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Patients with learning disabilities: Clinical frailty scale and DNA CPR orders – 3 April

inappropriate DNR decisions during pandemic

When to use the clinical frailty scale and ‘do not attempt cardiopulmonary resuscitation’ (DNA CPR)

In a letter sent to primary care providers, acute and community trusts on 3 April, NHS England said – 

We are writing to ensure that there is clarity in relation to the use of the Clinical Frailty Scale (CFS) and the use of do not attempt cardiopulmonary resuscitation (DNACPR) with younger patients, those with a stable long term physical need, learning disability or autism.

In May 2019 the National Medical Director, Professor Stephen Powis, wrote with regard to learning disability, death certification and DNA CPR orders, emphasising that:

The terms “learning disability” and “Down’s syndrome” should never be a reason for issuing a DNACPR order or be used to describe the underlying, or only, cause of death … Learning disabilities are not fatal conditions.”

Earlier this week NICE issued rapid guidance on admission to hospital and to critical care: COVID-19 rapid guideline: critical care in adults NICE guideline [NG159]. The guidance made reference to assessments using the Clinical Frailty Scale (CFS). The guidelines were amended on the 25th March to make it clear that:

“The CFS should not be used in younger people, people with stable long-term disabilities (for example, cerebral palsy), learning disability or autism. An individualised assessment is recommended in all cases where the CFS is not appropriate.”

NHS England / Improvement has published specialty guides for the active management of patients with suspected and confirmed COVID-19 which include specific guidance on the management of people with learning disabilities and autism to which clinicians are strongly recommended to refer:

The health of some people who have a learning disability and / or a diagnosis of autism may be at risk from the presence of co-existing physical conditions and also from inequities in access to and delivery of appropriate and timely assessment and treatment for physical health conditions.

It is imperative that decisions regarding appropriateness of admission to hospital and for assessment and treatment for people with learning disabilities and / or autism are made on an individual basis and in consultation with their family and /or paid carers, taking into account the person’s usual physical health, the severity of any co-existing conditions and their frailty at the time of examination.

Treatment decisions should not be made on the basis of the presence of learning disability and / or autism alone.

Source: NHS England, letter to primary care providers, acute and community trusts on the use of  the clinical frailty scale and DNA CPR orders [sent on 3 April]