Monday, March 23, 2009

DNR and AND Orders: How Not to Do Too Much

Last week one of the administrators in my hospital came to my office. The topic: was it appropriate for a particular patient to have written a “Do Not Resuscitate” or “DNR” order? And, if such an order were written, should that affect the plan for care for the patient in question?

That isn’t an unusual question in health care, nor in my practice. Until recently I had been for years the Chair of our hospital’s Ethics Committee, and I still serve on it. I also provide education for nursing staff on Health Care Treatment Directives, Durable Powers of Attorney for Health Care, and Do Not Resuscitate orders, and how our policies direct their use.

And in fact the issue was already bouncing around in my mind. I had recently run across an online article from USA Today, titled “'Do not resuscitate' vs. 'allow natural death'” There has been discussion for some time in health care about changing the phrase “Do Not Resuscitate” to “Allow Natural Death.” The USA Today article discussed the topic, especially in light of research published last year suggesting that, all other things being equal, families and perhaps patients themselves would be more comfortable making a difficult decision at the end of life if the decision was phrased as “allowing natural death” instead of “withholding resuscitation.”

The research article, “’Allow natural death’ vs. ‘do not resuscitate:’ three words that can change a life,” was published in January of last year (Venneman et al, Journal of Medical Ethics, 34 (1), pp. 2-6). The authors were themselves interested in this question. They noted that words are emotionally laden, and some phrases more laden than others. They also noted that people made decisions differently under emotional stress than when not under stress. Their central concerns were that the phrase, “do not resuscitate,” being stated in the negative (“do not”) could be heard as threatening in tone, and that those hearing it as threatening would make decisions about a patient’s health care based on the emotional reaction instead of on a clear discussion of the patient’s needs and the limitations of medical care.

So, to check this out they put together a study. They decided to put together a survey. They also wondered whether it would make a difference how much education and experience one had relevant to DNR orders. They thought, too, that nurses should be considered because in actual events nurses are very much involved in carrying out DNR orders, and in discussing them with and explaining them to families. So, they surveyed three groups to consider different levels of experience: experienced nurses in practice; nursing students; and a non-nursing control group. Each participant was given a written scenario about a near-death experience, which included definitions of the medical terminology in the scenario. They were asked to consider the scenario as for a member of the participant’s family. They were then asked to mark an analogue scale (0 to 100%) as to the probability that the participant would consent either to a “Do Not Resuscitate” order or an “Allow Natural Death” order. They also recorded some demographic information about participants.

The results of the study were that in all three groups participants were more likely to consent for a loved one to an order of “Allow Natural Death” than to an order of “Do Not Resuscitate.” There was also a difference according to levels of education and experience. While experienced nurses, those most likely to understand the orders in either form, were more likely to agree to AND than to DNR, the difference was not great. However, among both nursing students and the non-nursing control group the difference was significant; and more significant among the non-nursing control group than among the nursing students. They also noted that demographic “variables of gender, ethnicity and religious affiliation did not significantly impact endorsement. AND was statistically more likely to be endorsed even controlling for these variables.”

In their conclusion Venneman et al stated, “Increased support of the order through changing the title [from DNR to AND] should decrease tension and conflict during the consent. This would result in decreased emotion and therefore enhanced communication.” They also suggested, “Using the term AND should help eliminate difficulties in interpretation resulting from phrasing the directive in the negative “do not” and decrease negative semantic reaction, allowing all involved parties to focus the actual outcome of the order.”

This article did stimulate a response article. The article, titled “’Allow Natural Death’ is not equivalent to ‘do not resuscitate’: a response,” was published in December, 2008 (Chen and Youngner, Journal of Medical Ethics, 34 (12), pp. 887-888). Drs. Chen and Youngner challenged both assumptions and conclusions of Venneman et al. They suggest that, while DNR might be “more negative” than AND, the precipitating situation is not: the limits of what medicine can do are being reached. At that point they suggest that understanding and communications are less dependent on emotion-laden terms than on clear communication in discussion with physicians.

