Call for audit on CPR prevention
A healthcare review team has called for an urgent audit of orders preventing the resuscitation of some hospital patients with learning disabilities.
An advance decision can be taken not to provide CPR if the seriously ill suffer a heart attack - if that is deemed to be in their best interests - and placed in the medical records.
A watchdog in Northern Ireland highlighted a lack of clear documentation outlining the reasons for the measure, an apparent failure to communicate with some patients or families and no evidence of reviewing or revoking the restriction on care. It did not suggest the measure was made inappropriately.
Regulation and Quality Improvement Authority (RQIA) chief executive Glenn Houston said: "While the review team was satisfied that there is sufficient guidance, policy and professional codes to inform and guide clinical practice, on many occasions these were not followed."
Learning disability involves a significantly reduced ability to understand new or complex information or to learn new skills as well as a reduced ability to cope independently which started before adulthood, with a lasting effect on development.
Around 26,500 people are affected in Northern Ireland, half aged under 20. The number is projected to grow by 1% a year over the next 15, the report said.
Concerns were also raised by the review team around misunderstanding and poor practice related to consent, assessment of patients' capacity and best interest.
The report said: "While, the review team was not in a position to determine the appropriateness of Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders, it considered that all trusts should urgently review/audit practice and the process of documentation in this area."
Concerns raised included:
:: There was often no clear documentation, either within the non-resuscitate form or within the medical or nursing notes, outlining the main clinical problems and reasons why non-resuscitation was in the patient's best interest.
:: There were occasions when it was not evident what communication had taken place with the patient. The report asked: "And if not, why not."
The same applied to the patient's family, carers or friends.
:: There was frequently no evidence of the orders being reviewed or revoked.
The report said: "The review team noted/identified situations where nursing staff delivering care appeared to be uncertain about the DNACPR status, due to the absence of a DNACPR form in the patient's file."
It added: "The review team was particularly concerned around misunderstanding and poor practice related to the application of proper processes around consent, capacity assessment, best interest decisions in relation to DNACPR orders.
"While the review team was satisfied that there is sufficient regional guidance, local policy and professional codes to inform and guide clinical practice in this regard, the practice of all professional groups, with the exception of allied health professionals in a single trust, was not adequate."
People with learning disabilities who contributed to the review were unfamiliar with the concept of non-resuscitation, and considered that general hospital staff should always try to save people.
The report added: "However, all stakeholders involved in the service user seminar stated that learning disability should not be a consideration in such decisions. These should be based on the medical assessment of an individual's health at the time, and should be reviewed regularly."