I was surprised when a very old man told me that he had signed a DNAPR during an unaccompanied outpatient visit. He recounted how a nurse approached him as he waited and asked him to sign a piece of paper, which he had declined to sign on several previous occasions, but he gave in this time because he will refuse to be ‘carted off’ to hospital if he fell ill again. This experience has echoes of the experience of some older people during the first peak of the pandemic (Care Quality Commission (CQC), 2020) over which there was an outcry.
Griffiths (2018) set out clearly the legal position regarding a DNAPR and the protection that a lawful DNAPR offers district nurse (DNs). Crucially, a lawful DNAPR protects DNs from allegations of wilful neglect or ill treatment. Griffiths (2018) noted that a DNAPR may only be used when attempts at resuscitation would be futile; they would be against an individual's wishes or when not in the best interests of an incapable person. But, importantly, a DNAPR only applies to resuscitation and does not refer to any other treatment or care interventions, which should continue to be delivered and meet expected quality standards. There is a requirement to consult the individual; if they lack capacity, those holding power of attorney for health and welfare must then be consulted unless the individual has made a ‘living will’-that is, there is a legal statement from the individual stating what medical treatments/interventions they do not want.
The CQC (2020) confirmed that there had been potential breaches of the Equality Act 2010 and the European Convention on Human Rights. The Equality and Human Rights Commission (2020) confirmed that the right to life must be maintained even during the pandemic, which means obligations to protect life and prevent avoidable death continue, and that DNAPR decisions must not infringe an individual's rights to life or be discriminatory. Best practice should comprise broad conversations about future care and treatment, of which treatment escalation plans (TEP) and DNAPR decisions form a part (CQC, 2020).
While not suggesting that DNs have been party to unlawful DNAPR decisions, some GPs allegedly used DNAPR forms in a blanket manner in relation to care home residents (Queen's Nursing Institute (QNI), 2020) in addition to older people living in their own homes (CQC, 2020). This inappropriate use of DNAPR forms was compounded by difficulties in accessing GP and district nursing services at a time of need (QNI, 2020).
The growing success of the COVID-19 mass vaccination programme is a reason for optimism, but older people will continue to reach the end of their lives because of infections, progressive organ failure or cancer. Bowers et al (2021) anticipated that changes to healthcare delivery in response to the pandemic will herald new models of care delivery, with nurses in extended roles, but they cautioned that remote consultations cannot wholly replace face-to-face meetings and highlighted the need to understand the patient's and family caregiver's experience of new ways of working (Bowers et al, 2020). With increasing numbers of people dying at home, DNs have an opportunity to influence how future end-of-life care should be configured and delivered.
‘The growing success of the COVID-19 mass vaccination programme is a reason for optimism, but older people will continue to reach the end of their lives because of infections, progressive organ failure or cancer.‘