“Allow Natural Death”
There is a movement afoot to replace DNR with “AND” or Allow Natural Death. The idea is that patients and families are put off by the verbiage of DNR–that agreeing to a DNR is a death sentence. Families and patients do not want to sign such an order committing them to what appears to be certain death. However, Allow Natural Death puts distance between the final moments where the heart and lungs stop, and focuses on events leading up to death. It is more than a change in semantics, it is a change in the way we talk about death.
AND appears more humane and, forgive me, natural. Patients and families think that CPR/Code Blue results in saving most of the patients, most of the time, if TV’s ER is to believed. But the sad fact is, resuscitation is frequently an invasive end of life maneuver that ignores dignity and natural progression. Moving toward AND will require a shift in thinking whose time has come. Patients and families want a peaceful, dignified death. In order for patients to understand that death is a part of life that can’t be denied, we as physicians will have to do what we aren’t particularly good at. We will have to talk to patients and families about death.
We need to educate families (and ourselves) that death is part of living, and that sometimes it is best to let God and nature take their course, with out our highly invasive, technological, expensive interventions. I think the place to start occurs when a patient that is approaching the end of life. That is the time to get a grasp of what a patient wants/doesn’t want. We shouldn’t wait until a patient is at death’s door to talk about the end of life. Many patients want to die at home. (Most, actually want to die at home, and sadly, most die in the hospital.) The idea then is to address these desires when beforethe patient deteriorates so significantly that death is imminent. For instance, is it appropriate to treat every infection? Back in the day, pneumonia used to be called “the old man’s friend.” Does the patient and family want to treat the pneumonia? Do they want to go on toward intubation? Does the 95 year old wheel chair bound patient WANT her fractured hip replaced–or would she be more comfortable at home with a decent pain regimen? (Yes, just saw this last week when the orthopod called asking for “medical clearance” to replace the patient’s hip. No one had thought about AND in this case.) Just as important, does the patient and family want the new mass on chest Xray to be worked up in the 85 year old patient with COPD?
These are excellent examples of when AND would be a well placed directive. I think that AND is more than a directive, it is a direction to guide treatment. Much discussion should go into WHAT treatments families and patients want. I don’t think we can fore go DNR as it is a clear directive of what to do when a patient has a cardiopulmonary arrest. However, I think “AND” should be a primary topic of discussion way before we ever get to DNR.
Currently, AND is not a legal replacement for DNR. I don’t think it should be, but rather would use it as an adjunct to guide diagnosis, management and treatment. I think it is the responsible way to help patients face the end of life with dignity. We need to get good at these discussions, and help our patients in realizing their ultimate decision: the manner in which they wish to die.
Just to be very clear: this is in NO way a piece advocating that we help patients end their lives. I am advocating that patients choose how much medical treatment they want as they near the end of their lives, and that we help them explore various options to make this decision.