Thursday, March 5, 2009

Do Not (Attempt) Resuscitation vs. Allow Natural Death

The USA Today had a feature article this week highlighting the careful use of words to construct the order to no longer initiate CPR. (Don't miss the 170+ comments, very enlightening about how th epublic feels) The author focuses on the growth of the "Allow Natural Death" phrase as a compassionate alternative to "Do Not Resuscitate."

The prevailing medical order in the United States is "Do Not Resuscitate" and is usually abbreviated as DNR. It has been codified into law and etched in health care organization policies. The very direct nature of the command defines its usefulness. Do. Not. Resuscitate. Should be pretty clear with the precision and simplicity of the words. Some doctors would argue there are different aspects of resuscitation and a buffet approach could be approached. Chemical Code Only, Resuscitate but Do Not Intubate, Shock Only, etc. Specific changes to DNR orders should be written very clearly so as not to cause more confusion in an emergency, which is why I favor not making these changes unless absolutely necessary which is uncommon.

I first noticed the Allow Natural Death order on transfer paperwork for a hospice patient a few years ago. Never heard of it before then. What did it mean exactly as a medical order? Is morphine natural? Are antibiotics natural? Does this patient consider artificial hydration or nutrition as natural (To some that is a contradiction but others would disagree)? It left too many questions for me to consider it a helpful or accurate medical order.

I don't think I would write an order: "Make this patient's hemoglobin normal." I would need to write to transfuse a specific amount of blood and maybe specify to initiate the action when the patients hemoglobin was below a specified threshold. Ambiguity in medical orders is a situation ripe for error. For this reason medical orders regarding such momentous life and death decisions should not be ambiguous. Exactly the same reason to avoid orders such as DNR-A, DNR-B, DNR-C.

The article itself covers the pros and cons of each order very well. The proponents of Allow Natural Death orders believe it to be more compassionate and better accepted by patients and families. Anecdotal evidence to be sure but not to be ignored. But maybe the source of compassion does not come in the writing of an order but in the communication of the medical plan once the goals have been delineated. Efforts should be made to explain the medical care as defined by the goals of care set in a shared decision making situation. That would be the ideal situation.

To highlight how intrinsically the goals of care and the code status (DNR v CPR) are tied, I have begun writing the following orders as a set for any palliative care consultation and at any change in goals or code status.

Goals: Curative, Restorative, Comfort (occasionally I will use a combination of two if appropriate)
Code Status: Full Code, Do Not Attempt Resuscitation

Do any of you use the "Goals:" as a medical order or as a special section in your plan? I began doing this when doctors started jumping ship once a palliative care consult was called. This way I could alleviate their concerns the patient was still focusing on curative goals and we were following along for support. The DNR-A, B, C system seems to address this as well, but the abbreviation does not make sense, and would it really throw someone off schedule to write a few more letters for something so important?

Also, abbreviating DNR as a medical order is a shortcut that does not reflect the gravity of the decision so I have recently decided to write it out every time. That is another reason why Allow Natural Death does not work as an abbreviation. Imagine the following order in a chicken scratch illegible black pen (which I have seen before)

D/C abx
AND
xfer to medical floor

Once I saw that I quickly clarified a new order.

What are your pet peeves/concerns/thoughts about DNR orders?

I am just glad that no one mentioned DNR Commies in this article!

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