Allow Natural Death Do Not Resuscitate Orders

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					     Allow Natural Death: “Do Not Resuscitate” Orders
                                                            Kathryn A. Koch, MD

Abstract: Limitation of treatment decisions remain problematic despite        Illusion of Efficacy of CPR
both ethical and legislative endorsement of the patient’s right to choose a      Dying can be quite complicated, whether one chooses to
course of treatment. There is broad variation in public knowledge and         fight until the bitter end, regardless of pain and suffering,
attitudes about what is and is not possible at the margin between life and    or whether one chooses a path with different goals, hope-
death. There is an illusion of efficacy of cardiopulmonary resuscitation      ful for palliation and comfort. And therein lies the rub. As
(CPR). Originally proposed for witnessed collapse of circulation in the       a multicultural society fascinated with life and in denial of
Operating Room, CPR is now applied regardless of the circumstances            death, permitting a death to occur naturally is suspect and
through a presumption of consent. Do Not Resuscitate (DNR) orders             out of character.
occupy a unique niche in medical orders. They are orders to withhold
that specific intervention. Discussing the option not to resuscitate or         Outcome of cardiopulmonary resuscitation (CPR) is er-
to limit treatment can be difficult for patient, family, and caregiver        roneously, but commonly, held to be good by the lay public.
alike. If patients are unable to make their own decisions, a proxy or         Some blame this disconnect on television. In a review of all
surrogate decision-maker needs to be identified which adds another level      episodes of the television programs ER and Chicago Hope
of complexity, particularly if the patients never discussed their wishes      during the 1994-1995 season, and 50 consecutive episodes of
with their surrogate. Some practical suggestions are made to facilitate       Rescue 911 broadcasts over a 3 month period in 1995, 75% of
communication about these difficult choices. It must be clear that a          patients survived the immediate arrest, and 67% apparently
DNR order by itself is not an order to withhold other treatments and          survived to hospital discharge.8 The majority of these patients
is not a death sentence. It is a choice for dignity, respect, and comfort     were victims of trauma and were young.
if other treatments fail.                                                        The Europeans have also examined this question. The
                                                                              outcomes of cardiac arrest in 70 episodes of Spoed (a popular
Introduction: Oscar the Cat                                                   Flemish medical drama in Belgium) were more realistic,
   The schizophrenic quality of unrealistic expectations in                   more age-appropriate, and only 19% of patients survived
treatment of death and dying was exemplified by the media                     the resuscitation attempt.9 The authors postulated that any
reports in the last week of July, 2007. Oscar’s (a cat) activities            impressive examples of success might be more important to
were published in the New England Journal of Medicine and                     the lay public imagination than overall success rate. They
quickly became national news.1,2 Oscar accurately predicted                   also proposed that television depiction of cardiopulmonary
25 deaths (which took place within the next 4 hours) at a                     resuscitation, which demonstrates that treatment does not
nursing home in Providence, Rhode Island. Making his own                      stop simply because the patient is dead, supports the “illu-
independent rounds, he identified patients who will die shortly               sion of efficacy”. Otherwise, why would this treatment be
by laying down with them. This behavior is now viewed by                      given at all? Upon review of 64 episodes of three popular
the staff as a sign to notify family to assemble. Joan Teno, a                British medical dramas, Casualty, Cardiac Arrest, and Med-
member of the SUPPORT investigator group and who treats                       ics, only 62% of victims of full cardiac arrest underwent
patients at that nursing home, was reported to say that Oscar                 CPR, and only 8 attempts were successful.10 These authors
was better at predicting death than staff. 2,3                                concluded that widespread public optimism for resuscitation
                                                                              outcome was not based on the fairly realistic depiction seen
  Oscar’s activities hit prime time. He made it into Jay Leno’s               on British television.
