End of Life Care Decisions: DNR or AND?
March 8, 2015
The practices of end of life care globally are trapped in semantics, cultural demons, and fear.
The term “do not resuscitate” or DNR, has not been around for hundreds of years. Rather it only came into use after we learned that we could bring someone back from the brink of death, that we could keep them breathing even if they couldn’t.
In the mid-20th Century, CPR became a detailed protocol to do just that. Defibrillators went through their own development, starting with huge, AC-powered machines only used in hospitals to battery-operated ones we have today that can be used anywhere. Intubation was born out of early efforts to keep an individual breathing until help could arrive.
So, basically we are new at restarting life. And DNR, as a directive, removes our right and obligation to do this. It tells us to intentionally refrain from utlizing the miracles that took hundreds of years to discover.
Nonetheless, with the capacity to extend life, we have also created great confusion over death and dying and where our boundaries of control should end. Today, we are looking at many complex issues around end of life care and what it means to a nurse, physician, family member, and patient when the line between living and dying has become a matter of choice.
In response to the discomfort families have had in authorizing a DNR order, some hospitals have adopted the alternative term “AND,” or Allow Natural Death. Now being used in over 100 hospitals nationally, AND has opened the discussion of adequate and appropriate care at the end of life.
The late Reverend Chuck Meyer (who introduced this concept) offers insight into what Round Rock Medical Center (Texas) is doing to institute this change.
The objective is to ensure that end of life care is optimal. AND calls for comfort care, not curative care nor an absence of care. It is about effective pain management, ultimate comfort in every aspect of the patient experience.
Here is the explanation from Julie Benbenishty, Hadassah Medical Center, Jerusalem:
Allowing a natural death is a bit “more active” than just do not resuscitate- which means DO EVERYTHING except cardio-pulmonary heart massage.
Allow a natural death can be ‘removal of all tubes and lines’ so that the person can experience a “natural death.”
One of my neurosurgeons says, “I have done all that medicine can do , we will now leave the rest to God Almighty–if HE wants this person to live he will continue giving him breath without the ventilator and vasoactive drugs.”
So He removes everything.
This is defined as a natural death.
An article in Emergency Medicine acknowledges the weight on the emergency room staff who must walk families through critical decisions, concluding that this language offers a significantly more positive experience for families who will have to live with their decisions for the rest of their lives.
On a daily basis, nurses and physicians are having difficult conversations about end of life, sometimes only hours or minutes prior to death. Palliative care offers an earlier entrance into the discussion.
However, making a decision to remove artificial life-support and refuse any further life-saving efforts can feel in direct conflict with our belief in life itself. Any option that starts with “Do Not” sets up a defense and feeds into the helplessness that the end of life processes can present.
Of course, the circumstances surrounding end of one’s life dominates how the event is experienced. In reality, nothing may feel “natural” about a person dying whose life is not yet complete. At the same time, extending life into a life not worth living is yet another quagmire in which we struggle with what is no longer possible.
The big question is who decides DNR and AND?
If the patient decides then there is no problem fulfilling his or her wishes–whatever he or she decides.
The actual ultimate problem with decision making is in cases where patients cannot decide for themselves–which happens in the majority of instances. Then it doesn’t matter what we call it. Someone still has to decide.
Supporting a person in the natural process of dying is very different than perceiving the same event and choice as denying that individual life. Making a decision to permit nature and God to handle ones life and death at this specific time is very different than abandoning all other artificial options.
Nonetheless, someone has to decide.
How do you feel about AND? Would using this framework be easier and more comforting for your patients and their families? Would you be willing to try this language to see its impact?
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