Evolution of Advanced directives: Allowing a Natural Death


  • Home Health Columnist / Guide
    Specializes in Vents, Telemetry, Home Care, Home infusion. Has 46 years experience.

from center for nursing advocacy:

allowing a natural death

dmason_thumb.gifmarch 16, 2007 - today the weekly radio show "healthstyles" on wbai (new york) featured a typically enlightening discussion of key health issues from a nursing perspective. the show is hosted by american journal of nursing editor-in-chief diana mason, rn, phd, faan (right), who also serves on the center's advisory panel, and barbara glickstein, rn, ms, mph.

today's topic was end-of-life care, specifically the importance of advance directives and do not resuscitate (dnr) orders--or, as one of the guests noted, what some have started calling "allow a natural death" (and) orders. in addition to mason herself, who hosted today's show, two of the three guests were nurses, and the show provided an excellent forum for all to educate the lay audience about these health ideas. mason and her guests proposed taking a more holistic, patient-focused approach to dying, which often will mean no aggressive treatment. this alternate approach runs counter to what even many health workers still assume patients want. of course, in giving nursing leaders the chance to make this case, "healthstyles" also shows its audience that nurses are articulate, knowledgeable health professionals.


we salute diana mason and wbai for the show. more...and hear 4 sound clips or the full show...


4,491 Posts

This is so very important.

In my experience more people have some idea what "everything" can mean when asked if they want "everything" done.

As patient advocates we must facilitate education and communication about end of life wishes.


69 Posts

Has 16 years experience.

I can't access the clips but this is an issue that I feel very strongly about. Death is a natural process and will come to us all, sadly in some ways like childbirth it has been taken over and made a medical issue.

My Father and our family were fortunate enough to have him cared in his last days by a palliative care team that ensure that he was comfortable, pain free and dignified.

He died in his own bed my Mum lying with him with the rest of the family close by which is exactly what he and she wanted. Any and all possible equipment and drugs that we could have need was in the house, in place before it was required so there was never any need to rush around looking for things.

And despite having 2 daughters who are trained nurses there we also had a 24 hr pager number if we had any issues, the only time Mum had to use it the nurse carrying it was at the house in 10 mins.

From the minute he was first diagnosed as terminal and expressed a wish to die at home there was never any problem.

As it should be.

The above all took place in Ireland, where there is still much less stigma and fear surrounding death.

In the UK where I currently work it is so sadly different. Despite what patient’s wishes might be, they rarely died at home, the set up and services just aren’t there. There are very few palliative services available with community nurses been expected to take this very difficult role on. As they are not allowed to carry drugs on them if it is the weekend and the patients GP will not attend the patients house to deal with acute pain patients regularly end up in the ER and by then are to ill to be moved again.

If they are in hospital when they are diagnosed there is next to no info or support offered to allow them to go home.

And back to the main point, DNR is rarely discussed. I recently took report on a 80+ patient who was riddled with Ca, it was everywhere and it was clear that this patient was not long for this world, irregular breathing pattern, difficult to rouse etc however they were still for Resus and not on the Liverpool pathway……………….

When I spoke to the doc he felt it was inappropriate to discuss Resus etc with the family at this time, my reply (and it was in private out of patient ear shot) was

‘Well when is it appropriate? When they stop breathing? When we can’t feel a pulse? When, because of your reluctance to discus this, we legally as nurses have to put out a crash call and start to bag this person? Do you want to talk about it before or after we rip the patient’s night shirt off and send 200 joules of electricity through them?

(I can be a sarcastic cow when I start)

After we got through him threatening to make a complaint about me and me laughing at him and bring his boss the Registrar in to the conversation. We went a spoke to the family who were honestly surprised that (a) we need to ask this question, i.e.: it was clear to them that their loved one was dying their only concern was that it be pain free. And (b) that this had not been discussed before that patient had been in several days everyone knew the diagnosis…………….

I do wonder what if anything is taught about end of life care in Medical schools.

Liverpool pathways = The Liverpool Care Pathway (LCP) for the dying patient has been developed to transfer the hospice model of care into other care settings.

The LCP provides guidance on the different aspects of care required, including comfort measures, anticipatory prescribing of medicines and discontinuation of inappropriate interventions. Additionally, psychological and spiritual care and family support is included.

The LCP replaces all other documentation in this phase of care and is applicable in hospital, hospice, nursing home and community settings. The LCP is a key recommendation in the NICE guidelines for supportive and palliative care. It is an NHS Beacon project.


Dolce, RN

861 Posts

Specializes in Day Surgery, Agency, Cath Lab, LTC/Psych.

I like the phrase "allow natural death." Using the term "do not resuscitate" sounds like there is something we are not doing for the patient. It sounds like we are withholding care from the patient.

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