nightly monologue. He even was mentioned on the NBC
Nightly News. An email about Oscar was quoted by Bryan                           Yet, inappropriate optimism does seem to exist. In a random
                                                                              distribution of 400 surveys to 8 North Carolina church con-
Williams that said, “Has anyone considered the possibility
                                                                              gregations, almost all of the 269 respondents had unrealistic
that Oscar is killing those patients?” 4
                                                                              expectations of outcome of CPR. As a group they indicated
   In addition, two accompanying “perspective” articles in that               an expected survival rate of 65% for CPR, with younger re-
issue of the Journal reviewed factors that contribute to late                 spondents as a group reporting a higher probability of good
referral and possibly under-utilization of hospice services. 5,6              outcome; television exposure for older respondents was also
                                                                              associated with expectation of better outcome.11 In a random
   That same contrary week had begun with a front-page                        sample of 820 Belgian secondary students, the consumption
article in Newsweek with the headline: “This Man Was Dead.                    of medical television drama was related to an overestimation
He Isn’t Anymore. How Science is Bringing more Heart-At-                      of survival outcome following CPR.12
tack Victims Back to Life”.7 In this lay public discussion of
inducing hypothermia in victims of post-cardiac arrest to                        A survey of 100 patients 70 years of age or older revealed
improve neurologic outcome, the most accurate statement                       that 81 respondents (81%) believed that the chance of sur-
by the authors was that “Dying turns out to be almost as                      viving in–hospital CPR and leaving the hospital alive was at
                                                                              least 50%, and a quarter (23%) of those respondents expected
complicated as living”.7
                                                                              their outcome to be at least 90% probability of survival to
                                                                              hospital discharge.13 The largest proportion of these patients
                                                                              received information affecting their decision from the tele-
Address Correspondence to: Kathryn A. Koch, MD, University of                 vision as opposed to other sources, such as their physician.
Florida, Shands-Jacksonville. Email: kathryn.koch@jax.ufl.edu.                The clinician familiar with the patient’s specific medical


www . DCMS online . org                                                              Northeast Florida Medicine Supplement January 2008 13
situation, would be the ideal person to educate the patient,                  Table 1 Practical Suggestions in
but finding the time to identify and clear up disinformation                          Discussing DNR Decisions
is itself problematic.
   Another level of potential confusion about DNR orders             •    Educate to dispel inappropriate optimism
occurs when patients (or their families) are offered menu
choices in treatment indiscriminately. This is best exemplified      •    Offer options which may include limitation of treatment
by the patient who refuses intubation and mechanical ventila-             and should include discussion of circumstances where
tion should he/she fail other interventions, yet requests full            limitation would be appropriate
cardiac resuscitation. Such individuals may not understand
that refractory respiratory insufficiency is likely to lead to       •    Do not offer menu choices without education, address
cardiac arrest. This predictable series of physiologic events             goals of treatment, and then show how goals affect specific
must be discussed. If the patient doesn’t receive intubation              choices
and mechanical ventilation to prevent that deterioration,
what physiologic purpose is there to resuscitation when              •    Be specific about what treatment will be held, what treat-
                                                                          ment will be given. Differentiate this decision from a “Pull
the heart can’t take it any more? Patients or their families
                                                                          the Plug” decision. Detail discussion in writing in chart.
requesting such an order require time for further explanation             Be sure orders are clear
and education. Their decision is not well informed and their
expectations are unrealistic.                                        •    When discussing decision with a proxy or surrogate, focus
   A more realistic decision would be to attempt intubation               on what would be the patient’s choice and what would be
to prevent death if possible, but if death still occurs, then             in the patient’s best interest
withhold cardiac resuscitation. Address the goals of treat-
                                                                     •    Develop a plan to communicate decision to other family members
ment, what is possible and what is not given the medical                  and to other caregivers (consider outpatient DNR order)
circumstances and available treatment, how the goals can or
cannot be achieved, and then describe what choices on the
menu of options match those goals best (Table 1).                          Table 2 Problems in Establishing &
                                                                                   Maintaining DNR Decisions
DNR Orders are Unique
  DNR orders are a unique phenomenon in that they are
orders not to intervene, or not to take action: a “negative” or     •    Lay public illusion of efficacy of CPR
“passive” order set. Most medical orders are direction to take
some action and thus “positive” or “active”. Unless a DNR           •    Unique niche in medical orders as an order to withhold
order is written, consent for resuscitation is presumed.
                                                                    •    Presumed consent for resuscitation
   There are good medical grounds for such an attitude.
The patient has collapsed and is unable to make decisions           •    The margin of the DNR order can easily become blurred.
to consent or object to treatment. Prompt action optimizes               There are concerns that other treatment will be withheld
outcome. The longer action is delayed, the longer the patient’s
hypoxia time, the greater opportunity for accumulation of           •    Failure to address end of life issues with the patient while
                                                                         he/she is still able to make their own decisions
toxic metabolites. If delayed action is successful at returning
spontaneous circulation, survivors are at greater risk for nega-    •    Identification of decision-maker for the patient who lacks
tive consequences of reperfusion injury.                                 decisional capacity
   The greatest risk is to brain recovery, thus the exploration
of post-resuscitation interventions to improve neurologic           •    Failure to communicate chosen level of care within family
outcome.7,14,15 Death is clearly a process rather than an event,         and among caregivers over time
given our current medical knowledge and capability. Act now or
it may be too late — the fate resulting from delay might even      is to be held (or given). The intent of a DNR order is to limit
be worse than death. Dying is as complicated as living.7           aggression at the margin between life and death, particularly
   The presumption of consent for resuscitation was confirmed      where aggressive measures have already failed (or will probably
by the 1983 President’s Commission.16 The State of Florida         fail) to prevent deterioration to the events of death.
