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Covid-19: Don’t apply advance care plans to groups of people, doctors’ leaders warn

BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m1419 (Published 06 April 2020) Cite this as: BMJ 2020;369:m1419

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  1. Gareth Iacobucci
  1. The BMJ

Medical leaders have said it is “unacceptable” for advance care plans—with or without a completed “Do not attempt to resuscitate” (DNAR) form—to be applied in a blanket manner to whole groups of people during the covid-19 pandemic.1

The joint statement from the Royal College of General Practitioners, BMA, Care Provider Alliance, and Care Quality Commission comes amid concern that GPs are feeling under pressure not to admit their older vulnerable patients to hospital if they contract covid-19 because of restrictions on acute care capacity.

Last week an NHS health board in Wales apologised after a general practice advised some patients with serious illnesses to fill in a “Do not attempt cardiopulmonary resuscitation” form, meaning that emergency services would not be called if that patient became infected with covid-19 and their health deteriorated.2

In their statement, issued on 1 April, the four organisations said that decisions on advanced care plans and DNAR forms “must continue to be made on an individual basis according to need.”

They said, “It is unacceptable for advance care plans, with or without DNAR form completion, to be applied to groups of people of any description.”

Last week the Royal College of Physicians published ethical guidance for doctors during the pandemic,3 making it clear that treatment should be provided “irrespective of the individual’s background . . . where it is considered that it will help the patient survive and not harm their long-term health and wellbeing.”

Martin Marshall, chair of the Royal College of General Practitioners, said that the college endorsed the RCP’s guidance and would shortly be publishing its own to help GPs and their teams “navigate their way through the ethical decisions.”

Marshall said, “Conversations with patients about their wishes at or near the end of their lives are an essential part of general practice—and advanced care directives are key to ensuring their wishes are met.

“It is right that during the current covid-19 pandemic GPs continue to have these conversations with patients. But any decision to complete an advanced care directive or DNAR order must be made with a patient’s full consent—and any decision about a patient’s care must be made in a fair and equitable way, based on their individual circumstances and according to need.”

Graham Jackson, a GP and chair of NHS Clinical Commissioners, which represents clinical commissioning groups in England, said that commissioners supported the joint statement.

He said, “Most clinical commissioning groups will already have end of life care pathways in place. These are likely to be based on national NICE guidelines and were developed long before this pandemic in collaboration with their member GP practices and palliative care clinicians. At this time of increased risk to elderly people and those who have serious health conditions, it’s right that CCGs remind GPs of these pathways and that GPs have personal conversations about advanced care plans with those individuals and their carers.”

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