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A tale of two conversations.

Patient "J," let's call her Jane, was in the ICU of her local hospital. She was seventy-five and suffering from end stage pulmonary disease, high blood pressure, and impending renal failure. She had an eighty-year-old husband and two children in their early fifties. She had no advance directive. She was under strong medication and was not able to express her wishes.

Several urgent decisions needed to be made--whether to put her on a respirator, and what to do if she went into cardiac arrest and stopped breathing. The attending physician had discussed the problem of a cardiac arrest with several members of the family, but the family was struggling to reach a consensus. The physician decided to press for one by suggesting that they consider making Jane a "DNR"--"do-not-resuscitate." If Jane were to arrest, he explained, the medical team would not try to resuscitate her. Still the family struggled. Days passed, and the family grew ever more upset about the thought the no one would do anything for Jane if she arrested. Resolution was ever more distant.

Patient "Q," let's call him Quentin, was a seventy-eight-year-old male with end stage liver failure, hospitalized because he was having cardiac rhythm problems as a result of a metabolic imbalance relating to his liver failure. Quentin's wife had died two years prior and his two sons were concerned about losing their father.

Quentin's physician had spent a lot of time explaining to the sons the condition of their father and that at his age he would not be able to have a liver transplant. All felt that Quentin could not make his own decisions, but he had left no advance directive. The sons were confused about what decisions they should make for him. The physician explained that it was time to consider an "AND"--an "allow natural death" order. He explained that the health care team would do everything possible to make Quentin comfortable, would treat him compassionately, and would care for any pain he might have. Should he arrest, the team would allow him to die naturally and peacefully. The sons rapidly agreed that an "AND" would be in their father's best interests. They were glad to know their father would be cared for.

These situations are real, and similar cases occur everyday in all hospitals in America. In my experience as chairman of a hospital ethics committee for the past fifteen years, the biggest problems in end of life decisionmaking have to do with communication and semantics. End of life issues generate feelings of guilt, tension, and conflict within families, and how the health care team present!; the medical situation and the possible responses to it make all the difference.

We are in the midst of shifting from "DNR" to "AND" in my health care system. We now refer to "AND/DNR," and in the next year, when people have learned the new terminology, we will refer only to "AND." I have also discussed these terms with physicians in other health care systems around the state of Georgia, and I have found that their reaction to "AND" is uniformly positive. Georgia Health Decisions, a nonprofit, nonpartisan organization that works to promote public involvement on health issues, is now working to have the legislature incorporate the term into relevant state codes.

On its face, the change seems merely semantic. After all, the two terms have the same implications for actual patient care. What they say about the attitudes and intentions that lie behind these actions, however, is dramatically different. "Do-not-resuscitate" sounds cold, cruel--as though the health care team has given up. Families shy away from these implications and therefore resist DNR orders. So, too, do physicians, who are sometimes reluctant to suggest a DNR order and bad about adhering to one. "Allow-natural-death" sounds softer, more comforting, warmer--even though it contains a form of "the D word." It says that the team cares and will continue to care for the family member.

This can change the family's experience of the dying process. Those left behind will have memories of a loved one's passing. Will they take comfort in the knowledge that their loved one was treated with compassion and dignity? Or will they worry that their loved one was abandoned? "AND" puts compassion and dignity foremost.

Richard W. Cohen is an orthopedic surgeon with Wellstar Health Systems, based in Marietta, Georgia. He is also chair of Georgia Health Decisions.
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Title Annotation:perspective
Author:Cohen, Richard W.
Publication:The Hastings Center Report
Geographic Code:1USA
Date:May 1, 2004
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