The American Heart Association approved cardiopulmonary resuscitation in 1974.1 Over the years, do not resuscitate (DNR) guidelines and orders have been created in health care facilities and vetted through ethics committees to ensure ethical soundness. Despite good intentions, a difficult topic was created for patients, families, and providers. Part of that difficulty is how the topic is approached and the language that follows. The phrase do not resuscitate has a negative connotation, implying "something" is not going to be done.2 Some individuals may interpret this as abandoning care or stopping care altogether, but, as we know, it means that no resuscitation will be done if a cardiac arrest occurs.
Health care providers are dealing with the clinical aspect of this issue while the family is dealing with the emotional aspect. "Regardless of how much time and energy we spend explaining DNR orders to families, often all they hear is the 'not' in 'do not resuscitate.'"3 This creates a dichotomy in thought processing and decision making through (1) the perception of having to give permission to terminate their loved one's life or (2) causing a feeling of reluctance to agree to the order because they feel guilty that they are not helping their loved one as they feel they should.3
The late Rev Chuck Meyer,3 a nationally recognized expert on ethics and issues surrounding death and dying, introduced an alternative to DNR in 2000.4 According to Meyer,4 "allow natural death" (AND) is meant to ensure that only comfort measures are provided. The order may include the withdrawal of nutrition and hydration. By using the term allow natural death, clinicians are acknowledging that the person is dying and that everything is being done for the patient that would allow the dying process to occur as comfortably as possible, preventing unintentional pain and simply allowing a natural death.3,4 As mentioned earlier, how this topic is approached with families and the language used have great influence, as using less threatening and more descriptive terminology may help with acceptance and interpretation; AND eliminates interpretation difficulties resulting from phrasing the order in the negative using "do not."5 In addition to reducing misunderstanding by eliminating the term "do not," AND makes the intent of the order very clear by stating "death" in the title.5 A study by Venneman and colleagues5 tested a hypothesis with staff nurses, student nurses, and family members with no health care background. The data demonstrated that simply changing the title of the medical order from DNR to AND increased the probability of endorsement by all participants regardless of health care experience. This suggests that there would be a more positive influence of family members through their increased confidence in the AND order. The resultant decrease in tension, emotion, and conflict during consent could lead further to enhanced communication.5 With the shift from physician-focused decision making to an emphasis on patient autonomy and a cooperative model of health care, the concept of the AND order can include all stakeholders.5
This discussion has many aspects to be addressed, and this editorial is simply to stimulate thought around the terms. "As Hippocrates noted many years ago, clinicians should try to benefit patients with minimum harm. If a change in terminology can improve end-of-life care by reducing anxiety and costs, then surely such change is morally desirable."6
John J. Whitcomb, PhD, RN, CCRN, FCCM
Assistant Professor
School of Nursing
Clemson University
Clemson, South Carolina
[email protected]
Dr Whitcomb is a reviewer of manuscripts for Dimensions of Critical Care Nursing.
Nancy Ewing, MS, RN, ACNS-BC
Adult-Gerontology
Clinical Nurse Specialist
Faculty, School of Nursing
Clemson University
Clemson, South Carolina
[email protected]
References