The Chief Executive and Registrar at the Nursing and Midwifery Council (NMC) recently expressed concern that as result of the COVID-19 pandemic, there had been reports of blanket advance care plans, including do not attempt cardiopulmonary resuscitation (DNACPR) orders, being applied to specific groups of people. This is concerning as such decisions have been made without the individual’s involvement or an assessment of their specific needs. These decisions seemed to ignore the requirement that decisions must involve the patient unless to do so would cause harm and if the clinician’s decision is that attempting CPR is futile there is an obligation to tell the patient that this is the decision.
In light of these alarming reports and due to the increasing pressures on healthcare professionals to make urgent and complex clinical decisions, the NMC and the General Medical Council (GMC) issued a joint statement on 15 April 2020 to highlight the continuing importance of advance care planning for individuals during these unprecedented times. At the same time the Department of Health & Social Care (DHSC) also issued guidance on 15 April 2020 confirming that it is unacceptable for advance care plans, including DNACPR to be applied in a blanket fashion. DHSC guidance 15 4 20
GMC and NMC joint statement
The joint statement recognises that discussing future care with the individual or their family members can be difficult and distressing. However, this should not mean that those affected should be deprived of the opportunity to have this discussion due to the current climate. The NMC and GMC emphasise the need for healthcare professionals to adhere to their relevant professional code, and practice in accordance with the principles of person centred and individualised care. The pandemic does not mean that healthcare professionals can stray away from these principles and make advanced care decisions on a group basis.
Health and care providers are reminded that these discussions around advance care planning should be dealt with sensitively, and should take into account the individual’s needs and wishes. When this may involve a DNACPR or a recommended summary plan being put in place, it is fundamental that these decisions are made specifically with the involvement of the individual, their family members and the relevant health and care team.
The British Geriatrics Society (BGS) has reported that with many care home residents nearing the end of their life and with the continuing spread of COVID-19, addressing advance care planning including plans to escalate to hospital is more important than ever. In order to assist care home providers in either reviewing an existing advance care plan or revisiting the issue for the first time, the BGS has recommended that during the COVID-19 pandemic care homes should:
- Work with GPs, community healthcare staff and community geriatricians to review advance care plans as a matter of urgency with residents. This should include discussions about how COVID-19 may cause residents to become critically ill, and a clear decision about whether hospital admission would be considered;
- Advance care plans must be recorded in a way that is useful for healthcare professionals called in an emergency situation. A paper copy should be filed in the care home records and, where the facility already exists, an electronic version which can be shared with relevant services;
- Discussions should include how the COVID-19 pandemic may affect residents with multiple comorbidities and whether people want to be admitted for other long term conditions. If care home staff feel unable to explore these issues, they should be supported by GPs and primary care teams, with or without support from specialists in geriatric medicine or palliative care, to do this with residents and families;
- Discussions may need to take place by telephone or videoconferencing due to the current advice to stay at home. This will therefore require conversations to be planned in advance to avoid confusion and distress as much as possible.
For further information and guidance on making these decisions, the following links can be assessed:
- NICE recommendation for advance care planning
- NICE quick guide for registered managers of care homes and home care services on advance care planning
- NICE guidance on decision-making and mental capacity
- NICE guidance on end of life care for infants, children and young people with life-limiting conditions: planning and management
- Social Care Institute for Excellence: Guidance on advance decisions to refuse treatment
- Royal College of General Practitioners: Palliative and End of Life Toolkit
- Professional codes from the NMC
- Professional codes from the GMC
Although it is acknowledged that this is an incredibly challenging time for health and care providers, it is reiterated that it is unacceptable for advance care plans to be applied on a blanket basis.
Victoria Mortimer, Trainee Solicitor, BLM