JOURNAL OF PALLIATIVE MEDICINE Volume 17, Number 7, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/jpm.2014.0059
Letters to the Editor
You Keep Using That Term Robert Macauley, MD, FAAP, FAAHPM
Dear Editor: In well-publicized recent events,1,2 medical professionals have assumed that patients who are ‘‘DNR’’ would not want—or do not deserve—life-sustaining measures such as intravenous fluids and supplemental oxygen. This confirms what many studies have shown: patients who are DNR are less likely to receive care that has nothing to do with resuscitation, such as laboratory studies, x-rays, blood transfusions, even chart entries and physician visits.3 Despite the palliative care community’s frequent proclamations that DNR doesn’t mean ‘‘do not treat,’’ it would be more honest to say that it shouldn’t mean that, but sometimes does. Even after extensive debate about cardiopulmonary resuscitation—including whether to partially limit it,4 under what circumstances to not even offer it,5 and what to call orders not to do it6—it appears that we’re still not sure what ‘‘DNR’’ really does mean. This calls to mind the famous scene in the movie The Princess Bride where the purportedly brilliant Vezzini repeatedly uses the word ‘‘inconceivable’’ in response to events that are unusual, surprising, or undesirable. Eventually one of his henchmen can’t take it anymore. ‘‘You keep using that word,’’ Inigo Montoya says. ‘‘I do not think it means what you think it means.’’7 The same could be said about our use of ‘‘DNR,’’ which depends on one’s understanding of ‘‘resuscitate,’’ the intervention which it was coined to preclude. (One would hope that everybody—toddlers notwithstanding—can agree on what ‘‘do not’’ means.) Defined as ‘‘to revive a person or animal from a moribund state by medical treatment,’’8 ‘‘resuscitate’’ can refer to a variety of procedures. (For example, the standard response to hypovolemia is ‘‘fluid resuscitation.’’9) As part of DNR, however, the word refers specifically to cardiopulmonary resuscitation, which has a much narrower meaning: ‘‘An emergency procedure for life support, consisting of artificial respiration and manual external cardiac massage.’’10 Since the same word is used in different ways, it’s easy to see why DNR is often misunderstood and misapplied. This is particularly true for modalities that are commonly used in tandem with cardiopulmonary resuscitation in the inpatient setting, such as epinephrine and endotracheal intubation. Such interventions are certainly invasive and intensive—and thus might feel like they should be withheld from someone who is DNR—but they’re not intrinsically resuscitative in the
cardiopulmonary sense. For instance, epinephrine is used to prevent anaphylaxis, and patients can be intubated electively for procedures. One would never, however, refer to the prophylactic use of an Epi-Pen or intubation for scheduled surgery as ‘‘resuscitation.’’ The ambiguity inherent in that word—and, thus, by extension, in the abbreviation DNR—can lead to both underand overtreatment. Physicians might assume that a patient who is DNR doesn’t want more broadly resuscitative interventions, when in fact he or she might simply want to ‘‘die in peace’’ if his or her heart were to stop. Conversely, a patient who consented to DNR under the false impression that it was synonymous with comfort care may be subjected to unwanted treatments by a physician with a more precise understanding of the term. In order to avoid such misunderstandings, it’s critical to recognize that CPR refers less to a particular set of procedures than to a specific context. By definition, CPR ‘‘is used in cases of cardiac arrest or apparent sudden death.’’10 Therefore, as long as a patient has a pulse, the fact that he is ‘‘DNR’’ has no clinical relevance, and certainly doesn’t preclude the use of even rather intensive modalities such as pressors or mechanical ventilation. Following cardiac arrest, however, DNR precludes all medical interventions, even those that might seem rather benign. Over the years there have been many attempts to modify or improve the term DNR. Some—such as ‘‘Do Not Attempt Resuscitation’’—rightly emphasize that CPR is unlikely to be successful, yet still rely on an ambiguous term. Others—such as ‘‘Allow Natural Death’’— shift the focus from procedures to overall goals of care, in so doing providing little practical guidance in emergent situations. Left unanswered is how medications such as benzodiazepines and synthetic opioids—mainstays of end-of-life care, and presumably desired by patients who are A.N.D.—can be considered ‘‘natural.’’6 It’s time to admit that ‘‘DNR’’ cannot be resuscitated. We need another term, one that clearly means what it says and implies nothing more. It should emphasize what will be provided in the context of cardiac arrest—such as respect— rather than focusing on what will be withheld. Finally, it shouldn’t demonize CPR, a procedure that has saved many lives and one that many patients thoughtfully choose. A term that meets all these requirements is ORACA: Only Respect After Cardiac Arrest. After Cardiac Arrest makes it
Department of Pediatrics, University of Vermont College of Medicine, Burlington, Vermont.
