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A communication training perspective on AND versus DNR directives

  • Tomer T. Levin (a1) and Nessa Coyle (a1)



From a communication perspective, the term “do not resuscitate” (DNR) is challenging to use in end-of-life discussions because it omits the goals of care. An alternative, “Allow Natural Death” (AND), has been proposed as a better way of framing this palliative care discussion.


We present a case where a nurse unsuccessfully discusses end-of-life goals of care using the term DNR. Subsequently, with the aid of a communication trainer, he is coached to successfully use the term “AND” to facilitate this discussion and advance his goal of palliative care communication and planning.


We contrast the advantages and disadvantages of the term AND from the communication training perspective and suggest that AND-framing language replace DNR as a better way to facilitate meaningful end-of-life communication. One well-designed, randomized, controlled simulation study supports this practice. We also consider the communication implications of “natural” versus “unnatural” death.


Corresponding author

Address correspondence and reprint requests to: Tomer T. Levin, Communication and Research Training Laboratory, Department of Psychiatry and Behavioral Science, Memorial Sloan Kettering Cancer Center, 641 Lexington Ave, New York, New York 10022. E-mail:


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A communication training perspective on AND versus DNR directives

  • Tomer T. Levin (a1) and Nessa Coyle (a1)


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