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A communication training perspective on AND versus DNR directives

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

Abstract

Background:

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.

Case:

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.

Discussion:

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.

Copyright

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: levint@mskcc.org

References

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Azoulay, E., Pochard, F., Kentish-Barnes, N., et al. (2005). Risk of post-traumatic stress symptoms in family members of intensive care unit patients. American Journal of Respiratory and Critical Care Medicine, 171(9), 987994.
Barnato, A.E. & Arnold, R.M. (2013). The effect of emotion and physician communication behaviors on surrogates' life-sustaining treatment decisions: A randomized simulation experiment. Critical Care Medicine, 41(7), 16861691.
Levin, T.T., Li, Y., Weiner, J.S., et al. (2008). How do-not-resuscitate orders are utilized in cancer patients: Timing relative to death and communication-training implications. Palliative & Supportive Care, 6(4), 341348.
Meyer, C. (2000). Allow natural death: An alternative to DNR? Hospice Patients Alliance. Available from http://www.hospicepatients.org/and.html.
Reisfield, G.M., Wallace, S.K., Munsell, M.F., et al. (2006). Survival in cancer patients undergoing in-hospital cardiopulmonary resuscitation: a meta-analysis. Resuscitation, 71(2), 152160.
Wallace, S.K., Ewer, M.S., Price, K.J., et al. (2002). Outcome and cost implications of cardiopulmonary resuscitation in the medical intensive care unit of a comprehensive cancer center. Supportive Care in Cancer, 10(5), 425429.

Keywords

A communication training perspective on AND versus DNR directives

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

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