IN THE WAKE of a HIQA report on a Leitrim nursing home, Age Action has said it hopes legal clarity will be found on the issue of Do Not Resuscitate orders.
Eamon Timmons of Age Action told TheJournal.ie that he hopes the Government’s forthcoming mental capacity bill will help to clarify the issue around the orders, particularly when they are made by someone whose mental capacity is affected by illness or otherwise.
His comments came on foot of an investigation into Mulross Nursing Home in Carrick-on-Shannon, Co Leitrim, by the Health Information and Quality Authority (HIQA). The nursing home has since been put under the charge of the Health Service Executive and been closed.
The inspection came following a number of previous investigations, which found a series of issues at the home.
The purpose of the inspection was to monitor ongoing compliance with Regulations and Standards, and inspectors met with residents, relatives and staff members.
Inspectors were concerned on the first day of the inspection “regarding the fitness of the provider and person in charge and their ability to ensure the assessed needs of residents were met”. For example, there was a resident with a grade 4 pressure ulcer who was not receiving suitable safe care.
An incident of bruising to a resident, which had been recorded in the care file, had not been documented on an incident report and had not been investigated. Wound management, nutritional assessment and pain monitoring and assessment did not comply with evidence-based practice.
Other concerns included:
- Significant care and welfare issues identified regarding the provision of care to residents which posed a serious risk to residents
- The medication management system in place did not comply with best practice and could increase the likelihood of medication errors
- Concerns that records relating to the monitoring of residents’ health status were inadequate
- Wound prevention and management was not in line with evidence-based practice. There were poor arrangements in place to manage and monitor wounds.
Do not resuscitate orders
The inspectors found on reviewing some files that there was a line stating. ‘Do not resuscitate’.
There was no evidence available that the provider had ensured that this had been discussed with the resident or their relatives or members of the multidisciplinary team. There was no evidence available that the provider had ensured an assessment of the capacity of the resident had been undertaken or that any communication had occurred with regard to this order to ensure that the resident was involved in the decision.
“There was no evidence that the provider had ensured adequate engagement with a multidisciplinary team and the resident and complete a proper best interests process with regard to making this order,” said the report.
There was a policy on ‘Do not resuscitate orders’, which stated that there should be a discussion with all relevant parties and the outcome documented. This policy also stated that residents who are not for resuscitation should have a care plan in place identifying how the decision was made and ensuring that regular evaluation occurs. There was no evidence that this was occurring.
Eamon Timmons, spokesperson for Age Action, said they were concerned that while DNRs are put in place to protect dignity, unless strict protocols are put in place there is a “risk they could be abused”. He noted that DNRs don’t currently have any legal weight and it is a “very grey area in law”.
He said that if a person does not have the mental capacity, a multi disciplinary medical team has to be part of the consultation regarding a DNR order.
He said that Age Action were “alarmed” at the Mulross files but noted that the full details of each case are not known.
The issue with Mulross Nursing Home is if these decisions are made we will need to make sure vulnerable people are protected, that protocol around them is very strict, so that we don’t have them abused. It has got to be done with consultation.
Timmons said he hopes that the mental capacity legislation helps to clear up any grey areas, and that it will clarify the area of advanced care directives. He noted that to have DNRs in place for patients or residents at a nursing home is not unusual itself, but what was unusual was the lack of clarity around consent.
“If they have a wish [not to be resuscitated], that is their decision,” said Timmons, asking “is it going to be respected?”. Timmons added that assisted suicide and euthanasia are “completely separate issues” to DNR orders.
Timmons said that he believes in law there needs to be a directive concerning if a person says they want a DNR, and if the doctor does not comply with that.
He also said that information on DNR orders needs to be communicated properly between nursing homes and hospitals.