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

[jeastridge]

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.

[Susie2310]

1 hour ago, Susie2310 said:

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.

 

To clarify, I meant to say that the patient in their 80's who experienced cardiac arrest survived to discharge and walked out of the hospital.

[Susie2310]

2 hours ago, Susie2310 said:

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.

 

 

xxx

[subee, MSN, CRNA]

Brilliant concept and easy to impleme

On 8/14/2021 at 9:31 PM, Susie2310 said:

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.

 

DNR applies to  people  have a terminal diagnosis and are approaching death.  Having a heart attack is no indication for a DNR in a patient who is survived a heart attack.  As far as I know, heart attacks aren't terminal in patients who recover.  

[jeastridge, BSN, RN]

On 8/14/2021 at 7:48 PM, Kitiger said:

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.

Excellent point. Thank you. Joy

On 8/14/2021 at 6:28 PM, Snatchedwig said:

Great article

Thank you for your comment. Joy

[Susie2310]

The problem I have with substituting AND for DNR is that while the patient in cardiac arrest who has chosen DNR status will not receive resuscitation measures and will instead receive care to keep them comfortable until they die - thus allowing them to die naturally; substituting the term AND for DNR, as I understand it, means that the patient who would wish to not be resuscitated and who is not in cardiac arrest, will not have the option of receiving the full range of care to diagnose/cure/treat their medical problems up until the point they experience cardiac arrest; instead their care will be limited to measures to keep them comfortable, not to diagnose/cure/treat their medical problems.  This is an enormous difference in meaning with significant implications for the types of care the patient receives and the outcomes they can expect to receive from the care. As I understand it, for patients who wish to have their medical problems diagnosed/cured/treated and who wish to continue living or to prolong their lives up until the point they experience cardiac arrest, this would be the equivalent of choosing not to receive treatment to diagnose/cure/treat their medical problems up until the point they experience cardiac arrest, and choosing to receive care to keep them comfortable only.  

Some people say that:  "DNR is for terminally ill people."  I'm not sure if the people saying that think it's acceptable to give patients who wish to have DNR status no choice to receive care to diagnose/cure/treat their medical problems in order to help them to continue living/prolong their lives and to reduce the onset of additional medical problems PRIOR to their experiencing cardiac arrest, and instead, once the  patient has chosen not to be resuscitated, requiring the patient to accept AND status - comfort care only up until the point of their experiencing cardiac arrest, but it appears to me that some health care professionals do believe that this is acceptable.   

Regardless of whether the patient who chooses DNR status is terminally ill, chronically ill, or chooses DNR status for another reason, all patients have the right to make choices as to the types of care they receive, and have the right to make end of life choices that they want to make for themselves.  The only limitation I am aware of is that physicians can decline to provide a patient with care that is considered futile, that is, care that a patient cannot expect to receive any benefit from.

I think the general public would benefit from education as to the meaning of all the terms:  DNR; AND; Full code; Curative/Aggressive Care; Comfort care; Palliative care; Hospice care, etc., along with information about what the different types of care entail and what limitations on care would result due to various choices.  It is difficult even for health care professionals to be faced with making these choices for themselves or loved ones suddenly or unexpectedly; how much more difficult it must be for lay people to properly understand the ramifications of the various choices in emergency situations.  I believe asking one's primary care physician about these options with the goal of obtaining good information can be a good place to start. 

 

[jeastridge, BSN, RN]

2 hours ago, Susie2310 said:

The problem I have with substituting AND for DNR is that while the patient in cardiac arrest who has chosen DNR status will not receive resuscitation measures and will instead receive care to keep them comfortable until they die - thus allowing them to die naturally; substituting the term AND for DNR, as I understand it, means that the patient who would wish to not be resuscitated and who is not in cardiac arrest, will not have the option of receiving the full range of care to diagnose/cure/treat their medical problems up until the point they experience cardiac arrest; instead their care will be limited to measures to keep them comfortable, not to diagnose/cure/treat their medical problems.  This is an enormous difference in meaning with significant implications for the types of care the patient receives and the outcomes they can expect to receive from the care. As I understand it, for patients who wish to have their medical problems diagnosed/cured/treated and who wish to continue living or to prolong their lives up until the point they experience cardiac arrest, this would be the equivalent of choosing not to receive treatment to diagnose/cure/treat their medical problems up until the point they experience cardiac arrest, and choosing to receive care to keep them comfortable only.  

