Should DNACPR be banned in Care Homes?
‘Do Not Attempt Cardio-Pulmonary Resuscitation’ (DNACPR) is a instruction in resident’s notes that informs health staff that no intervention is necessary if the person has a cardiac arrest that will result in their death. The media have reported cases where families have been shocked at the use of DNACPR on their loved ones without their knowledge. Such stories have led to outcries about the inappropriate use of DNACPR in care homes. As a result, the Care Quality Commission was asked by the Department of Health and Social Care in 2020 to conduct a rapid review of how DNACPR decisions were used during the coronavirus pandemic.
DNACPR informs End-of-Life decisions. But on its own it is a blunt instrument, often a tick box exercise. Planning for End-of-Life care requires sensitive conversations between residents, families, and health care staff about choices at the end of life. Every person is different and unique and such conversations need time so that trust can be established between those involved. These conversations go much further than DNACPR and include individual’s wishes and preferences of care. These may cover likes and dislikes, including food and drink; personal care, for example around cleanliness; religious or spiritual issues, attitude to hospitalisation and values about the balance between quality of life versus longevity. Later conversations may discuss the process of dying.
However, talking about dying can be difficult. For some, broaching the topic may bring relief. Others will be less happy to enter such conversations (whether family member or resident), but they should be given the opportunity. Explanation of what treatments may be offered towards the end of life should be outlined, to help make decisions about whether to accept or reject particular interventions. These include treatments for life-threatening infection, artificial feeding, a severe stroke, a coma or emergency surgery.
Conversations can be helpful to residents and families to understand what happens towards the end of life. When someone is close to death due to a terminal illness or simply old age, the body begins to shut down. All internal organs begin to fail. This is a natural part of the dying process. Sometimes the heart is the first organ to stop but sometimes it is the last. Attempting CPR will only prolong the dying process, may cause complications (such as broken ribs), and is rarely successful.
Residents in care homes should have conversations very soon after admission. Documentation of these conversations form their Advance Care Plan. This ensures they are being treated as individuals; allow the family to know and respect their loved one’s wishes; empower the healthcare staff to ensure that the patient’s wishes, hopes and aspirations will be carried out. A DNACPR form may not be required with a comprehensive Advance Care Plan. The earlier these conversations start, the better. It is the only way of guaranteeing the best roadmap to end-of-life care and a good death.