DNR vs. AND
A DNR (Do Not Resuscitate) form is a common component of the advanced care planning documentation. This legal, binding document states that a person does not wish to be resuscitated in the case of cardiac or respiratory arrest.
There is a movement in the hospice world to change the DNR document to an AND form. AND stands for Allow Natural Death.
The AND form serves the exact same purpose as the DNR form, so why bother with this name change?
Think about the difference in the language here.
Do Not Resuscitate. Does that leave you with a feeling that there is something that you could do, you have just chosen not to? Does it feel like you could have done more but, instead, you gave up? This language gives patients and families a mixed message.
Allow Natural Death. This reminds us that death is natural; something that is easy to forget in the emotional frenzy of modern medicine. This language gives us permission to not pursue resuscitation, a medical intervention that can sometimes lead to more complications and pain.
It is not surprising that this motivation to change the DNR terminology came from pediatric hospice professionals. It is difficult for a parent to "not do everything" and the DNR language comes with that implication. The hope is that the AND language will feel less like a judgement and give families more room to contemplate the best course of action for the one they love.
Different but Synonymous:
A similar example of how language may frame a situation can be found in actual professional titles. In recent years, hospice organizations began to distinguish comfort care from end of life care by creating a separate team of professionals called palliative care. This new language was developed as a way to comfort those who were not ready for the end of life journey--and therefore not ready/eligible for hospice--but were very ill and would benefit from a team specializing in pain management and other serious complications.
Unfortunately, over time the terms hospice and palliative care have become synonymous. When lay people are told they are being referred for a palliative care consult they usually associate that with end of life. The idea to change the language so as to create a distinction between comfort and end of life care has been unsuccessful. Patients and families tend to respond the same way to both.
So what is the solution? Some might suggest a continued effort to educate the public on the difference between palliative care and hospice. Others are advocating for a new name altogether. One possible name I have heard, "The Family Care Team," is far less technical and may be more appealing to patients and families not yet ready for hospice. No matter what, it is easy to see from these two examples that language can sometimes have a major influence on how patients and families feel about a particular option. It can even determine the success or failure of a service.
How Do You Ask Me How I'm Doing?
The way we use language can change the patient experience. In one institution, professionals have been trained to no longer initiate communication with patients in the traditional way of saying "How are you today?" In our culture, that is a rhetorical question and is usually met with the knee jerk response "I'm fine. How are you?"
In a healthcare setting, this opening interaction between patient and professional has the potential to be an important interaction for gathering data. If the primary question remains "how are you?" the patient will likely not respond with useful information. Just by training professionals to ask "How has your experience been so far?" to those patients in the hospital, the language has already greatly reshaped the value of the conversation. This is a very different question, is not rhetorical, and holds the space open for honest and important communication.
It's so simple, right? But it's so complicated. Healthcare leaders, professionals, patients, and families have to look at what has become routine language and ask themselves how a slight change in vocabulary might create a higher level of communication and sharing of pertinent information. Language impacts the way we frame things in our mind, even when we are not aware of it.
Take some time and think about other examples you have of medical terminology that hold the potential to box you in to an impression, a belief, or an expected course of action? What other language can you use to open the lines of communication and have a shred mental model with those around you?