowledged the issue and written numerous letters into the system, as I have mentioned; and we are putting in place the resources needed to support the necessary training and interactions. We are taking this extremely seriously and we are moving as quickly as we possibly can.

As the Minister has suggested, decisions on end-of-life care are best taken long before they are necessary, so could he encourage GPs to offer all patients the opportunity to make an advanced decision to refuse treatment, properly witnessed by two individuals, if it is to become effective?

The noble Baroness is entirely right, and a growing number of people do take that kind of pragmatic approach. But we have to be realistic: many people are not prepared to put those sorts of arrangements in place until much later on in their lives, and it is often the family and relatives of those in care who have to be part of those important conversations.

My Lords, regardless of Department of Health and Social Care policy and NHS instructions to clinicians, we know that DNACPR orders were made without adequate consultation and safeguards. Can the Minister assure this House that the Government will meet with families who have raised concerns about DNACPRs as the cause of deaths? Will he emphatically agree with this House and the families themselves that senior case reviews should be undertaken, with a panel of experts, of all cases where families have raised questions? Will he state categorically again that DNACPR without consent is—

We will now hear from the Minister.

I reassure the noble Baroness that there has been a huge amount of stakeholder engagement, with Mencap, Turning Point and others. It is not the role of the CQC to do individual family reviews, but I can reassure her that we have learned important lessons from this process.

Does the Minister agree that the ministerial oversight committee should also consider looking at end-of-life care?

My Lords, yes, I do.

My Lords, I should declare my interest as chair of Dignity in Dying. What plans do the Government have to increase dramatically the numbers of people who have advanced decisions expressing their views on medical treatment? Does the Minister agree that patients’ wishes should be central to DNACPR decisions, and indeed to all significant medical decisions, particularly at the end of life?

My Lords, we absolutely agree. That is exactly how the guidelines are written and exactly the guidance sent into the system. The issue we face is much more pastoral in nature: it is one of training and creating the space and resources necessary to have extremely difficult conversations. That is the kind of front-line support we need to put in place. It is a question of patient engagement rather than a change of guidelines, but I completely take on board the noble Baroness’s recommendations.

My Lords, with the help of the Leader of the House, all supplementary questions have been asked.

Sitting suspended.