Do Not Resuscitate (DNR) vs. Allow Natural Death (AND)

[TheMoonisMyLantern, ADN, LPN, RN]

Thanks for the article. I think that could be a helpful for families facing the loss of a loved one. DNR makes them feel like they are giving up on their loved one and didn't do "everything" to save them. 

For a while in my state our advanced directives and living wills were automatically having the patient/family mark Y/N to IV antibiotics, fluids, feeding tubes, Bi-pap, pressors, etc and it was really helpful too but for some reason it lost favor. Probably because it requires more extensive time spent explaining things.

[JBMmom, MSN, NP]

4 hours ago, TheMoonisMyLantern said:

Probably because it requires more extensive time spent explaining things.

This makes me SO sad, and angry. I feel like one of the MOST important jobs of healthcare providers is to educate patients and families. Especially with issues related to something as important as end of life care. We can't be bothered to sit and explain things appropriately to families so we are left scrambling when a patient's health takes a turn for the worse. Would they want us to start pressors? Should we be inserting central lines for pressors and TPN? Do they want BiPAP even if the patient can't tolerate it without sedation? Do they want their loved one restrained? I believe that every single person deserves as good a death as we can manage. One with dignity and preferably with minimal invasiveness. This is where all the damn paperwork and charting take our time away from the doing the things that are right for patient care. 

We recently had a patient that the family stated had a living will at home. She had been an ICU nurse for years and family members said she was very clear on what she did and didn't want. Well, the oldest daughter refused to bring it in and no one else knew where it was. The woman managed to extubate herself while restrained, she told me to my face that she wanted us to let her go. I got in touch with the hospitalist who called the daughter and her response was "she's on medications that make her unable to make her own decisions, I am the medical decision maker as her next of kin." Unfortunately, this was true, so she was re-intubated. Eventually the ethics committee got involved but not until she had been on a ventilator for weeks. It was heartbreaking and infuriating. 

[jeastridge, BSN, RN]

31 minutes ago, JBMmom said:

This makes me SO sad, and angry. I feel like one of the MOST important jobs of healthcare providers is to educate patients and families. Especially with issues related to something as important as end of life care. We can't be bothered to sit and explain things appropriately to families so we are left scrambling when a patient's health takes a turn for the worse. Would they want us to start pressors? Should we be inserting central lines for pressors and TPN? Do they want BiPAP even if the patient can't tolerate it without sedation? Do they want their loved one restrained? I believe that every single person deserves as good a death as we can manage. One with dignity and preferably with minimal invasiveness. This is where all the damn paperwork and charting take our time away from the doing the things that are right for patient care. 

We recently had a patient that the family stated had a living will at home. She had been an ICU nurse for years and family members said she was very clear on what she did and didn't want. Well, the oldest daughter refused to bring it in and no one else knew where it was. The woman managed to extubate herself while restrained, she told me to my face that she wanted us to let her go. I got in touch with the hospitalist who called the daughter and her response was "she's on medications that make her unable to make her own decisions, I am the medical decision maker as her next of kin." Unfortunately, this was true, so she was re-intubated. Eventually the ethics committee got involved but not until she had been on a ventilator for weeks. It was heartbreaking and infuriating. 

Thank you for sharing your story. It contains more than a word of caution for us all. Many facilities are now able to keep copies of the Living Will on the EMR. I am hoping that eventually this will help us all in cases like the one you shared. 

[FolksBtrippin, BSN, RN]

Best article I’ve seen in a while. Thanks!

[jeastridge, BSN, RN]

1 hour ago, FolksBtrippin said:

Best article I’ve seen in a while. Thanks!

Why, thank you! What a nice comment. Joy

[LibraSunCNM, BSN, MSN, CNM]

I haven't heard of the movement to change the terminology, but I love that idea.  I don't work in critical care where these scenarios are seen daily, but I know very clearly what I and my loved ones do and do not want at the end of our lives, to hopefully avoid the horror of torturous, artificially prolonged life.  My kids were born at home, in my bed, and I have every hope that I will die there comfortably (a long, long time from now! ?)  It's sad that we avoid conversations about death so much in our culture.

