D.N.R. by Another Name

December 6, 2010, 2:12 pm
D.N.R. by Another Name
By PAULA SPAN

Let’s imagine an end-of-life scenario. Your ailing and elderly parent has been admitted to the hospital yet again with a condition she’s not going to recover from. The medical team asks what they should do if her heart stops. She’s always said she didn’t want to die “hooked up to a bunch of machines,” but you’ve never really explored the details. Besides, though she has a terminal illness, no one has yet mentioned the d-word.

The key question: Should your parent have a D.N.R. order, meaning “do not resuscitate”?

Before you answer, another key question: Would that decision be any clearer, easier or less painful if the order was instead called A.N.D., for “allow natural death”?

Some health care professionals think it might be. Even if the staff’s subsequent actions were exactly the same, if in either case a patient would receive comfort care to relieve pain but wouldn’t undergo cardiopulmonary resuscitation, nomenclature might make a difference.

“It’s only beginning to come to people’s attention,” said Ruth Wittman-Price, nursing department chair at Francis Marion University, who assessed use of the new term in a recent study in the journal Holistic Nursing Practice. “But a lot of paradigm changes in society start with a language change.”

The phrase “do not resuscitate” signals an intent to withhold or refuse, she pointed out. “It says you’re not going to do something.” To “allow natural death,” on the other hand, connotes permission.

“It doesn’t sound so overwhelming or scary,” said Christian Sinclair, associate medical director at Kansas City Hospice and editor of the Pallimed blog, who sees the term catching on.

Natural foods, natural childbirth — we’re inclined to favor natural stuff these days.

The palliative care specialists I talked with had very different takes on this wording. Michael Nisco, a proponent, has written a new policy implementing A.N.D. at St. Agnes Medical Center in Fresno, Calif., where he’s medical director of hospice and palliative care.

“Everyone in health care has a different definition of what ‘do not resuscitate’ means,” he said. It refers to forgoing attempts at cardiopulmonary resuscitation, surely, but does it mean refusing a ventilator? Avoiding the intensive care unit? Such understandings vary not only from one hospital to another, but from one unit or even one shift to the next.

“A new term is free of a lot of that baggage,” said Dr. Nisco.

Perhaps, but some critics see further evasion afoot. We still don’t like talking about death, so we’ll find another way to tiptoe past it.

Besides, “it brings in a lot of vagueness, and that’s probably its downfall,” said Eric Widera, assistant professor in the University of California, San Francisco geriatrics division. “When something happens very quickly, physicians and nurses want to know what to do.” He thinks the more specific approach called “physician orders for life-sustaining treatment” offers more precision.

Personally, I’m not uneasy with the phrase D.N.R., and my own health care proxy (carefully mounted on my refrigerator door for the ambulance crew to find) specifies no resuscitation. But it also authorizes “the administration of pain-relieving drugs.” Is that “natural”?

Dr. Wittman-Price’s study, based on a non-randomized sample of almost 200 physicians, nurses, medical and nursing students at Hahnemann University Hospital in Philadelphia, is the most recent to show that professionals like the new label. Eighty-three percent of nurses and nursing students, and 78 percent of physicians and medical students, said they’d be “highly likely” to consent to an A.N.D. order if a loved one was near death.

Missing from this debate, so far, is any data on what patients and families think. “Allow Natural Death” — comforting new perspective that eases the burden of decision-making? Or mostly a pointless distinction?

Let’s undertake our own non-randomized research here. If you and other family members have to shoulder this decision for a relative who can no longer make her own wishes clear, would you rather her hospital bracelet read “Do Not Resuscitate” or “Allow Natural Death”? Or, at a time of crisis, would that really barely matter?

Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”

http://newoldage.blogs.nytimes.com/2010/12/06/d-n-r-by-another-name/?partner=rss&emc=rss