Some people say that:  "DNR is for terminally ill people."  I'm not sure if the people saying that think it's acceptable to give patients who wish to have DNR status no choice to receive care to diagnose/cure/treat their medical problems in order to help them to continue living/prolong their lives and to reduce the onset of additional medical problems PRIOR to their experiencing cardiac arrest, and instead, once the  patient has chosen not to be resuscitated, requiring the patient to accept AND status - comfort care only up until the point of their experiencing cardiac arrest, but it appears to me that some health care professionals do believe that this is acceptable.   

Regardless of whether the patient who chooses DNR status is terminally ill, chronically ill, or chooses DNR status for another reason, all patients have the right to make choices as to the types of care they receive, and have the right to make end of life choices that they want to make for themselves.  The only limitation I am aware of is that physicians can decline to provide a patient with care that is considered futile, that is, care that a patient cannot expect to receive any benefit from.

I think the general public would benefit from education as to the meaning of all the terms:  DNR; AND; Full code; Curative/Aggressive Care; Comfort care; Palliative care; Hospice care, etc., along with information about what the different types of care entail and what limitations on care would result due to various choices.  It is difficult even for health care professionals to be faced with making these choices for themselves or loved ones suddenly or unexpectedly; how much more difficult it must be for lay people to properly understand the ramifications of the various choices in emergency situations.  I believe asking one's primary care physician about these options with the goal of obtaining good information can be a good place to start. 

 

Thank you for your thoughtful comment. I especially appreciate your insight regarding the need for education for the public. Joy

[MunoRN, RN]

We tried using the term but found it problematic because it suggests no interventions will be provided, including those intended to provide comfort at the end of life.  "Natural death" can be brutal, avoiding natural death is why comfort measures exist.

On 8/18/2021 at 5:58 PM, subee said:

Brilliant concept and easy to impleme

DNR applies to  people  have a terminal diagnosis and are approaching death.  Having a heart attack is no indication for a DNR in a patient who is survived a heart attack.  As far as I know, heart attacks aren't terminal in patients who recover.  

I find this interpretation to not be all that unusual in these discussions, but have never seen it in practice, maybe it's a regional thing?

Someone who has a terminal condition where resuscitation would not be beneficial would be a DNR, but specifically a declared medical futility DNR, where they aren't even given the option.  Someone who could potentially benefit from resuscitation can still choose to be DNR even though they are given the option.  I find that often people who choose this who are not medically futile codes are typically referring to unwitnessed out of hospital arrests where their chance of meaningful recovery are low and the chance of pointless torture is high.

[subee, MSN, CRNA]

11 hours ago, MunoRN said:

We tried using the term but found it problematic because it suggests no interventions will be provided, including those intended to provide comfort at the end of life.  "Natural death" can be brutal, avoiding natural death is why comfort measures exist.

I find this interpretation to not be all that unusual in these discussions, but have never seen it in practice, maybe it's a regional thing?

Someone who has a terminal condition where resuscitation would not be beneficial would be a DNR, but specifically a declared medical futility DNR, where they aren't even given the option.  Someone who could potentially benefit from resuscitation can still choose to be DNR even though they are given the option.  I find that often people who choose this who are not medically futile codes are typically referring to unwitnessed out of hospital arrests where their chance of meaningful recovery are low and the chance of pointless torture is high.

I am usually the confused one:)  I thought we were discussing an 80 year old man who came to the ER with a heart attack.  The poster does not tell if the patient had to be resuscitated or if he needed less dramatic treatment, which would be a completely different scenario.  I assumed, perhaps incorrectly, that an 80 year old man came to the ER with symptoms of having a heart attack; not in cardiac arrest.  If we make DNR's TOO conditional, they will create existential problems for the staff.  I have a DNR.  It means only that if you get called to resuscitate me.....don't.  Under any circumstances.

[Leader25, ASN, BSN, RN]

Death is natural,it is living by tubes ,tests,and machine that is unatural.

Changing the wording does not matter if wishes are not enforced.

I have seen doctors have a  hard time talking plainly to families,making false promises of 100% recovery.

Prolonged suffering does not help anyone,I am sure many remember the case and the drawn out court battle between a husband and comatose wife's family.I hope we one day follow Switzerland's policy and allow humane natural transition.

[kbrn2002, ADN, RN]

I have the same reservations about the terminology as @Susie2310.  I have an extensive background in LTC and DNR does not mean do not treat. Allow natural death could encompass not treating acute condition's that are very treatable, including in some cases cardiac events.

With a DNR it's made clear that if a person is found unresponsive with no appreciable vital signs that measures to restore those vital signs will not be taken. Decisions to prolong life through means other than performing CPR are discussed as well. 

Allow Natural Death muddies those waters too much for my liking as it can be interpreted to include things as simple as not treating a UTI before it becomes septic.