requires a stated objection to a standard medical intervention,       DNR is a “negative” statement. Reverend Chuck Meyer
if the provider acts as any reasonably prudent person would        from Texas proposed the terminology of “Allow Natural Death”
have acted under same or similar circumstances.17                  (AND) as a more positive and more comforting expression of
  Thus, CPR has become a standard of care. It can be imple-        the same decision.18 Empirical report from Kentucky where
mented by any bystander, ideally as quickly as possible. See       some institutions have adopted this alternative wording has
                                                                   been positive.19 Some are convinced that use of “AND” as
Table 2 for some practical problems in not providing CPR.
                                                                   opposed to “DNR” as terminology can help change the
DNR Order Does Not Limit Other Treatment                           experience of making decisions about facing death in a very
   One of the practical problems in establishing a DNR order       positive way.20 The challenge is that the expression “AND”
is achieving the mutual understanding that a DNR order is          is less explicit and more vague than “DNR”, thus even more
neither a “Do Not Treat” nor a “Comfort Measures Only”             likely to mislead.21
order. It is a “No CPR” order – a “Do Not Allow Resuscitation”       Be aware that some individuals do not understand that
order – ideally with clear direction as to what “resuscitation”    interventions like dialysis and mechanical ventilation are

14 January 2008 Northeast Florida Medicine Supplement                                                          www . DCMS online . org
“life support”. Also recognize that some individuals believe                 Table 3 Ethical Principles Informing
that because a patient is on “life support”, he/she cannot die.                      End of Life Decisions
Minimize confusion about the plan by careful documentation
in the medical record.
                                                                      “Full Code”
Proxy/Surrogate Decision-makers                                        • Respect for life
    Another practical problem with establishing a DNR order            • Beneficence: Of course, our goal is to preserve life
                                                                       • Non-Malefience: It would be a harm to die
is that the decision-maker may not be the patient. This person         • Autonomy: Of course, patient would want to live
may view a DNR decision as a decision to “pull the plug”. To
this end, a separate form for termination of treatment may be         DNR
useful. The DNR decision and the “pull the plug” decision             •   Respect for persons
must be distinguished; the latter not possible until the former       •   Beneficence: If we are not able to preserve life,
has already been decided. The surrogate should be reminded                then it would be good to minimize the suffering
by the clinician that their job and responsibility is to make         •   Non-maleficence: If the treatment is worse than
the decision the way they think the patient would choose                  the disease, then it has become a harm
or in a way that would meet the patient’s best interest given         •   Autonomy: Would the patient choose to fight
the circumstances. To facilitate the decision, help the family            regardless of suffering, or let go
members imagine an empty seat at the table or in the room
for the patient to be present, at least in spirit.                   concerned about full clarity, consider reviewing the resulting
   The ethical principle of respect for persons informs a DNR        written order carefully with the decision-maker. This will make
decision and the principle of respect for life informs a “full       as certain as possible that there is true mutual understanding
code” decision. The principles of beneficence, nonmaleficence,       about what will or will not be done in an emergency, and
and autonomy could each be in favor of either decision,              what will or will not be done in the meantime.
depending on the circumstances (Table 3). Acknowledge                  As in any situation where the physician is informing the
that you know they do not want to lose their loved one.              patient of options so he/she can make an intelligent decision
Offer a limitation to aggressiveness as an option when other         among potential choices, any consideration about allowing
treatment is failing or is likely to fail. If the situation is one   natural death requires a discussion of comfort and caring at
where dying and suffering are being prolonged and there is no        the end of life. Palliative care, hospice, and/or chaplain con-
realistic expectation that the patient can recover to functional     sultation may all be beneficial. Patients may be concerned that
independence, offer to adjust treatment to a primary goal of         they not suffer, that they be as independent as possible for as
comfort. Offer to ensure that the loved one is treated with          long as possible, and that we will share those goals.
respect as they die.
                                                                     Communication of Decisions on Level of Care
Raising End of Life Issues with Patient                                 The issue of communication about level of care, or “code
   The biggest practical problem with DNR orders is the fail-        status”, between patient/family and multiple caregivers over
ure to raise end of life issues with patients and explore all of     time is one that has not been effectively solved. Institutions
their options, when a diagnosis is made. Options to address          are required to enquire about advance directives on admis-
might include comfort measures in addition to treatments             sion, but an advance directive is not a DNR order itself. A
intended to cure or to at least palliate. The timing ideally         DNR order at one institution may not be considered valid
ought to be when the patient is well enough to think clearly         at another, a prior DNR order on one admission may not be
and certainly should be prompted by recognition of medical           considered durable for the next.
circumstances which predict a poor outcome. Limitation of
aggressive medical interventions should be considered if the            Discharge planning for a patient who was DNR during
clinician can imagine that the patient will be dead within           a hospitalization should include planning about code status
the next 6-12 months.                                                after discharge. In the State of Florida, there is a specific order
                                                                     for outpatient DNR (DNRO) which can be implemented if
  The SUPPORT study showed clearly that we do not pay                desired.25 At the author’s institution, this is the only order
good attention to matching patient preferences to predicted          that is considered durable from one admission to the next.
medical outcomes.22 This requires a frank discussion of              In the absence of a DNRO, complete reevaluation of level of
death and the end of life and should be initiated when the           care and code status must be made if the patient returns to
patient is still well enough to consider how he/she wishes           the hospital. He/she will be assumed to be “full code” until
to face the situation. The objective is to optimize quality of       the issue can be revisited.
remaining life, to help the patient choose new goals. It’s not
about losing hope, it’s about changing what to hope for. A              Advance communication about code status ought to
practical tool is the CARING criteria, developed to identify         minimize confusion and concern, but this is problematic.
patients on hospital admission with whom to address end              Only 13/209 (6.2%) metastatic cancer patients referred for
of life (EOL) issues, who might benefit from a palliative            outpatient palliative radiation treatment had documented
approach to care. 23,24 (Table 4, p.16)                              reference to their code status on referral.26 A retrospec-
                                                                     tive review of 392 cardiac arrest 9-1-1 calls to Emergency
   It is within this context that terms such as “allowing nature     Medical Services in Seattle revealed that 139 (35%) residents
to take its course” or “allowing natural death” may be useful        had DNR orders, and 29 (21%) of these patients actually
during dialogue. Whatever terms are used, it should be ex-           received resuscitation due to problems in communication of
plicit what will and will not be done. If the clinician is at all    the DNR orders.27

www . DCMS online . org                                                     Northeast Florida Medicine Supplement January 2008 15
                      Table 4 CARING24                                      the OR was exactly what Kouwenhoven had in mind when he
                                                                            first published on closed chest cardiac massage.34 The policy
                                                                            on this issue has been established. The American Society of
 C: Primary diagnosis of cancer                                             Anesthesiologists in conjunction with the American College of
                                                                            Surgeons formalized the policy of “required reconsideration”
 A: Two admissions for chronic illness in the past year                     with guidelines initially approved in 1993.35
 R: Resident in nursing home                                                   DNR orders will not be automatically rescinded for a trip
 I: Intensive care unit admission with multi-organ dysfunction              to the OR, although the patient/surrogate may choose that
                                                                            as an option. An alternative option is to leave the DNR order
 N: Noncancer hospice patient with 2 or more hospice criteria               in place with a clear outline of goals and objectives of said
 G: Refer to hospice guidelines/NHPCO                                       operation or with a detailed list of procedures and interven-
     (Table adapted from information National Hospice and Palliative Care
                                                                            tions that are permitted (or refused). A solution to the level
                     Organization website/www.nhpco.rog)                    of treatment that is both patient-specific and situation-spe-
                                                                            cific needs to be sought.36 See Table 5 for some practical
                                                                            tools in such difficult discussions. It has been proposed that
   Unless the patient personally instructs the clinician about              continuation of a DNR order into the OR is analogous to
their DNR status, in the State of Florida the patient must be               performing surgery on Jehovah’s Witnesses who have refused
found by 2 physicians to be end stage or terminal and un-                   a life-saving transfusion.37
able to make his/her own decisions (and unlikely to recover
that ability in the future), and the family must concur that
limitation of treatment is appropriate, before a DNR order                    Table 5 Tools & Tips for Difficult Discussions
can be recorded.28 This leads to problems when patients ar-
rive in extremis unable to make their own decisions, little is
known by available caregivers about them, and no family or                   •    Set an appointment with patient or decision-maker and
other knowledgeable caregiver can be contacted immediately.                       any folks they wish to also be present
Implementing this process in a medical emergency is difficult,
which may lead to treatment against the patient’s previously                 •    Block the time to talk without interruption
stated wishes. An informatics mechanism using a computer-
ized search for keywords in prior hospital dictated reports is               •    Select meeting location for privacy
theoretically possible to help identify patients with prior DNR
orders on previous admissions.29 The DNRO could also be                      •    Bring another caregiver, such as a nurse, to witness and to
                                                                                  help confirm there is mutual understanding
used as a vehicle to notify about such wishes from admission
to admission and caregiver to caregiver.                                     •    Be prepared to listen
   In the absence of discoverable family or friends willing to
step forward as proxy decision-maker, the State of Florida has               •    Identify the decision-maker if you don’t already know.
established a mechanism to appoint a proxy to speak for the un-                   Introduce everybody
friended patient who is unable to make his own decisions.28
                                                                             •    Fire a “warning shot”, eg: “We have a difficult situation to
DNR: A Death Sentence?                                                            face….”
   In reviewing the outcome of patients who become DNR
                                                                             •    Start the conversation by asking what they already know
after admission to an ICU service, it was discovered that
                                                                                  so you can clear up any misinformation up front
most died during that hospitalization, but that the DNR
decision was not a death sentence. Some patients were even                   •    State medical facts of situation in simple terms
discharged alive.30 However, a retrospective review of 13,337
consecutive stroke admissions at 30 hospitals, revealed that the             •    Be prepared to face tears and even anger
2,898 (22%) of patients who had DNR orders established at
any time during their hospitalization had a higher propensity                •    If the patient is making their own decision, the rest of the
adjusted rate of death than those who had no such orders.31                       family is there to support them in that decision
Some oncologists have voiced a concern that some patients
may die because they have DNR orders, as opposed to having                   •    If there is another decision-maker, remind them that their
a DNR order established in anticipation of death.32                               job is to try to make the decision the way they think the
                                                                                  patient would want it made
   Patients may even choose to not limit treatment because
they are concerned that this choice may limit other aspects                  •    Seek a decision on goals in medical treatment and then
of their treatment; that they will be treated differently.33                      confirm the medical treatments that would be included to
It must be very clear that a DNR order by itself does not                         attempt to achieve those goals
limit treatment in any other way. Whenever a DNR order is
established, concerns about how to handle other aspects of                  Conclusion
aggressive care should be addressed.                                           Lack of comprehension of the risks and benefits of attempted
                                                                            resuscitation are overshadowed by inappropriate optimism
  This issue is best exemplified over the issue of DNR in                   that independent survival will be the outcome of any attempt.
the Operating Room (OR). DNR patients may be potential                      This misunderstanding, if uncorrected, may contribute to
candidates for certain surgical procedures, particularly                    confusion. Persons who hold such erroneous beliefs need
palliative interventions. Resuscitation for witnessed arrest in             more education to make a fully informed decision but, in fact,

16 January 2008 Northeast Florida Medicine Supplement                                                                   www . DCMS online . org
DNR decisions are made in the absence of better knowledge                     Advance Directives, and Title XLV on Medical Malpractice,
all of the time.                                                              Chapter 766 on Medical Consent, and Chapter 768 on
                                                                              Negligence, part I General Provisions, section 768.13 Good
   As long as a DNR order is understood to withhold specific                  Samaritan Act. The 2007 Florida Statutes. www.leg.state.
treatment if other treatment fails, there should be no change                 fl.us/statutes/ accessed 7/31/7.
in the level of care of the patient unless additional decisions         18.   Meyer C. Allow Natural Death – An Alternative to DNR?
to reduce interventions are made.                                             www.hospicepatients.org/and.html/ accessed 7/31/7.
   As Oliver Wendell Holmes Sr. aptly said, “To cure rarely,            19.   Knox, C, Vereb JA. Allow Natural Death: A more humane
to heal sometimes, to comfort always.” Oliver Wendell Hol-                    approach to discussing end-of-life directives. J Emerg Nurs.
mes Sr. (1809-1894. US physician, poet, humorist, father                      2005;31:560-1.
of Oliver Wendell Holmes Jr the jurist, Dean of Harvard                 20.   Cohen RW. A Tale of Two Conversations. Hastings Cent Rep.
Medical School)                                                               2004;34(3):49.
                                                                        21.   Chessa, F. “Allow Natural Death” – Not so fast. Letters to
Acknowledgement: Linda Suydam for her expert editorial assistance.            the Editor. Hastings Cent Rep. 2004;34(5):4.
                                                                        22.   SUPPORT Principle Investigators. The Study to Understand
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