Older people face ‘unacceptable failures’ in how DNACPR orders are communicated

Poor communication surrounding DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) decisions is “eroding trust” between people and the health professionals caring for them, according to a new report.

The report by Compassion in Dying, commissioned by the Parliamentary and Health Service Ombudsman (PHSO), says older people are facing ‘unacceptable failures’ in how DNACPR orders are communicated, with many not being told when a do not resuscitate decision had been made.

The charity and the PHSO say urgent improvements are needed to ensure these conversations are happening in a timely and caring manner.

DNACPR conversations happening too late or not at all

DNACPR decisions are a crucial part of end-of-life care that protect people from often futile treatment. However, older people must be given the chance to consider whether CPR is right for them, and this new research reveals that, often, this is not happening.

During the Covid pandemic, it was revealed that blanket do not resuscitate orders were imposed in some care homes. Now, Compassion in Dying’s report, What people need from a DNACPR decision and discussion, reveals that some older people are still not being told when DNACPR decisions have been made. The charity says this causes significant distress for those implicated as well as their families.

The report also found that conversations often happen too late and in times of crisis, with some decisions communicated in an ‘uncaring’ way, leaving people feeling scared, angry and frustrated.

Furthermore, the research found that DNACPR decisions were sometimes ignored, which caused people to feel disrespected. At other time, a person’s DNACPR decision was not accessible meaning it was not fulfilled. This meant people lost trust in ‘the system’ and the healthcare professionals involved in the person’s care.

Families want to be involved in DNR decisions

The distress this can cause is highlighted by the case of Conrad Jenkin, 95, who took part in Compassion in Dying’s research. Mr Jenkin said: “My wife Jennifer was 87 when she had what the doctor called a ‘massive stroke’ and was taken to hospital. We only learnt after she came home that she had been marked ‘DNR’ – we found it in the bits of paper she’d been sent away with.

“The Registrar had written on the form that he had informed the next of kin. He hadn’t, nor had he spoken to our daughter who was also present at hospital. At the time I felt distressed and truly shocked. I didn’t know why he’d made that decision and why he said he had informed the next of kin when he had not.

“I know doctors have difficult jobs and I’m not upset at him for making the decision, but I am upset at him for marking her as ‘DNR’ without telling us and then recording that he had.”

The need for ‘urgent cultural and practical changes’

Compassion in Dying and the PHSO say urgent improvements are needed in order to ensure that DNACPR decisions are made appropriately and lawfully.

They say conversations must happen in a timely, open and person-centred way and discussions should occur within the context of other planning for an individual’s future healthcare and treatment.

The report summarises a series of recommendations made by the people they spoke to during the research. This includes:

• Conversations about DNACPR decisions must happen earlier in life, before a health crisis and in a normalised, routine way, as part of a broader conversation about a person’s wishes and concerns for the end of life.
• Doctors must follow the law and always communicate a DNACPR decision when one has been made.
• Clinicians should be trained and supported to ensure these important conversations happen with compassion.
• There must be better public information and awareness, including a public health campaign, to help people understand how DNACPR decisions work and why they matter – including what CPR involves and its success rates.

Usha Grieve, Director of Partnerships and Services at Compassion in Dying, says DNACPR decisions are a ‘crucial part’ of end-of-life care and can prevent prolonger suffering, however, older people must be involved in these decisions.

“DNACPR decisions are often communicated insensitively, far too late, or not at all. Poor communication is causing harm and eroding trust between people and the health professionals caring for them.

“The older people we spoke to, like all of us, simply want to be treated like a human being, not a tick box exercise. People want and need DNACPR discussions to happen earlier, before a crisis, on a bedrock of compassion, empathy and honesty.

“A public health campaign around DNACPR decisions, for instance, would help ensure both doctors and patients feel equipped to have these important conversations in a timely way. We need urgent cultural and practical changes to right these wrongs and forge a more personalised, compassionate approach to DNACPR conversations and end-of-life decisions.”