They also suggest that AND may not be less confusing than DNR in that AND is focused on a specific, expected, and unavoidable result: the patient’s death. DNR, on the other hand, may be appropriate if a patient would not want the rigorous efforts of chest compressions and electric shock in the event of an arrest, but who still has the possibility of some therapeutic or palliative benefit. Thus, a DNR order does not automatically imply that a patient is terminal, much less that the plan of care is for comfort measures only. However, they point to studies that suggest that “healthcare professionals tend to provide less medical care to DNR patients than to those patients without DNR orders.” So, while DNR and AND are not really interchangeable, there may be a tendency for healthcare professionals to act as if DNR were in fact AND. If so, providers might not discuss with patients and/or families the full range of possible treatments and their respective benefits and risks.

Finally, Chen and Youngner challenge the interpretation of the results of the survey. Specifically, they note that among the practicing nurses the difference of choice between DNR and AND was not significant. Thus, they question whether there is really a desire among practicing professionals (either the practicing nurses who were surveyed, or among doctors, who were not) to replace DNR with AND.

As a chaplain I have been aware for some time of the discussion about changing from DNR orders to AND orders. That desire has certainly come from a concern among chaplains, and others, that families may not hear clearly, and certainly have trouble accepting, when the therapeutic limits of medicine have been reached. In that instance, would it be clearer to present as appropriate the decision to “allow natural death?” If death is unavoidable, it might well be more appropriate, independent of the thought that it might be easier to hear and accept.

When thought through, it becomes clear that the two terms are not really interchangeable; and the differences can be important. Venneman et al are certainly correct in noting that the DNR and AND are semantically different; but they may not make clear just how different they are. Chen and Youngner are correct in noting that AND is focused on, and indeed is explicit about, an unavoidable death. Yet, in the circumstances of a hospital just how “natural” is such a death? In fact care does not end at that point. Instead, it changes. While therapeutic benefit – curing, healing – might no longer be possible, care continues for palliative benefit. Death, then, may well not be “natural” in the sense that things don’t just stop; but it may well be better than “natural” in that the resources of care continue, with the intent changed to preserving comfort.

On the other hand, “do not resuscitate” certainly is a “negative” order. As my Best Beloved observed as we discussed it, it implies that resuscitation is normative, and the new order not to resuscitate is the exception. If therapeutic benefit is still the goal of care, an exceptional event might justify an exceptional order. So, an elderly patient might well hope the orthopedic surgery will be successful, and still not want heroic measures if in the process the patient suffers a massive stroke. At the same time, death is normative, sooner or later. Yet, without good communication from the physician(s) that there’s no therapeutic benefit left to offer, how is a patient and/or family to accept the “exceptional” order?

Moreover, in so many cases aggressive resuscitation is the last thing that professionals want to inflict; and I use the word “inflict” advisedly. Chest compressions can and do break fragile ribs, and too often pierce lungs. Electric shock is a visible physical shock to the body. In the situation where best medical advice is that it will not succeed, doctors and nurses don’t want to do CPR under the rubric of “first, do no harm.” Doctors will frequently press a family for a DNR order, even when the family has not yet understood that we’ve reached the limits of medicine, simply to avoid treating the patient in a way the professionals see as explicitly harmful.


Anonymous said...

I am a Registered Nurse. I work primarily in ER/ICU. I have 2 comments.

First, yes, every day I see the quality of care change when a physician or nurse learns a patient has a DNR order. It's sad. To me a DNR order means that if all else fails, allow me to die without tubes or defibrillation. What I see in practice is DNR seems to mean 'do not treat' and this is wrong. If you've come to the hospital you must want something. We need to ask more questions.

When faced with asking the 'DNR' question of patients and/or their families, I ask "do you want to be allowed to die naturally or do you wish to be placed on a ventilator ect." Everyone wants to die naturally but they tell me what they want done first. Some want to be intubated and if that doesn't work, take them off and allow them to die naturally. Others don't want any tubes at all but want medication. I've found it to be a better way to discuss the options. It opens the door to allow people to say what they really want.

fading nurse.

Marshall Scott said...

fading nurse:

Thanks for your comments I appreciate what you're saying about listening to the patients and their families. All too often, the conversation seems to get shortchanged. For example, in my experience when someone says, "Of course I want them to do everything," what the person means is "everything helpful." That is, they don't mean to include things that won't benefit the patient; but they assume that goes without saying. Our concept of "everything" is far wider than theirs, usually; and they do expect us to exercise discretion. If we can tell them what we think will be helpful and what won't, they usually concur. It's just so hard sometimes to get the professionals to take the time.