Allow Natural Death--An Alternative To DNR? by Reverend Chuck Meyer

Health care workers of all kinds--physicians, nurses, chaplains, social workers and case managers--inadvertently terrify patients and their families with medical terminology perceived as harsh, insensitive, and downright confusing. A prime example is the "Do Not Resuscitate" (DNR) order. Perhaps the time has come to replace the concept of DNR with a gentler, but in fact more definitive, approach--Allow Natural Death (AND).

Examining "Do Not Resuscitate" Orders

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.

As most of us in the medical field know, asking for a DNR does not mean that we have stopped care. What it means is that we have simply changed the goal of treatment. But to patients and family members who are emotionally--not clinically--involved in the situation, this truth may not be apparent.

While a completed DNR tells physicians and other medical professionals not to start CPR if the patient suddenly goes into cardiac arrest, the order does not differentiate between a terminally ill patient and a potentially healthy person who may die due to current circumstances. A non-terminal patient may be in a DNR category and continue to receive aggressive or supportive treatment aimed at a cure or at nudging him through this medical crisis. If symptoms start to respond, then the DNR category might even be changed to a full code.

On the surface, it would appear that a DNR order is put in place to carry out the patient's (or family's) wishes. But does it go far enough? Although the patient or family, or the patient's living will or other legal documentation may say that no extraordinary measures are to be taken at a critical time, physicians may still be keeping the patient alive with artificial nutrition, hydration, antibiotics, and ventilators. For patients who are dying or in a terminal condition, the DNR order is not really appropriate because active, aggressive, life-sustaining treatment of any kind is not appropriate.

Allow Natural Death

An order to Allow Natural Death is meant to ensure that only comfort measures are provided. By using the AND, physicians and other medical professionals would be acknowledging that the person is dying and that everything that is being done for the patient--including the withdrawal of nutrition and hydration--will allow the dying process to occur as comfortably as possible. While a DNR patient in Intensive Care might be put on a ventilator, given artificial hydration, or have a feeding tube inserted, an AND patient would have all of those things withdrawn, discontinued, or not even started, since such treatments are painful and burdensome for the terminally ill. The AND would prevent this unintentional pain and simply Allow a Natural Death.

So far, this new AND concept has been presented to about 100 hospitals throughout the United States and to many hospices and nursing homes. They are considering adding AND to their language, in order to reflect better the needs of their terminally ill patients.

When questioned about how AND would be defined, Rev. Meyer has written:

There are a couple of ways to implement the AND designation. In facilities where there are only two codes, Full Code and DNR, we could change the DNR to AND. In Austin, as in other cities, we have three codes: Full Support, Intermediate Support and Comfort Support. At our Round Rock facility we have changed the second category to INTERMEDIATE SUPPORT - ALLOW NATURAL DEATH. With this, medical procedures may be continued (vent, IV's, artificial nutrition/hydration)to see if the patient can be nudged through the illness. But if not, we ALLOW NATURAL DEATH (without coding.) Category III is called COMFORT SUPPORT - ALLOW NATURAL DEATH. Here comfort is the primary goal, and all care is aimed at that goal.

I agree that caution is in order. At our Round Rock Hospital, we are phasing in this language over a 16- month period to be certain that everyone is familiar with it and understands it. We are monitoring it to make sure it works the way we would like. The terminology, when presented to lay groups (as I did this morning to a group of elderly church women), was VERY clear to them. This was not the case with the DNR language which could allow many things to be continued, prolonging the dying process.

The Rev. Chuck Meyer was Vice President of Operations and Chaplain at St. David's Medical Center in Austin, Texas. We have been informed that Rev. Meyer passed away in an accident and are deeply saddened by the loss of such a dedicated force in the health care community.

The Hospice Patients Alliance definitely supports the creation of this new end of life care designation (A.N.D.) which is designed to increase the number of terminally ill patients who are allowed a death with dignity. A.N.D. is currently being used at the Round Rock Medical Center within the St. David's Medical Center health system. For more information on A.N.D., you may contact Chaplain Amy Donohue-Adams by phone at 512-341-6493, and by e-mail at: amy.donohueadams@stdavids.com.

All material copyright of Hospice Patients Alliance ("HPA") unless otherwise credited.