Allow natural death

Allow Natural Death (AND) is a medical term defining the use of life-extending measures such as cardiopulmonary resuscitation (CPR). These orders emphasize patient comfort and pain management instead of life extension.[1] Currently, American medical communities utilize “do not resuscitate,” (DNR) orders to define patients’ medical wishes. Those who propose to replace DNR with AND posit that DNR orders are ambiguous and require complex understanding between several parties, while AND orders are clearer.[1][2]

DNR VS AND

DNR orders range from solely prohibiting the use of resuscitation to prohibiting any action seen as life extending. Because there are many parties involved in a patient’s end of life care - significant others, family, personal doctors, specialists and nurses - DNR orders are not always completely clear, leaving open possible violation of the patient’s wishes.[1] “DNR orders may lead to conflict, unnecessary suffering, and inappropriate care at the EOL [end of life.]” Those who propose to replace DNR orders with AND orders posit that AND are less ambiguous, clearly instructing medical personnel to not use any artificial, life extending measures. This would be especially helpful in regards to emergency care, when medical personnel who are unfamiliar with the patient must decide what medical practices should be used. Pros are that AND increases clarity on meaning and the choice of life or death.[3] Also it doesn’t use negative wording that could be confusing to interpret. Furthermore, proponents of AND claim that because it contains “death” in the title it is more clear to the patient and family exactly what the patient is agreeing to.

Critics of AND claim it is simply the replacement of one ambiguous term with another. Cons include that death can be vague and CPR isn’t mentioned in the phrase.[3] Just as DNR particulars vary so too would AND particulars vary.[3] Thus, the change would be ineffective.

Ethics

AND terminology represents an ideology of patient care that emphasizes bodily autonomy and respect of the individual.[4] As opposed to “do not resuscitate”, which has been criticized for placing emphasis on potential negative outcomes associated with hospitalization—the act of “not” resuscitating is a conscious decision to “not” engage in life-extending care. Proponents of AND argue that, by “allowing” natural death, the provider is, instead, consciously deciding to engage in care; although such care is not life-extending, this form of care respects the wishes of patients to die peacefully, in their minds.[5]

AND and DNR share similar ethical dilemmas, however, in cases of attempted suicide or medical mismanagement, as such cases raise questions surrounding the meaning of a “natural” death. Some argue that, in special cases such as these, physicians should have the capability to revoke DNR or AND, though a wide consensus has yet to be reached.[6][7]

Studies and Outcomes

Most studies regarding AND are surveys based on hypothetical situations and are given to specific groups. One study gave a scenario regarding loved ones to nurses, nursing students, and people with no nursing background.[2] Each group rated how likely they were to agree to end of life care when DNR or AND was used. Participants were significantly more likely to agree to end of life care when AND was used.

Another study found similar results when giving a scenario to 524 adults- end of life care was more accepted when AND was used.[8]

However, when patients with cancer were given a scenario about how much time they had left to live (1 year, 6 months, or 1 month), the results were different. In two studies conducted by the same authors, there was no significant difference in choosing end of life care when AND or DNR was used.[9][10]

Finally, an anonymous survey asked residents and doctors about their experience with end of life care after their hospital switched to using AND over DNR. A majority agreed that using AND improved discussions about end of life care and decreased the burden of decision making.[11]

Future Directions

There are barriers that exist in implementing “allow natural death”. Some argue that costs will occur with the need to reeducate clinical staff and replace forms and edit electronic medical databases. People are looking into high-end care for when it comes to end of life decisions and AND can help provide more autonomy for patients.[3]

See also

  • Letting die
  • Coup de grace

References

  1. 1 2 3 Schlairet, Maura C (2013). "Allow-Natural-Death (AND) Orders: Legal, Ethical, And Practical Considerations". HEC Forum. 25 (2): 161–171. doi:10.1007/s10730-012-9181-1. PMID 22752437. S2CID 3291552.
  2. 1 2 Venneman, S.S. (2008). "'Allow Natural Death' Versus 'Do Not Resuscitate': Three Words That Can Change A Life". Journal of Medical Ethics. 34 (1): 2–6. doi:10.1136/jme.2006.018317. PMID 18156510. S2CID 7414134.
  3. 1 2 3 4 Breault, Joseph L (2011). "DNR, DNAR, or AND? Is Language Important?". The Ochsner Journal. 11 (4): 302–306. ISSN 1524-5012. PMC 3241061. PMID 22190879.
  4. ↑ Schlairet, Maura C.; Cohen, Richard W. (2013-06-01). "Allow-Natural-Death (AND) Orders: Legal, Ethical, and Practical Considerations". HEC Forum. 25 (2): 161–171. doi:10.1007/s10730-012-9181-1. ISSN 1572-8498. PMID 22752437. S2CID 3291552.
  5. ↑ Stecher, Jo (July 2008). "'Allow Natural Death' vs. 'Do Not Resuscitate'". The American Journal of Nursing. 108 (7): 11. doi:10.1097/01.NAJ.0000325789.62339.2e. ISSN 0002-936X. PMID 18580104.
  6. ↑ Humble, Michael Brian (2014-11-01). "Do-Not-Resuscitate Orders and Suicide Attempts: What Is the Moral Duty of the Physician?". The National Catholic Bioethics Quarterly. 14 (4): 661–671. doi:10.5840/ncbq201414469. Retrieved 2021-09-13.
  7. ↑ Hébert, Philip C.; Selby, Debbie (2014-04-15). "Should a reversible, but lethal, incident not be treated when a patient has a do-not-resuscitate order?". CMAJ : Canadian Medical Association Journal. 186 (7): 528–530. doi:10.1503/cmaj.111772. ISSN 0820-3946. PMC 3986316. PMID 23630240.
  8. ↑ Fan, Sheng-Yu; Wang, Ying-Wei; Lin, I-Mei (2018-10-10). "Allow natural death versus do-not-resuscitate: titles, information contents, outcomes, and the considerations related to do-not-resuscitate decision". BMC Palliative Care. 17 (1): 114. doi:10.1186/s12904-018-0367-4. ISSN 1472-684X. PMC 6180419. PMID 30305068.
  9. ↑ Emuron, Dennis Omoding; Miljkovic, Milos; Rhodes, Lori; Abraham, Joseph; Miller, Kenneth David (2013-05-20). "Are "Allow Natural Death" orders preferable to "Do Not Resuscitate" orders for patients with advanced cancer?". Journal of Clinical Oncology. 31 (15_suppl): e20685. doi:10.1200/jco.2013.31.15_suppl.e20685. ISSN 0732-183X.
  10. ↑ Miljković, Miloš D.; Emuron, Dennis; Rhodes, Lori; Abraham, Joseph; Miller, Kenneth (May 2015). ""Allow Natural Death" versus "Do Not Resuscitate": What Do Patients with Advanced Cancer Choose?". Journal of Palliative Medicine. 18 (5): 457–460. doi:10.1089/jpm.2014.0369. ISSN 1557-7740. PMC 4442561. PMID 25825919.
  11. ↑ Lutchmansingh, Denyse; Maroz, Natallia; Allen, Kenyani; Wilson, Thomas; Scott, Penelope; Mete, Mihriye (2012-05-01), ""Allow Natural Death". What Have We Learned?", C105. ETHICS AND END OF LIFE CARE IN THE INTENSIVE CARE UNIT, American Thoracic Society International Conference Abstracts, American Thoracic Society, pp. A5217, doi:10.1164/ajrccm-conference.2012.185.1_meetingabstracts.a5217, retrieved 2021-09-13
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