Monday, September 29, 2008

Do Not Resuscitate Color Confusion

Image representing The New York Times as depic...The New York Times featured an article on color-coded bracelets for quick communication of vital health information. (Also noted on NYT Health Blog w/ comments.) Recent efforts by states to coordinate the bracelet colors of allergy (red), at risk limb (pink), fall risk (yellow) and do not resuscitate (purple) have hopefully decreased confusion for employees who may have recently worked at another institution with a different color scheme.

Apparently* in 2005, a nurse mistook yellow for DNR when it meant restricted limb and a patient nearly died. (*I could not find any news record of this case but the New York Times describes it as notorious. Yes, we sometimes do our own primary research.)

Some of the concern with this new push for standardization is the not-new worry that patients don't want to see DNR on their wrist band, nor do their families.

The nation’s leading hospital-accreditation agency, known as the Joint Commission, has expressed caution about the new system, citing concerns about branding patients by their end-of-life choices, or inadvertently broadcasting those choices to family and friends who have not been consulted. The commission also said that children who do not understand the system had been prone to trade the wristbands like baseball cards.
The branding of patients is a somewhat valid issue but as the article later states most patients are willing to talk openly about their decisions. The article describes them as being proud of their choice. It may be those staff or family who are uncomfortable with the DNR that feel paternal and want to protect the patient by avoiding subtle reminders of what the patient lives on a daily basis. The 'kid swapping bracelet issue' is easily solved by making sure they are on tight enough.

Another interesting quote:

In Arizona, one hospital embossed its purple bracelets with a white dove carrying an olive branch, rather than D.N.R., while another chose the initials A.N.D., for “allow natural death,” as a gentler alternative. Kim Miyauchi, associate nursing director at Kingman Regional Medical Center, the Arizona hospital that uses the white dove, said officials there worried that wearing the initials D.N.R. on one’s wrist was “a little bit harsh,” and also failed to convey nuances best captured in a medical chart, as with a patient who wants medication for heart failure but not to be shocked by a defibrillator. “Sometimes people want varying levels of treatment at the end of life,” she explained. “Sometimes it’s not so clean as just don’t do anything.” (italics mine)
As Drew has said before being ill and dying is not an easy time, so pretending that a change of words or letters may make someone feel less sad diminishes the impact of what caring staff can overcome. Do Not Resuscitate** is explicit in what it sets out to do. Allow Natural Death (AND) could mean a whole number of things, and once it becomes de rigueur, people will be clamoring for another terminology change. And AND resembles 'and' which is a conjunction and can canfound confound a plan. I have seen doctors write "AND" as an order but I truly think this causes more confusion unless there is a set policy about what this means at one's hospital.

The last quote is an important one since it perpetuates one of the biggest stereotypes of hospice and palliative medicine. My job description does not include 'do nothing' for my patients. A whole medical specialty like palliative medicine can not be constructed around 'doing nothing.' Communication, education, symptom control, conserving dignity, advocacy, coordination of care, and so on and so on.

To address the nuances of end-of-life decision making compasisonate conversations followed by clear legible documentation of wishes and goals, followed by clear detailed orders in the medical record is the best solution. A bracelet is a shortcut, and shortcuts have risks but in an emergency this could be vital information to signal a clarification of the DNR order in the chart.

** And to be more explicit, some advocate for Do Not Attempt Resuscitation since outcomes are by no means guaranteed for a survival after the initial resuscitation.
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