DNR versus AND

Pediatric Critical Care Columnist · Jun 18, 2012

We're in the process of changing our language from DNR to Goals of Care... similar to your AND. On our unit these conversations are handled poorly by some of our (11) intensivists and very well by some others. It's not so much the sensitivity as it is the offering of ridiculously escalating futile care (wecanstilldothisandthisandthisandthis), the recommending that we give the child "just a little more time" to declare themselves or the implicit expectation that parents will "make the decision" to end their child's natural life instead of being presented with the medical facts and told that there is nothing more that can be done that will produce the desired outcome so it's time to stop now. When it is presented in that way, there's really only one of our docs who will do it - most of them will back down if the family says they're not ready. (When are they EVER going to be ready???) Needless suffering? In spades.

We have a peds palliative care team and the doc is very compassionate, while also being realistic. Education about palliative care is sporifice. There is nothing in our unit orientation about it, just a little blurb about moral distress. We have a system-wide computer module on Goals of Care that has been incorporated into our BLS and hospital-based competency recertification, but it only takes about 15 minutes to read through and so far it hasn't been introduced in the real world.

merlee · Jun 18, 2012

I love the idea of 'AND'. It sounds much better, has a positive feeling. I have been fortunate in that neither of my parents suffered a prolonged dying experience, nor did most of my other family members.

I applaud the efforts of the health care team who can courageously discuss this sad topic with grieving family members.

Penelope_Pitstop, BSN, RN · Jun 18, 2012

Okay, I may sound dumb here, but it hasn't stopped me before so...

Am I understanding that these two terms are to be used synonymously?

Because I see a large difference in the two.

To me, DNR, in its plainest terms, indicates that no efforts to resuscitate will be made in the event of cardiac and/or respiratory arrest, but that all interventions will be performed up to that time.

AND, as I see it, means that no interventions at all will be performed, unless they provide comfort vs. medical necessity, (allowing nature to take its course, so to speak.)

I believe both are fine, of course, but I can see a problem if the terms are used interchangeably. At my facility, we don't use AND, we use the term "comfort care," but do not ever use it in place of DNR.

sapphire18 · Jun 18, 2012

I agree with DeLana. I think using "AND" is a great thought, but it has to be specifically stated exactly what it will entail. If it is just another term for "DNR," then great. I agree that the language is such that it could make these grieving parents feel less guilt over their decision. However if it is more of a "CMO (comfort measures only)" term, then that needs to be spelled out as well, and the distinction made between the two.

Esme12, ASN, BSN, RN · Jun 18, 2012

Like many things...when associated with death, people are uncomfortable with the subject of dying. The are times I miss the old days when the doc would write in the chart....."Slow Code" or "Code not indicated" and we would rush to the room and close the door while we "coded their love one".

Using terms like DNR...which is universally known (even if the ultimate "treatment" meaning varies), and changing it to vary again between facility to facility may cause more confusion than is necessary. I think a better education of healthcare professionals on the meaning of DNR.......that it doesn't mean Do NOT Treat. A special team that is consulted to help the family Dela with the comfort and loss of their loved one. I have found it is the individuals relationship with death that affects the interpretation what DNR means that the term itself.

A re-clarification that DNR does not mean Do not Treat. It means if while you are treating them aggressively they code.....you don't perform CPR and call a code. "Comfort care" means make them comfortable. Many families need the comfort that even if they are going to "allow their loved one to die and let nature take it's course".......is the loving thing to do. Having a patient die isn't a failure.

I remember once and oncologist stood at the bedside of a seizing 24yo in status insisting it was hypoxia that was causing the Status epilepticus and has nothing what so ever to do with the Grade 4 astrocytoma....stuns me to this very day. This Doc used to the family the "proof" that this was true because when the breathing tube was placed the Seizing stopped......had NOTHING to do with the paralytics used to stop/paralyze the muscles so we could give an airway. :bugeyes:

It isn't so much the vocabulary used....it's the education of the personnel using it. I like the term "Goals of Care" where the "terms" comfort care, DNR/DNI, hospice and palliative care will be used by the "team" as a part of the systems in place to care for their loved one in end of life issues.

Great post Ashley!!!

wooh, BSN, RN · Jun 18, 2012

Love this idea. LOVE it. We just got a new ethics person and a palliative care group just got started, so I'm really hopeful that a lot of the things that have been burning me to a crisp (i.e. parents forcing us to torture their child who has absolutely no quality of life) will slowly change for the better.

