The importance of getting it right during the coronavirus pandemic.
The decision not to carry out CPR on an unwell patient is made following a detailed discussion between the patient and the clinician. In many cases, the decision not to perform CPR may be made as part of advanced care planning in those who are vulnerable or elderly. Where possible, the discussion should be directly with the person. If the person does not have capacity, then a decision should be made in line with the person’s best interests, involving where possible, their family members or other appropriate individuals. In any event, the decision must be person-centred.
In the community, the GP will play an integral role in the completion of advanced care planning or the completion of a DNAR.
As the coronavirus outbreak continues to develop, this may result in more difficult decisions being made for those receiving intensive support, as a result of COVID-19. The ethical considerations during a pandemic change significantly and there may be some doctors who find themselves having to make these difficult decisions. Equipment and resources are not without limits and the success rate of CPR in patients with COVID-19 has been reported to be poor. Attempting CPR on a patient who has COVID-19 may even place a number of healthcare staff at risk.
To ease the burden during this difficult time, it is imperative that more advanced care planning decisions are made, and this includes the need for DNAR decisions, where appropriate. This is particularly important for those in the community, who are able to make early decisions, without the pressure of time and distress.
There is an emphasis on ensuring the approach taken in respect of such difficult discussions and decisions is considered and individualised. It has recently been reported that some GP surgeries sent out letters to patients either informing them that they have had DNAR notices applied to them or asking them to complete a DNAR notice. The Resuscitation Council has responded to these reports, stating that the approach was unacceptable. It remains important for GP practices to take a person-centred approach when discussing DNAR orders with patients. On 1 April 2020, a joint statement published by the British Medical Association, Care Provider Alliance, Care Quality Commission and Royal College of General Practitioners stated that the “importance of having a personalised care plan in place…has never been more important than it is now during the COVID-19 Pandemic.” The statement went on to say it is “unacceptable for advance care plans, with or without DNAR form completion, to be applied to groups of people of any description. These decisions must continue to be made on an individual basis according to need.”
The GMC has stated that their guidance “continues to apply as far as is practical in the circumstances. The primary requirement for all doctors is to react responsibly and reasonably to the circumstances they face.” The GMC further states that in the event “more individuals have life-threatening conditions than can be treated at once, doctors will have to make very difficult decisions about how to allocate resources…the patient’s wishes, preferences and fears in relation to their future treatment and care should be explored as far as possible”. This emphasises the importance of making decisions about future care as early as possible.
At the time of preparing this blog, there has been no formal guidance about how practitioners should carry out such difficult discussions remotely. However, it is clear that more advanced care planning is needed during this difficult time and it remains imperative that doctors continue to use clear communication, approach the topic sensitively and clearly record decisions.