[summertx]

The change in terminology will not change the outcome. The 'allow natural death' is just masking what it really is, a 'DNR'.

[Rose_Queen, BSN, MSN, RN]

Just now, summertx said:

The change in terminology will not change the outcome. The 'allow natural death' is just masking what it really is, a 'DNR' order.

But the families will accept it much easier. There are days I wonder if my mother wouldn’t have spent the last six weeks of her life between hospital and inpatient (futile) rehab back to hospital before we brought her home on hospice if the terminology was different and her oncologist consulted better with the admitting doc (oncologist was different organization than hospital). I understood what DNR meant, but my dad and siblings are less versed. 

[Snatchedwig, BSN, CNA, LPN, RN]

Great article

[Kitiger, RN]

I would go with "Allow Natural Death", but I fear that "AND" would bring confusion into the mix - confusion within the hospital staff.

Until people became familiar with the acronym, it should be spelled out.

[Susie2310]

On 8/12/2021 at 5:01 AM, jeastridge said:

A Typical DNR Scenario

The 90-year-old man was whisked into the Emergency Department by the rescue squad. He was found on the floor of his kitchen by his daughter and son-in-law who rushed into the area almost at the same time as the gurney pushed by the nurses’ station. The patient was unresponsive, ashen, and taking uneven breaths. His pulse was thready and weak. After a quick assessment that revealed a major cardiac event, the ED physician asked the nurse to take the family members to a consultation room.

The physician quickly filled them in on what they already could see: the patient was critical and there were decisions to be made. The doctor asked if the patient had a living will. The family tearfully said he did, and he requested no artificial means to prolong his life. The physician offered words of comfort and explained what would happen next as she procured their signatures on a Do Not Resuscitate (DNR) order. Crying, the daughter asked, “But you will do everything you can for him, right?” The doctor explained that the team would do everything to help her father be comfortable and ensure that he experienced comfort and dignity at the end of life.

Replace Do Not Resuscitate (DNR) Terminology with Allow Natural Death (AND)

These scenarios repeat themselves every day in our hospitals. The movement to consider a change in terminology from Do Not Resuscitate (DNR) to Allow Natural Death (AND) has been underway since Rev. Chuck Meyer of Austin, Texas proposed it in the late 90’s. Research is beginning to reveal that words used in the conversation surrounding death matter, and having AND as part of the terminology presented can be helpful.

According to Rev. Meyers:

When we health care professionals speak to patients and family members about DNRs, all too often the family believes we will abandon care and stop all treatment. Yet, all the DNR is designed to do is relay the information that it is the patient/family wish that resuscitation attempts (CPR) will not be started if the patient dies. Regardless of how much time and energy we spend explaining DNR orders to the family, often all they hear is the "not" in "do not resuscitate." This negativism confuses many people, who think that approving a DNR order gives permission to terminate their loved one's life. Or, they may be reluctant to agree to the order because they feel guilty that they are not helping their loved one as they feel they should.¹

Do Not Resuscitate is common terminology to nurses. Studies show that nurses are generally supportive of appropriate end-of-life conversations independent of terminology, but that laypersons prefer the Allow Natural Death, possibly because it is perceived as a more positive approach. AND may convey a focus on comfort rather than cure; DNR could possibly convey a sense of failure of treatment. “The DNR policy is framed in terms of crisis…AND approach emphasizes palliation and encourages families to talk earlier…AND can be seen as a positive choice, not a last resort.”²

The discussion of DNR vs. AND is not without controversy. In his review of the study done by Venneman, et al, Chen and Younger counter with analysis that indicates the approach is over-simplified and would not allow for the full range of end-of-life modalities. “Making discussion of end-of-life decisions more positive and specific is certainly a laudable goal.  AND, as presented by Venneman and colleagues, is not an advisable way of achieving it.”³