CapeCodMermaid, RN · Jun 18, 2012

I work on the other end of the age spectrum, but no matter what age the patient is, end of life care is not easy for most people to discuss.We have an Advanced Directives form that spells out what the person wishes or does not wish to have done: Do Not Rescusitate, Do Not Intubate, No Feeding Tubes, No Artificial Hydration, Do Not Hospitalize with room at the bottom for other choices.As long as there has been a discussion with the patient before the need arises, it works well. What I think is the most distressing is the case in which the resident has made his needs known, has a significant decline, health care proxy is invoked, and the health care proxy decides to "do everything possible" to keep the patient alive.

phil1968, ADN, BSN, LPN · Jun 18, 2012

I really like the idea, but I think the real problem is communication. I work on an oncolgy floor, and some of our oncologists will not talk about hospice or comfort care untill the pt is in the throws of death. Hospice is such a wonderful service, but it is nearly useless whe someone is mere hours from death. Physicians do not want to talk about end of life issues. I have been put in a position too many times of having to have this discussion with the family about their loved one who is just about to die, trying to figure out do I need to send them to ICU or not. All because their doctor would not talk to the family.

What we really need is a better dialogue with patients and families.

VictoriaGayle · Jun 18, 2012

I think that AND and DNR should both be options, in every facility.

AND would mean comfort care and allowing death, and DNR would just mean what it always means, just don't recussetate.

I think having both choices could benifit patients, help make sure their wishes are honored and that they recieve the kind of care they really need.

babyNP., APRN · Jun 18, 2012

We use AND in my children's hospital (I work NICU). AND can mean a variety of things and when our docs sit down with parents, they clarify things and parents get to choose what they want/not want done, like no CPR/CV meds, intubation, blood products, labs, etc etc. On each shift, the off going nurse brings up the document on our powerchart so there's no confusion. And of course, a parent may revoke it at any time.

I think it's great. We need to get away from this culture of the negative "Do Not Resuscitate." I feel like the public is so scared of death and this does not help things, with the picture in mind that we are not helping their loved one or themself.

Double-Helix, BSN, RN · Jun 18, 2012

I understand the comments about the differences between the terms DNR and AND. However, the unique aspect of pediatrics is that our patients who pass away on our unit very often have chronic illnesses (genetic defects, histiocytosis, autoimmune disorders, neuromuscular disorders) that will eventually cause death no matter what we do. The choice becomes when we stop managing the disease and start managing the symptoms. By the time we reach end of life discussions, it's when we've exhausted our medical options and they just aren't working anymore- like our oncology patients who have completed all the chemotherapy courses, radiation, surgeries, etc. and the cancer isn't going away. Or, it's a condition that's just going to get worse no matter what we do- such as SMA. There aren't too many situations where it makes sense to continue aggressive treatment without coding because we know the patient with either 1. never be able to get off the ventilator or 2. never recover despite our best interventions.

AND also allows for great flexibility of interventions- because the goal is providing comfort. Antibiotics, diuretics, feedings, BiPAP/O2, even palliative chemo or radiation can be included. But at the same time, if any of the above are uncomfortable for the patient or causing increased stress, we can stop them.

Just DNR or DNI has it's drawbacks as well. It is truly all about education, but the problem is when your doctors are not able to explain end of life in terms the parents can comprehend, it can create problems. For example, we recently had a patient with a genetic disorder who had been in and out of the hospital frequently. She was having increased respiratory distress over the weekend and her condition suggested the intubation was indicated. But the mother, who had spent lots of time in the hospital with her daughter, didn't want her intubated. However, none of our doctors were adequately able to explain the ramifications of that decision- that is was possible that eventually her daughter would get tired of working so hard to breathe and her body would give out. So even though the patient was a DNI, she was not a DNR, because the mother still wanted treatment and, like many parents, was equating DNR with not treating her daughter's condition with all of our best interventions. . We continued to treat aggressively, but in the early morning she went bradycardic and eventually asystolic. We ran a full code on this child but we were never able to get a perfusing rhythm back and she died. Could this situation have been prevented, and the child allowed to pass away naturally, with greater comfort and less pain, if there was greater education about AND versus DNR? I think so.