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North West London Hospitals Trust

CQC finds improperly completed DNR forms at London hospital

Care Quality Commission inspectors found four improperly completed “do not attempt resuscitation” orders at North West London Hospitals Trust, an inspection report reveals.

The CQC report on the visit to the trust’s Northwick Park Hospital, which took place on 9 May, said: “Records we looked at showed that patients had consented to their care and treatment. Four patient’s records we looked at included a ‘do not attempt cardiopulmonary resuscitation’ order. We found these were not completed to an acceptable standard.”

The regulator’s report added: “Patient’s relatives had not been involved in the decision where the patient did not have the capacity to make this decision independently.

“The orders were not reviewed at regular intervals to ensure this decision still applied. This showed that procedures were not followed and that relevant persons were not involved in the decision to not be resuscitated.”

In response, trust medical director Professor Rory Shaw said: “It is really important to get this right for patients. Understanding and documenting the wishes and thoughts of patients and carers is our key priority at the very end of a person’s life.

“I was very concerned to discover we had not been doing this right every time. I have reinforced the message to all staff, changed how we monitor these forms, and I have personally walked round the wards checking the forms.”

He added: “The Care Quality Commission revisited the trust on 27 June and I hope that they will have seen a marked improvement in this area.”

 

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Readers' comments (6)

  • michael stone

    The problem is, so far as I can work out, that the CQC has decided the law around CPR is what I understand it to be, so the CQC writes:

    'The regulator’s report added: “Patient’s relatives had not been involved in the decision where the patient did not have the capacity to make this decision independently.'

    because the CQC and I don't see 'MCA section 4 decisions as resting with clinicians'.

    But many clinicians and hospitals hold a different view of the law (of the Mental Capacity Act's meaning).

    That is the root, of this issue.

    DNACPR Forms are a bit of a dog's breakfast at present, as well - all part of the same problem: to start with, they should not be described as 'orders', they should be described as 'forms'.

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  • michael - do relatives or clinicians sign a consent 4 for DNR decisions?

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  • Are there times when it has to be the clinicians decision to either not resus or not continue with resus?
    Is it against the law not to involve relatives in the decision - what happens if relatives either don't agree with each other or don't agree with the patients decision?
    What happens if a patient does not want to be rescusitated and the relatives wants everything done (or vice versa) - could this affect their relationship or bereavement process?
    Who decides that a patient does not have the capacity to decide if they want to be rescusitated or not?

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  • My father suffered a deterioration in his condition and died within 8 hours. He had not been properly monitored. The hospital EWS scoring system left a lot to be desired.

    In mine and my sisters absence the doctors decided he wasn't worth transferring to HDU. "causes likely reversible, but frail and losing his independence" actually documented in the notes as a reason. ( Not actually true)

    No DNAR had been agreed with my perfectly compos mentis father during the 2 days of his admission nor had we been approached. The family were only asked when in shock we arrived at the bedside of our nearly dead father and it was obviously too late. Even then the family did not agree to a DNAR but it has been documented in the nursing and medical notes that we agreed . Make of that what you will . This happened very recently.

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  • michael stone

    Anonymous | 3-Jul-2013 12:07 pm

    If I answer, I'll be accused of getting on my pet topic in detail, again. But, assuming that resuscitation might be clinically possible, the ranking for a DNACPR decisions goes in this order:

    1) You know the patient, while mentally capable, forbade attempted CPR

    2) Nobody has discussed CPR with th epatient, but there is what seems to be a validly-completed Advance decision which prima facie refuses CPR in the situation beign considered

    3) If there is a single attoreny appointed under the LPA with powers over life-sustaining treatments, the attorney can EFFECTIVELY 'issue a section 4 bes tinterests decision forbidding attempting CPR'

    4) Anyone faced with a CPR decision to make, who has been sifficiently involved in 'the situation' to be able to legitimately claim the defence provided by section 4(9) of the Mental Capacity Act, can make a DNACPR section 4 best interests decision (this is however hugely complicated by the consequence sof section 42 of the MCA).

    5) People who could not claim to have complied with section 4 of the MCA, but are 'adequately guided/persuaded' can SAFELY follow someone else's more 'authoritative' DNACPR decision.

    Current DNACPR Forms, fit in at no 5 on that list, if only signed by a clinician - of course, if they doubled as an Advance Decision and were ALSO signed by the patient, they would be an instruction and go to the top.

    To fit the law properly, clinicians should only be signing DNACPR forms to say 'CPR would not work' - so, yes, in theory relatives (and others) should be signing 'best interests' DNACPR Forms, to 'prove that everyone has discussed this, and to state that there is a consensus'. BUT AT PRESENT the forms ARE NOT DESIGNED THAT WAY.

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  • michael stone

    http://www.endoflifecareforadults.nhs.uk/assets/downloads/EoLC_Care_Planning_WEB.pdf

    The above should take you to a download of a wallchart published by the National End of Life Care Programme, about ‘The differences between general care planning and decisions made in advance’.

    The wallchart is largely correct, and of particular interest it tells the reader these two things:

    1) … if the ADRT is assessed as complying with the Mental Capacity Act and is valid
    and applicable. If it is binding it takes the place of best interests decisions about that treatment.

    2) under the section covering DNACPR, we can read ‘Does not need to be witnessed, but the usual practice is for the clinician to sign.’

    Now, 1) is correct, and can be easily found in the Mental Capacity Act, if you bother to actually read the Act. But 2) is downright cruel – there is no explanation, of ‘what that means’. Actually, because a DNACPR Form is simply a method of ‘informed people’ telling ‘uninformed people’ about various things relevant to CPR decision making, signatures on DNACPR Forms are totally irrelevant, IF you are INSIDE the group of ‘informed people’ (and similarly, a written Advance Decision is to inform people who have been UNABLE to discuss the patient’s decision, directly with the patient: if you have been able to discuss a patient’s refusal, it simply doesn’t matter TO YOU whether or not the patient’s refusal of a future treatment has been written down {what matters, is that you understand the refusal}).

    I e-mailed a consultant last autumn, with a comment along the lines of ‘although not perfect, your DNACPR Form is the best I’ve seen so far – but your Advance Decision template is seriously flawed, as they all are’ and he sent me a chart he had put together (typically, I can’t work out where I’ve stored it at present), with about 15 DNACPR Forms along one axis, and about 12 ‘complies with’ questions along the other axis, and he had marked them all out of 12 (only his own, got full marks).

    A few of these DNACPRs included ‘partial resuscitation’ (as I acerbically pointed out, ‘the objective being to restore the patient to a half-dead and half-alive state ?’).

    DNACPR Forms are ‘a mess’ – but DNACPR Forms, are hugely ‘complex and intricate’ in legal terms, so it isn’t really surprising that if people get Advance Decision templates wrong (they do, and ADRTs are much simpler legally) they can’t get DNACPR forms right.






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