Over the last few weeks there have been some concerning news stories about older people being pressured into signing 'Do Not Attempt Cardiopulmonary Resuscitation' [DNACPR] forms, which would leave them exempt from receiving CPR if they went into cardiac arrest.

We have written a letter to all care homes and supported living placements within the areas we work to remind them to be vigilant of such practice taking place, highlighting the legal duty and duty of care a GP continues to have when completing DNACPR forms in light of COVID-19.

Therefore, we are calling on all doctors to bear in mind the Mental Capacity Act when completing DNACPR orders, which states that if a person lacks capacity to make this decision, they have a right to an Independent Advocate. 

We are sharing this letter in the hope that many doctors will be reminded of the process to refer for an Advocate. Advocacy providers across the UK have come together and have shared their template to tackle this issue, feel free to adapt ours if you need to.

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Advocacy Focus - Do not attempt cardiopulmonary resuscitation (DNACPR)

Advocacy Focus provides statutory advocacy services in Lancashire and Trafford. Part of the service we offer is the Independent Mental Capacity Advocacy (IMCA) service. The IMCA role is there to support and represent the person in the decision-making process and ensure that the Mental Capacity Act (MCA) 2005 is being followed. We gather, evaluate and present information to help the decision maker reach a best Interest decision for the person. The IMCA service will also provide a comprehensive report however this can be a verbal report in time sensitive urgent cases.

Under the Coronavirus Act 2020 legislation there is still a duty for you to refer for an IMCA when your patient lacks mental capacity in relation to the decision and has no family or friends “appropriate to consult” (a paid carer or support worker cannot fulfil this role)

The criteria for an Independent Mental Capacity Advocate is:

  • The person is aged 16 or over
  • A decision needs to be made about either a long-term change in accommodation
  • A review of a change of accommodation decision
  • or serious medical treatment
  • or around DNACPR orders
  • or for people who are being assessed as to whether they are currently being, or should be deprived of their liberty (referrals made via the DoLS team)

*Serious Medical Treatment is defined in the MCA as:

“giving new treatment, stopping treatment that has already started or withholding treatment that could be offered in circumstances where there is a fine balance between the likely benefits and the burdens to the patient and the risks involved; where a decision between a choice of treatments is finely balanced, or what is proposed is likely to have serious consequences for the patient.”

We have become aware of the use of blanket DNACPR decisions being made within care homes and supported living placements, these decisions should be made on an individual basis, following the principles of the MCA 2005. The clinical frailty scale was updated on the 25th March 2020 to make it clear that:

“The terms “learning disability” and “Down’s syndrome” should never be a reason for issuing a DNACPR order or be used to describe the underlying, or only, cause of death … Learning disabilities are not fatal conditions.”

‘The CFS should not be used in younger people, people with stable long-term disabilities (for example, cerebral palsy), learning disability or autism. An individualised assessment is recommended in all cases where the CFS is not appropriate’

Please see this letter from the NHS for further reading on lawful and appropriate use of DNACPR.

Peoples' legal and human rights need to be upheld now more than ever and we want to safeguard against any discrimination or unlawful practice. As you can expect we are keeping a close eye on the spread of COVID-19 Coronavirus in regards to how we deliver our service and are regularly reviewing government, NHS, and Public Health England guidelines.

At this moment in time, the team is working remotely and how we deliver services may look a bit different. We are using digital platforms with video facilities to maintain public safety and speed up referral processes.

Recently Mr Justice Hayden, a court of protection judge said that ‘staff within care settings should be creative in their attempts to keep families in touch with each other’. The judge was very clear that care home staff need to use all the creative options available to them to facilitate effective communication with people’s families, during the pandemic this is of extreme importance.

Where possible, Advocacy focus will facilitate face to face work where absolutely necessary and in exceptional circumstances. All referrals will be followed up face to face once the restrictions are lessened and it is safe to do so.

  • To refer for an Advocate, you can download a referral form here.
  • Or call Advocacy Focus on 0300 323 0965 for further support and guidance.

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Download this letter as a word template: