- Email: [email protected]
Allow Natural Death: A More Humane Approach to Discussing End-of-Life Directives
CLINICAL NOTEBOOK
Allow Natural Death: A More Humane Approach to Discussing End-of-Life Directives Authors: Crissy Knox, RN, BSN, and John A. Vereb, RN, BSN, CEN, SANE, Memphis, Ind, and Louisville, Ky Section Editor: Gail Pisarcik Lenehan, RN, EdD, FAAN
Crissy Knox, Kentuckiana Chapter, is Student, Masters in Nursing Administration Program, Indiana University, Indianapolis, Ind; and Clinical Practice Educator, Emergency Services, University of Louisville Hospital, Louisville, Ky. John A. Vereb, Kentuckiana Chapter, is Staff Nurse, Emergency Department, Baptist Hospital East, Louisville, Ky. For correspondence, write: Crissy Knox, 1115 Harvest Ridge Blvd, Memphis, IN 47143; E-mail: [email protected]. J Emerg Nurs 2005;31:560-1. 0099-1767/$30.00 Copyright n 2005 by the Emergency Nurses Association. doi: 10.1016/j.jen.2005.06.020
560
D
o not resuscitate (DNR), do not intubate (DNI), and comfort measures only (CMO) are among many terms that are all too familiar to health care professionals. Quite often, these terms are frightening for families who do not fully understand what they mean. It is not uncommon to hear family members say they do not want their loved one to have DNR status because they interpret that as meaning nothing will be done for the patient. Health care workers know that interpretation is not true but find it difficult to explain what DNR means under such circumstances. An alternative to DNR was introduced in 2000 by Reverend Chuck Meyer, a nationally recognized expert on the ethics and issues surrounding death and dying.1 According to Meyer, ‘‘Allow Natural Death’’ (AND) is meant to ensure that only comfort measures are provided. By using the term AND, clinicians are acknowledging that the person is dying and that everything is being done for the patient, including the withdrawal of nutrition and hydration, that would allow the dying process to occur as comfortably as possible. AND prevents unintentional pain and simply allows a natural death.2 Although AND status is not really different from DNR status, it is presented in a language that is more suitable for patients and families. AND orders may help families make more appropriate end-of-life decisions. To date there have been no empirical studies of its effect and no sustained analyses of its ethical implications.3 According to Meyer, AND initially was presented to approximately 100 hospitals in the United States, as well as many hospices and nursing homes.2 The AND movement seemed to slow after Reverend Meyer’s death in November 2000.1
JOURNAL OF EMERGENCY NURSING
31:6
December 2005
CLINICAL NOTEBOOK/Knox and Vereb
In 2004, Baptist Hospital East in Louisville, Kentucky, officially adopted the ‘‘allow natural death’’ language, and the Ethics Committee at the University of Louisville currently is reviewing the information, with the support of our chaplaincy. A limited number of ED nurses in the Kentuckiana area were familiar with the term AND when the hospital began this process. Interestingly, based on information gathered from a number of phone calls made to area chaplains, other hospitals in the Kentucky and southern Indiana area also are considering using the term but have not yet formally presented the concept to their staff. Baptist Hospital East in Louisville, Kentucky, has not only added the use of the AND language but also has expanded on the basics so that patients and families understand it better. According to Diane Huber, RN, the Critical Care Resource Team at Baptist Hospital East articulates 3 levels of care: (1) Full Support, which includes CPR, defibrillation, and chest compressions if necessary; (2) Conditional Support and AND, which allows the patient, family, and doctor to determine which interventions will be used to restore or maintain functions as the patient’s needs change; and (3) Comfort Support and AND, in which no CPR or chest compression will be performed if the patient experiences cardiac or respiratory arrest and health care workers will allow the patient to die naturally while providing comfort and support to both the patient and family (personal communication, Diane Huber, May 29, 2005).4 Huber believes that working with the ‘‘allow natural death’’ language has been easier and more effective and that patients seem to understand it better. Every nurse I have spoken to at Baptist Hospital East who has worked with this new wording seems to agree.
[T]he patient’s family will spend a lifetime remembering or regretting the conversations and decisions of that day. As with everything in health care, end-of-life care terminology is changing. Frank Chessa points out in his paper ‘‘A Rose by Any Other Name’’ that bad connotations have been applied to various terms throughout history and terms that are now considered not politically correct once were,
December 2005
31:6
in fact, quite politically correct.3 Chessa argues that AND eventually may be viewed as negatively as DNR.3 However, we (CK and JV) are both experienced ED nurses who have had to discuss or clarify DNR issues and have found that the AND terminology makes it easier for families to discuss end-of-life care. We believe that the change from DNR to AND is worth the effort. The terminology may change yet again, but AND may be the best conceptual description we have to offer at this point, the best way of helping those with difficult end-of -life decisions to feel a little more comfortable with the process. Emergency nurses spend a relatively brief amount of time giving explanations to families on a given day. However, the patient’s family will spend a lifetime remembering or regretting the conversations and decisions of that day. They need to be at peace with the decisions they make. The families, not the health care provider, will carry the guilt or other emotions evoked by the death of a loved one. We believe it is our duty to help ease their suffering along with the suffering of the patients, and the AND advance directive helps to do just that. Our sense is that this concept will become more common, and we believe that emergency nurses should embrace it. REFERENCES 1. Texas Association of Healthcare Volunteers, INC. Newsletter [online, Winter 2001, retrieved 29 May 2005]. Available from: URL: http://www.tahahealthvolunteers.org/outlook%20newsletters/ 2000/winter%202001/winter%202000/2001winter.htm 2. Meyer C. Allow natural death: an alternative to DNR? [online, retrieved 16 March 2005]. Available from: URL: http:// hospicepatients.org/and.html 3. Chessa F. A rose by any other name: changing terminology to inf luence choices about end of life medical care [online, 2004, retrieved 16 March 2005]. Available from: URL: http://abacus. bates.edu/acad/depts/phil/Faculty/chessa/Rose.pdf 4. Baptist Hospital East. Critical care and life support [online, retrieved 16 March 2005]. Available from: URL: http://www. baptisteast.com/critical-care-and-life-support.cfm?renderforprint=1
Send descriptions of procedures in emergency care and/or quickreference charts suitable for placing in a reference file or notebook to: Gail Pisarcik Lenehan, RN, EdD, FAAN c/o Managing Editor, 77 Rolling Ridge Rd, Amherst, MA 01002 800 900-9659, ext 4044 . [email protected]
JOURNAL OF EMERGENCY NURSING
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Allow Natural Death: A More Humane Approach to Discussing End-of-Life Directives Authors: Crissy Knox, RN, BSN, and John A. Vereb, RN, BSN, CEN, SANE, Memphis, Ind, and Louisville, Ky Section Editor: Gail Pisarcik Lenehan, RN, EdD, FAAN
Crissy Knox, Kentuckiana Chapter, is Student, Masters in Nursing Administration Program, Indiana University, Indianapolis, Ind; and Clinical Practice Educator, Emergency Services, University of Louisville Hospital, Louisville, Ky. John A. Vereb, Kentuckiana Chapter, is Staff Nurse, Emergency Department, Baptist Hospital East, Louisville, Ky. For correspondence, write: Crissy Knox, 1115 Harvest Ridge Blvd, Memphis, IN 47143; E-mail: [email protected]. J Emerg Nurs 2005;31:560-1. 0099-1767/$30.00 Copyright n 2005 by the Emergency Nurses Association. doi: 10.1016/j.jen.2005.06.020
560
D
o not resuscitate (DNR), do not intubate (DNI), and comfort measures only (CMO) are among many terms that are all too familiar to health care professionals. Quite often, these terms are frightening for families who do not fully understand what they mean. It is not uncommon to hear family members say they do not want their loved one to have DNR status because they interpret that as meaning nothing will be done for the patient. Health care workers know that interpretation is not true but find it difficult to explain what DNR means under such circumstances. An alternative to DNR was introduced in 2000 by Reverend Chuck Meyer, a nationally recognized expert on the ethics and issues surrounding death and dying.1 According to Meyer, ‘‘Allow Natural Death’’ (AND) is meant to ensure that only comfort measures are provided. By using the term AND, clinicians are acknowledging that the person is dying and that everything is being done for the patient, including the withdrawal of nutrition and hydration, that would allow the dying process to occur as comfortably as possible. AND prevents unintentional pain and simply allows a natural death.2 Although AND status is not really different from DNR status, it is presented in a language that is more suitable for patients and families. AND orders may help families make more appropriate end-of-life decisions. To date there have been no empirical studies of its effect and no sustained analyses of its ethical implications.3 According to Meyer, AND initially was presented to approximately 100 hospitals in the United States, as well as many hospices and nursing homes.2 The AND movement seemed to slow after Reverend Meyer’s death in November 2000.1
JOURNAL OF EMERGENCY NURSING
31:6
December 2005
CLINICAL NOTEBOOK/Knox and Vereb
In 2004, Baptist Hospital East in Louisville, Kentucky, officially adopted the ‘‘allow natural death’’ language, and the Ethics Committee at the University of Louisville currently is reviewing the information, with the support of our chaplaincy. A limited number of ED nurses in the Kentuckiana area were familiar with the term AND when the hospital began this process. Interestingly, based on information gathered from a number of phone calls made to area chaplains, other hospitals in the Kentucky and southern Indiana area also are considering using the term but have not yet formally presented the concept to their staff. Baptist Hospital East in Louisville, Kentucky, has not only added the use of the AND language but also has expanded on the basics so that patients and families understand it better. According to Diane Huber, RN, the Critical Care Resource Team at Baptist Hospital East articulates 3 levels of care: (1) Full Support, which includes CPR, defibrillation, and chest compressions if necessary; (2) Conditional Support and AND, which allows the patient, family, and doctor to determine which interventions will be used to restore or maintain functions as the patient’s needs change; and (3) Comfort Support and AND, in which no CPR or chest compression will be performed if the patient experiences cardiac or respiratory arrest and health care workers will allow the patient to die naturally while providing comfort and support to both the patient and family (personal communication, Diane Huber, May 29, 2005).4 Huber believes that working with the ‘‘allow natural death’’ language has been easier and more effective and that patients seem to understand it better. Every nurse I have spoken to at Baptist Hospital East who has worked with this new wording seems to agree.
[T]he patient’s family will spend a lifetime remembering or regretting the conversations and decisions of that day. As with everything in health care, end-of-life care terminology is changing. Frank Chessa points out in his paper ‘‘A Rose by Any Other Name’’ that bad connotations have been applied to various terms throughout history and terms that are now considered not politically correct once were,
December 2005
31:6
in fact, quite politically correct.3 Chessa argues that AND eventually may be viewed as negatively as DNR.3 However, we (CK and JV) are both experienced ED nurses who have had to discuss or clarify DNR issues and have found that the AND terminology makes it easier for families to discuss end-of-life care. We believe that the change from DNR to AND is worth the effort. The terminology may change yet again, but AND may be the best conceptual description we have to offer at this point, the best way of helping those with difficult end-of -life decisions to feel a little more comfortable with the process. Emergency nurses spend a relatively brief amount of time giving explanations to families on a given day. However, the patient’s family will spend a lifetime remembering or regretting the conversations and decisions of that day. They need to be at peace with the decisions they make. The families, not the health care provider, will carry the guilt or other emotions evoked by the death of a loved one. We believe it is our duty to help ease their suffering along with the suffering of the patients, and the AND advance directive helps to do just that. Our sense is that this concept will become more common, and we believe that emergency nurses should embrace it. REFERENCES 1. Texas Association of Healthcare Volunteers, INC. Newsletter [online, Winter 2001, retrieved 29 May 2005]. Available from: URL: http://www.tahahealthvolunteers.org/outlook%20newsletters/ 2000/winter%202001/winter%202000/2001winter.htm 2. Meyer C. Allow natural death: an alternative to DNR? [online, retrieved 16 March 2005]. Available from: URL: http:// hospicepatients.org/and.html 3. Chessa F. A rose by any other name: changing terminology to inf luence choices about end of life medical care [online, 2004, retrieved 16 March 2005]. Available from: URL: http://abacus. bates.edu/acad/depts/phil/Faculty/chessa/Rose.pdf 4. Baptist Hospital East. Critical care and life support [online, retrieved 16 March 2005]. Available from: URL: http://www. baptisteast.com/critical-care-and-life-support.cfm?renderforprint=1
Send descriptions of procedures in emergency care and/or quickreference charts suitable for placing in a reference file or notebook to: Gail Pisarcik Lenehan, RN, EdD, FAAN c/o Managing Editor, 77 Rolling Ridge Rd, Amherst, MA 01002 800 900-9659, ext 4044 . [email protected]
JOURNAL OF EMERGENCY NURSING
561