Compassionate, informed advice about healthcare decision making

Archive for May, 2013

DNR vs. AND—AND Wins!

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You know what is curious to me? Why is there STILL so much discussion in the medical community about discussing CPR with patients and families?

CPR has been around for over 50 years. We know many situations where it offers no medical benefit, yet we continue to do research on how to talk to patients and, mostly, their families.

Death-and-death decisions

I know. I am a chaplain and am not a physician who has to face these families daily with such discussions. I do feel for the docs sitting across from distraught and conflicted families who have to make such “life-and-death decisions.” Of course, in many cases, these are really “death-and-death decisions” because. in some cases, we know ahead of time when CPR will not work. So the conversation is really about what is going to be done to the patient as they die knowing that CPR will not save their life.

Thirty-nine years ago JAMA published guidelines on the use of CPR. Under the ethics section (1) we find this:

“The purpose of cardiopulmonary resuscitation is the prevention of sudden, unexpected death. Cardiopulmonary resuscitation is not indicated in certain situations, such as in cases of terminal irreversible illness where death is not unexpected or where prolonged cardiac arrest dictates the futility of resuscitation efforts. Resuscitation in these circumstances may represent a positive violation of the individual’s right to die with dignity.”

Did that memo get out? Well, it did but it got buried under the memos on how to do CPR and the one that said 15% of all hospital patients who receive CPR survive to be discharged. For the general public, the issue got warped by the fact that the CPR success rate on the TV show Rescue 911 was 100%. Nowhere close to reality but convincing enough to the lay person that “maybe we should try it on granny.” As seen on TV.

Terms used to withhold CPR … greatly influence the decision.

Now a new study from the medical publication Critical Care Medicine suggests that the terms used to withhold CPR and information a physician shares with a family member greatly influence the decision. The researchers found that if the physician told a family “most people decline CPR in a situation similar to your mother’s” then most family members declined the procedure. Conversely, if the doc said “most chose CPR” then the majority wanted the procedure. In other words, most people want to feel they are in the majority.

The other interesting finding has to do with how the order to withhold treatment is worded. DNR, for Do Not Resuscitate, has been the norm in most healthcare facilities. It implies withholding a possible life-saving treatment. So, for many, it has a negative connotation. But when no more that 15% of patients, on average, are going to be successfully resuscitated, hardly is the decision between resuscitation and no resuscitation. It is between resuscitation attempts and no resuscitation attempts.

“Allow Natural Death” just sounds so much more gentle

The researchers had the “physician” on a video in the study call the order “Allow Natural Death” (AND). When the order was called DNR, 61% wanted CPR attempted but when it was termed AND, only 49% opted for resuscitation attempts. “Allow Natural Death” just sounds so much more gentle, in my view. The family is not made to feel they are withholding anything but letting the natural course of event move forward.

I was put on to this both from an article in Time Magazine and from Paula Span’s always thoughtful blog in the New York Times, “The New Old Age.” She titled her article “DNR by Another Name.”  Indeed just that subtle change of wording helps families choose a more compassionate death for their dying loved one.

When I started my work as a nursing home chaplain in 1983 we reviewed the charts of all 200 residents under our care. Only 17 had any sort of advance directive or physician’s order regarding end-of-life care. This was a family-owned stand alone long term care facility. With little direction from the outside, the administration and medical director chose the term “No CPR” to indicated how to treat a patient if their heart or breathing stopped. It was so honest because it said exactly what we were not going to do for a dying patient. No illusion about resuscitation implied in the DNR order.

This is where I cut my teeth considering heroic measures. I am so grateful to Pat Smith, RN, Administrator, and Beth Kleb, RN, Director of Nursing, for showing me that compassionate end-of-life care did not have to include CPR. Nurses know this stuff.

1. National Conference on Standards for CPR and Emergency Cardiac Care.  “Standards for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiac Care (ECC)” JAMA, Vol 227, No. 7, Feb. 18, 1974.



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