DNACPR
15. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not seen any indication that something has gone wrong for some aspects of the complaint.
16. Mrs I complains that given Mr O's presenting symptoms, the Practice’s decision that CPR should not be attempted is inappropriate.
17. BMA guidance says every decision about CPR must be made on the basis of a careful assessment of each individual’s situation. Anticipatory decisions about CPR are best made in the wider context of advance care planning, before a crisis necessitates hurried decision making. The decision as to whether CPR is appropriate must be made on the basis of the patient’s best interests.
18. This guidance also outlines where a patient has not appointed a welfare attorney, had a welfare guardian or deputy appointed or made an advance decision, the treatment decision rests with the most senior clinician responsible for the patient’s care.
19. GMC guidance also says for patients who lack capacity, the overall benefit of the treatment for the patient must be considered when making decisions. This involves weighing up the risks of harm and potential benefits for the individual patient of each of the available options, including the option of taking no action. The concept of overall benefit is consistent with the legal requirements to consider whether treatment is in the patient’s best interests.
20. From Mr O’s medical records, we can see he had heart issues and had a pacemaker fitted. He had dementia and was also very frail. The lead clinician in Mr O’s care discussed the DNAPCR decision with Mr O’s nursing team. Our adviser said the decision for Mr O to have a DNACPR was made for the overall benefit of Mr O.
21. Therefore, the actions of the Practice in relation to the DNACPR decision are in line with guidance. The most senior clinician in Mr O’s care made the DNACPR decision and discussed this first with Mr O’s nursing team. Given Mr O’s presenting symptoms of heart issues, dementia and frailty, the decision was made for his overall benefit. This is because CPR was unlikely to be successful and is likely to cause Mr O more harm than benefit.
22. We acknowledge how distressing it was for Mrs I to find out the Practice had decided CPR should not be attempted. We hope our consideration provides Mrs I with reassurance there is no indication of a failing in the Practice’s actions, as its decision to put this in place was in line with the guidance set out above. Because of this, we have decided not to consider this part of the complaint further.
Hospital avoidance plan
23. Mrs I also complains the Practice’s hospital avoidance plan is inappropriate. A hospital avoidance plan is a type of advanced care plan which focusses on preventing unnecessary hospital admissions by caring for the patient in their usual place of residence. A hospital admission is associated with risks, such as infection, loss of independence and stress, particularly for elderly or vulnerable patients such as those with dementia.
24. The ACP guidance says ACP discussions can occur over time, between people and those important to the patient, such as family, friends, people in their communities as well as with health and care professionals. As described above, the GMC guidance around decision making also applies here in relation to the overall benefit and best interests of a patient.
25. As the guidance outlines, where a patient cannot make a decision on their care, the lead clinician will make a clinical decision for the overall benefit of the patient. We can see from Mr O’s medical records that he has dementia and lacks capacity, insight and awareness to express his view on his care needs.
26. We can see that when Mr O was discharged from hospital, there was a request from the hospital for a discussion to take place around an advanced care plan for Mr O. The nursing home also requested a discussion around this.
27. We can see that the care plan was put in place because of Mr O’s frailty and cognition, as leaving the nursing home causes him significant distress and he becomes severely agitated. The plan notes that Mr O does not tolerate interventions and due to his frailty and poor physical reserves, he would not be fit of invasive investigations or treatment.
28. Our adviser said the decision to implement an advanced care plan was for the overall benefit of Mr O, and was in his best interest.
29. Considering the evidence we have seen, we think the decision to put an advanced care plan in place for Mr O was in line with guidance. As set out in paragraph 15, because we have seen no indication of a failing in the Practice’s actions here, we will not be considering this part of the complaint further.
30. We acknowledge this has caused Mrs I considerable worry and distress. We hope this provides Mrs I reassurance about the Practice’s decision.
Communication
31. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the events complained about had a negative effect which the organisation has not put right. Having done so we think the Practice has already done enough to put right the impact of these events. We have explained our decision below.
32. Mrs I complains the Practice decided CPR should not be attempted and put an advanced care plan in place for Mr O without any consultation with his family.
33. BMA guidance outlines those close to the patient must be consulted about CPR decisions that are made on a balance of benefits and risks. GMC guidance also outlines in relation to an ACP, clinicians should consult with those close to the patient and other members of the healthcare team, take account of their views about what the patient would want.
34. As set out above, Mr O has dementia and lacks capacity to make decisions about his care. We have seen no indication he has a lasting power of attorney for his health and welfare.
35. From the records, we have seen no evidence to suggest Mr O’s family was consulted about whether to attempt CPR or the advanced plans for his care, or that their views about what Mr O would want were taken into account. There is an indication of a failing here in the Practice not communicating with Mr O’s family before making the decision, and once the decision had been made.
36. The NHS Complaint Standards say that where a failing has an impact, the first step is to provide an apology. Where appropriate, the organisation should also consider other remedies, which can include reviewing a decision, and putting changes in place.
37. Although Mr O’s family were not consulted by the Practice, we think Mr O’s clinical care would have remained unaffected. While the guidance says to consult with Mr O’s family, it was for the clinicians to make the decisions about CPR and advanced care.
38. We can see that following receipt of Mrs I’s complaint, the Practice reviewed the decision not to attempt CPR on two occasions. As set out earlier in the report, we have seen no indication of a failing in the Practice’s decisions. As such, we do not think the Practice needs to review the decision it made further than it already has.
39. We acknowledge the Practice failing to communicate with Mr O’s family caused Mrs I significant emotional distress. We accept finding out about this after the decision was made was devastating for Mrs I.
40. The Practice in its response to the complaint has acknowledged that it should have informed Mrs I about the plans. It has apologised this communication did not take place and it has apologised for any upset this caused. It has also outlined it has taken a learning point due to the lack of communication it has identified.
41. We think the Practice’s actions here are in line with the NHS Complaint Standards, and are enough to put things right here.
Summary
42. As we have seen no indications of failings in the Practice’s decision not to attempt CPR, and to put an advanced care plan in place, we will not consider this further. Although we have seen indications of failings in the Practice’s communication of both decisions, we think the Practice has done enough to put things right.
43. We recognise the distress Mrs I has experienced following these events. We understand our decision may be disappointing but hope our decision provides Mrs I with some reassurance. We hope we have explained our decision clearly. We thank Mrs I for bringing her complaint to us.