Professional nurses are always seeking out the best ways to help patients. “Simply changing the title of the medical order from DNR to AND increased the probability of endorsement by all participants regardless of healthcare experience or lack thereof.”⁴ The article goes on to describe the difficulties in communicating during times of high stress and emotions. In those times, negative words such as “Do Not” can assume stronger associations. More studies need to be done, but nurses have a role to play in helping positive change emerge from this conversation. “Nurses are often important contributors to treatment decisions and serve multiple functions, including patient advocacy.”⁵

The elderly patient in the case cited above, passed away within the hour with his daughter and son-in-law beside him, a chaplain nearby and staff working to make sure everyone’s needs were addressed. Would DNR vs. AND make a difference in this case? Perhaps. Perhaps not. But words do matter. As we work together to improve, we must re-assess our terminology to see if there is an opportunity for improvement.

References

¹Hospice Patients Alliance - preserving the original mission of hospice

² Stecher, Jo. "Viewpoint: 'Allow Natural Death' vs. 'Do Not Resuscitate'." The American Journal of Nursing 108, no. 7 (2008): 11. Accessed August 7, 2021. 

³ Chen, Y-Y., and S. J. Youngner. ""Allow Natural Death" Is Not Equivalent to "Do Not Resuscitate": A Response." Journal of Medical Ethics 34, no. 12 (2008): 887-88. Accessed August 7, 2021. 

⁴ Venneman, S. S., P. Narnor-Harris, M. Perish, and M. Hamilton. ""Allow Natural Death" versus "Do Not Resuscitate": Three Words That Can Change a Life." Journal of Medical Ethics 34, no. 1 (2008): 2-6. Accessed August 7, 2021. 

⁵ Ibid.

I'm afraid I have reservations about the situation as described in the OP.  I also don't agree that DNR should be replaced by the term AND, as not proceeding to resuscitate a patient who's heart has stopped, I.e, the patient is unresponsive, pulseless, with agonal gasps, is not the same as declining to provide curative care and instead providing comfort care only.  They are two different situations, and I believe it is very wrong to use them interchangeably.  In addition, this muddies the waters for both health care providers and lay persons.

In the scenario, the 90 year old man had collapsed at home and was taken to the ER, where he was observed to be unresponsive, ashen, with irregular respirations and a thready, weak, pulse.  We aren't told how long the drive was from the patient's home to the ER (it could have been just a few minutes away), or whether the rescue squad were professional paramedics/EMT's,  or how long the patient had been unresponsive before the rescue squad arrived, or whether BLS/CPR were started.  We are told a quick assessment in the ER revealed a major cardiac event; since the patient had a palpable pulse, albeit thready and weak, I assumed this meant the monitor showed a pre-arrest rhythm and that a 12 lead EKG was done which showed a STEMI.  We are also told the patient had a Living Will, and had requested no artificial measures to prolong his life.  But the patient still has a pulse, albeit thready and weak (the patient is not in V Fib/PVT, PEA or Asystole) and has irregular respirations.  

I think the course of action taken in the OP to proceed to AND was likely appropriate due to the patient having a Living Will that requested no artificial measures to prolong his life, but we don't KNOW what care the patient had actually specified they did not want; the term "artificial measures to prolong one's life" covers a wide area from no CPR, to no intubation/mechanical ventilation, to no prolonged life support, to no feeding tube, etc.  However, in the OP, it was deemed sufficient to provide no treatment apart from comfort care because the OP's Living Will said: "no artificial measures to prolong life."

I believe we need to keep in mind that elderly patients are individuals and many wish to receive curative care.  Some patients in their eighties and nineties are being treated by cardiac interventionists and wish to continue to receive curative care as they want to continue to stay alive and still have quality of life.  While a family member was a patient in the ER, a physician gave me to understand that just recently a patient in their 80's who had had a heart attack had survived to discharge and had walked out of the hospital.