Northern Ireland’s Commissioner for Older People is calling for a public enquiry to take place into the treatment of care home residents in the province’s care homes during the Covid-19 crisis, describing as “disturbing” the use of Do Not Resuscitate orders which were reportedly placed on some older people without consulting either them or their families.
Eddie Lynch said that, “Families deserve an answer on why deaths in care homes here were so extensive and why care home residents were disproportionately affected by this pandemic.
“Covid has impacted us all, but for older people, and particularly care home residents, those impacts have been exceptionally arduous,” he said.
“Over the past year we witnessed the incorrect recording of care home deaths, families having no access to loved ones, personal protective equipment (PPE) supply problems, inappropriate use of ‘do not attempt resuscitation’ orders, the slow introduction of testing, the transfer of Covid-positive patients into care homes — the list goes on.”
The News Letter reports that Mr Lynch said he had been provided with anecdotal information on cases early on in the Covid crisis about Do Not Resusicitate (DNR) notices being put in place on some care home residents coming out of hospital or going into hospital. He said that in some cases instructions were given to care home workers to place DNR notices on older people. He said that the number of cases raised, although in the single figures, “was enough to raise concern”.
Mr Lynch also said it was impossible to ascertain how widespread the use of DNR notices without patient or family consultation was.
“Exactly, and that is one of the issues I would like a public inquiry to look into to see how extensive that was. Certainly some families raised concerns about poor communication with them on the issue. So to me that is one of the reasons why a public enquiry is needed, to get to the bottom of how extensive that practise was,” he told the Newsletter.
He noted that while it is not unusual for DNR notices to be put in place with some older people, particularly those living in care homes, the person themselves must be consulted first, followed by family.
“It is usually a medical decision about the treatment somebody can receive in later life and possibly in their last days. But the best practise is that families should be consulted about this and the older person themselves should also be consulted at an earlier stage, if they have capacity to make that decision.
“And I think what was concerning to the people who brought it to my office – some of these orders were put in place without their knowledge and I think that is what is disturbing; that because they were a certain age, that they may not be treated. So I think that is something that needs an inquiry to see what was happening.”
He also said that the inappropriate application of DNR notices to patient files could have been happening without the older person themselves or their families knowing.
“There were definitely families that contacted us to say that they weren’t aware that an order had been placed on the resident. In some of those cases the person may have been living with dementia and not aware of it [the DNR notice].” The mood of the people contacting him would have been “concern and worry” he told the paper.
“Naturally there would be concern if somebody is feeling that their relative may have medical care withheld if they are seriously ill,” he said. He affirmed that some older people may have died during the pandemic as medical treatment was withheld due to a DNR notice in their file – but that some families may still not be aware the DNR notice was there.
“That is why we need an inquiry because I don’t have the answers to that and an inquiry should look at that in more detail.”
The Commissioner’s calls for a probe into the treatment of care home residents follows a Care Quality Commission (CQC) investigation in the UK which found evidence that DNR orders were used without the consent of patients of their families. Last December, the care watchdog warned that doctors may have made blanket decisions about DNR orders without the input of patients or their families, with the organisation saying the number of complaints it had received about do not attempt cardiopulmonary resuscitation (DNACR) orders jumping to 40 between March and September that year, an increase on 9 similar complains in the previous six months.
The Daily Echo reported: “Early results of the CQC’s investigation found DNACPRs may have been used inappropriately when care services were under extreme pressure following misunderstanding of the guidance on their use.
“Although it can cause punctured lungs, fractured ribs and severe bruising, failing to fully appraise a patient or their loved ones of their options is a breach of their human rights, the CQC warned.”
CQC guidance states decisions on DNACPRs must never be dictated by blanket policies, must be free from discrimination, and not made on a clinician’s “subjective view of a person’s quality of life”. The CQC said that, despite reminding care providers of these obligations, it had received evidence from both staff and patients’ families that DNACPR orders had been applied without consultation.
The Daily Echo also reported that: “One carer told said an on-call doctor had informed care home staff that if a resident were to catch Covid-19, a DNACPR order would automatically be put in place.”
In a separate case: “Another witness said some care homes and learning disability services had been told by GPs to place blanket orders on everyone in their care.”
Other staff members in the UK said it was unclear how or whom to escalate concerns to. One senior member of staff at a care home said that whilst they had challenged every inappropriate DNACPR order they knew of, this had been challenging and they felt clinicians had ignored their concerns.