John C. Moskop, Ph.D.
Among the most significant and difficult decisions facing patients, families, and health care professionals are those involving treatment near the end of a patient’s life. Caregivers, patients, and families may struggle mightily to reach a clear understanding of the patient’s condition, prognosis, and treatment options, to come to grips with strong feelings of fear, grief, guilt, or suspicion, and to choose a treatment strategy in harmony with deeply held beliefs and values. Because patients and families rely on their caregivers for advice and assistance with these difficult choices, it is crucial that caregivers be able to communicate effectively and sensitively about end-of-life care, both with patients and families and with one another.
To improve communication about end-of-life care, the Pitt County Memorial Hospital Medical Ethics Committee recently recommended, and the Medical Executive Committee approved, a new physician order form for end-of-life care and an accompanying revision of the Hospital’s policy for do-not-resuscitate orders. The Medical Ethics Committee undertook this effort in response to reports from committee members about serious ambiguities and inconsistencies in orders regarding resuscitation and end-of-life care using existing order forms. The new order form and policy revision were developed by a working group of the Medical Ethics Committee that included representatives from the medical staff, Care Management, Legal Affairs, Risk Management, and the Bioethics Center.
The new order form represents a significant departure, in terminology, format, and scope, from its predecessor. Hospital-wide educational programs to acquaint caregivers with the new form will therefore be essential to its successful implementation. In the rest of this column, I will offer a brief description of several key features of the new form.
Terminology
The new form adopts several new terms to refer to important treatment choices. For example, the term "Do Not Attempt Resuscitation" (DNAR) is used in place of "Do Not Resuscitate” (DNR). As many commentators have noted, “Do Not Attempt Resuscitation” more clearly conveys the fact that, although resuscitation can be attempted, in the large majority of cases it will be unsuccessful. In contrast, ‘Do Not Resuscitate’ may suggest that patients can be resuscitated at will. The term "Individualized Resuscitation" is used to convey the order that resuscitation should be attempted, but should not include one or more specific modalities noted on the order form. Similarly, the term "Individualized Care" is used to indicate that medically indicated life-sustaining treatments should be provided except for specific treatments noted on the form. Finally, the term "Allow Natural Death" (AND) is used to convey the order that the patient’s care should be directed toward comfort and should not include further diagnostic teats and life-prolonging treatments. This term was chosen to emphasize what will be provided for patients near the end of life, namely, comfort measures to allow a peaceful and natural death, rather than what will not be provided, namely, non-beneficial efforts to prolong life.
Format
The new form looks significantly different from the previous DNR order form. It is a two-column form featuring check-off boxes for specific treatment orders in each column of the form. The left-hand column contains specific choices regarding the resuscitation status of the patient, ranging from "Full Resuscitation" through "Individualized Resuscitation" to "Do Not Attempt Resuscitation." The right-hand column contains specific choices regarding the overall treatment status of the patient, from ‘Routine Care’ through "Individualized Care" to "Allow Natural Death." This linking of resuscitation and treatment orders on a single-sheet order form will allow physicians to coordinate these orders and to communicate them more clearly to other members of the health care team.
Scope
As is obvious from its altered format, the new form expands the scope of the old DNR order form in several important ways. First, it specifically recognizes the option of orders for individualized resuscitation attempts. Though Hospital policy has permitted such orders for some years, there was no way to indicate such orders on the previous DNR order form, and so physicians were forced to alter that form in ad hoc and often vague or confusing ways in order to convey that a resuscitation attempt should not include a specific treatment modality.
Second, the new order form allows physicians to communicate clearly and concisely, not only the resuscitation status of patients near the end of life, but also which other life-sustaining treatments should and should not be provided for these patients. The drafters of the new order form believe that linking these two decisions on the same form will encourage a more comprehensive approach to decisions about end-of-life care and a more effective way to communicate those decisions to all members of the health care team.
