Wales urged to improve Do Not Resuscitate decision making processes

Healthcare Inspectorate Wales (HIW) has called for significant improvements in the decision-making processes regarding Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) for adults in Wales.

The review, which examined the involvement of patients in DNACPR decisions and the clarity of these decisions among healthcare professionals, found both commendable practices and areas requiring urgent attention.

Cardiopulmonary resuscitation (CPR) is a critical emergency procedure performed when a person’s heart and lungs stop functioning. DNACPR decisions, which determine whether CPR should be attempted, are crucial components of end-of-life care.

The review highlighted the necessity of sensitive and effective communication to respect the wishes of patients and their families.

The report revealed that while there are examples of good practice, there are significant opportunities for improvement, particularly in communication and documentation.

HIW reviewed around 280 DNACPR forms and found inconsistencies in the recording of key information.

Some forms were thoroughly completed, while others were incomplete or difficult to read.

However, there were positive examples of detailed patient discussions and comprehensive narratives supporting DNACPR forms.

Effective communication is essential in DNACPR decision-making.

The review identified a need for earlier initiation of DNACPR conversations with patients, rather than waiting until the end stages of illness.

Almost half of the public survey respondents felt their accessibility needs were not considered during DNACPR discussions, indicating a need for more personalised and accessible communication.

A significant issue identified was the inconsistent recording of mental capacity assessments.

For patients lacking capacity, forms often lacked evidence of proper assessment, raising concerns about adherence to the all-Wales policy.

Additionally, nearly a third of healthcare staff surveyed felt that communication across teams regarding DNACPR was ineffective.

The report suggests establishing an all-Wales electronic repository for DNACPR forms to facilitate prompt access to crucial information.

Training and support for healthcare staff emerged as a consistent theme.

While national resources and training modules are available, awareness and accessibility of these resources need improvement.

Enhanced training would help ensure that DNACPR discussions are conducted in a person-centred and respectful manner.

Alun Jones, Chief Executive of Healthcare Inspectorate Wales, emphasised the importance of understanding patients’ end-of-life wishes.

He called on health boards, trusts, and the Welsh Government to carefully consider the report’s findings and feedback from both staff and the public to drive improvements in DNACPR decision making.

“I must take this opportunity to pay tribute to the staff who take part in discussions about DNACPR decisions, and to those who provide care and support to people at the end of their lives.

“The compassion and dedication of those we engaged with throughout this work is heartening and provides a strong and positive basis upon which to improve,” Mr Jones said.

Responding to the report, Older People’s Commissioner for Wales, Heléna Herklots CBE, said:

“Clinical decisions relating to Do Not Attempt CPR (DNACPR) are often very difficult for patients and their loved ones, and the ways in which these decisions are made can seem unclear and difficult to understand, particularly during times of crisis. That’s why timely, sensitive and informed discussions about DNACPR are vitally important.¹

“I therefore welcome the findings of Healthcare Inspectorate Wales’ review of DNACPR decisions in Wales, which shine an important light on areas where improvements are required, particularly the need for more opportunities and support for staff training and greater consistency in the way that these decisions are discussed, recorded and shared.

“While the review did find examples of good practice and highlights the compassion and dedication of many staff providing care and support to people at the end of their lives, which is positive, it is clear that action is required throughout Wales to tackle the issues identified.

“I look forward to seeing the impact of the action that will be delivered through improvement plans developed in response to the review, which is important to help ensure people have the information they need and their rights are upheld.”