"Perhaps the time has come to replace the concept of DNR with the gentler, but in fact more definitive, approach - allow natural death (AND)."1
This concept, developed by Rev. Charles Meyer, chaplain at St. David's Medical Center, Austin, TX, before his death in an auto accident in 2000, is supported by the Hospice Patients Alliance and something all nurses and healthcare professionals should support.
Explaining the Acronyms
Do not resuscitate (DNR) is often viewed in a negative way. DNR does not mean do not treat. It does not mean abandon the patient, nothing more can be done; it does not mean give up hope.
A DNR order does not give permission to end someone's life; it gives direction not to start CPR if a person dies.
An order to AND recognizes the patient is dying and allows for patient autonomy, and supports aggressive symptom management with the goal of comfort for patient and family.
Establishing a palliative care supportive treatment plan assures symptoms are anticipated, prevented and managed with a team approach that includes the patient and family. Withdrawal of life-sustaining medical treatment and unnecessary procedures allows death to occur naturally in as comfortable and stress-free an environment as possible.
No two patients or family units are the same and developing an aggressive comfort treatment (ACT) plan is often a challenge. The team only has one chance to get it right.
Most people are not afraid of dying as much as they are afraid of dying in pain, distress and with a lack of control. The goal of ACT is a peaceful end, with comfort and dignity.
In "'ACT': Taking a Positive Approach to End-of-Life Care" Patricia Murphy defines ACT as "a concept that frees yourself of the constraints of the care-oriented medical model," allowing you to "better focus on caring for the whole person."2
Palliative Care in Acute Care
The World Heath Organization defines palliative care as "total care of the patient whose disease is not responsive to curative treatment. It includes control of pain and symptoms and addresses psychosocial and spiritual problems."3It is a transition from hope for cure to hope for comfort. When a patient and/or family choose palliative care and allow AND, a team approach is used to anticipate and meet patient/family needs.
A hospital palliative care team will advocate for the patient/family to assure their wishes are being honored that pain and non-pain symptoms are managed effectively. Spiritual and cultural issues are addressed and patient/family values and beliefs/burdens are discussed. The goal is to better prepare a patient and family for the dying process through a care plan sensitive to change, providing quality end-of-life care.
When I think of the art of symptom management one analogy defines it so well. Think of a really good spa treatment, how they manipulate your senses to achieve their goal (serenity) - lighting, music, aroma therapy, therapeutic touch and guided imagery. You always leave feeling much better than when you arrived.
I am not advocating we convert hospital rooms to a spa but similar principles work. Transform the noisy hospital environment, play music the patient likes, turn off alarms and call bells, and move the patient away from the nurses' station, preferably to a private room to give the family more personal space.
You don't need bright lights but there should be some light as dying patients may become fearful. Tell the family it is OK to speak and touch the patient but explain dying extremities may become cold and change color.
Tell the family what it looks like to die. The Hospice and Palliative Nurses Association Web site offers a family education sheet on this.4Remember you don't have to say much; the most precious gift you can give is your presence.