747
748
absolutely clear that the term does not apply to any patient who has a pulse, thus preventing inappropriate limitation of treatment. Respect emphasizes that our obligation to a person who will soon be declared dead is not limited to resuscitative interventions, and also avoids the negativity of DNR and DNAR. Only acknowledges that providing CPR to a patient struggling to survive can also be an act of respect, not to mention potentially beneficial. The term thus reassures patients they will be allowed to ‘‘die in peace’’ if their heart were to stop, while also making it clear to clinicians that as long as a patient’s heart is beating, the-code-status-onceknown-as-DNR is irrelevant. Ultimately, though, any abbreviation will have limitations. A patient’s hopes and dreams can’t be reduced to a handful of letters, and a ‘‘code status’’ can never replace a thoughtful description of a person’s goals. The term ORACA—like DNR before it—encompasses patients who have accepted their impending death, as well as those who hope to live longer but want to avoid the burdens and uncertainties of CPR. Perhaps, then, the greatest flaw in our approach to resuscitation isn’t the term we’ve chosen to decline it, but relying on a single term in the first place. Viewed in this light, Montoya’s response to Vezzini is particularly apt. Much like the common misunderstanding of DNR, Vezzini’s use of ‘‘inconceivable’’ is close enough to its true meaning to not arouse suspicion. Nobody dared question him because he was, like today’s medical establishment, in a position of power and considered—at least by himself—to be brilliant. (A few pages later he refers to Plato and Socrates as ‘‘morons.’’) The observation of Inigo Montoya might just as easily be directed at physicians and our (mis-)use of DNR: ‘‘You keep using that term. I don’t think it means what you think it means.’’ It’s time to heed those immortal words and stop using an ambiguous and oft-misunderstood term, especially when the stakes are so high.
LETTERS TO THE EDITOR References
1. Billings JA, Block SD: The demise of the Liverpool Care Pathway? A cautionary tale for palliative care. J Palliat Med 2013;16:1492–1495. 2. Fink S: Five Days at Memorial: Life and Death in a StormRavaged Hospital. New York: Crown, 2013. 3. Beach MC, Morrison RS: The effect of do-not-resuscitate orders on physician decision-making. J Am Geriatr Soc 2002;50:2057–2061. 4. Berger JT: Ethical challenges of partial do-not-resuscitate (DNR) orders: Placing DNR orders in the context of a lifethreatening conditions care plan. Arch Intern Med 2003; 163:2270–2275. 5. Curtis JR, Burt RA: Point: The ethics of unilateral ‘‘do not resuscitate’’ orders: The role of ‘‘informed assent.’’ Chest 2007;132:748–751; discussion, 755–756. 6. Breault JL: DNR, DNAR, or AND? Is language important? Ochsner J 2011;11:302–306. 7. Goldman W: The Princess Bride: S. Morgenstern’s Classic Tale of True Love and High Adventure. Orlando, FL: Harcourt, 2007. 8. Oxford English Dictionary. Oxford: Oxford University Press, 2002. 9. Perel P, Roberts I, Ker K: Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev 2013;2:567. 10. Concise Colour Medical Dictionary, 5th ed. Oxford: Oxford University Press, 2010.
Address correspondence to: Robert Macauley, MD, FAAP, FAAHPM University of Vermont College of Medicine 111 Colchester Avenue, Smith 266 Burlington, VT 05401 E-mail: [email protected]
Letters to the Editor
You Keep Using That Term Robert Macauley, MD, FAAP, FAAHPM
Dear Editor: In well-publicized recent events,1,2 medical professionals have assumed that patients who are ‘‘DNR’’ would not want—or do not deserve—life-sustaining measures such as intravenous fluids and supplemental oxygen. This confirms what many studies have shown: patients who are DNR are less likely to receive care that has nothing to do with resuscitation, such as laboratory studies, x-rays, blood transfusions, even chart entries and physician visits.3 Despite the palliative care community’s frequent proclamations that DNR doesn’t mean ‘‘do not treat,’’ it would be more honest to say that it shouldn’t mean that, but sometimes does. Even after extensive debate about cardiopulmonary resuscitation—including whether to partially limit it,4 under what circumstances to not even offer it,5 and what to call orders not to do it6—it appears that we’re still not sure what ‘‘DNR’’ really does mean. This calls to mind the famous scene in the movie The Princess Bride where the purportedly brilliant Vezzini repeatedly uses the word ‘‘inconceivable’’ in response to events that are unusual, surprising, or undesirable. Eventually one of his henchmen can’t take it anymore. ‘‘You keep using that word,’’ Inigo Montoya says. ‘‘I do not think it means what you think it means.’’7 The same could be said about our use of ‘‘DNR,’’ which depends on one’s understanding of ‘‘resuscitate,’’ the intervention which it was coined to preclude. (One would hope that everybody—toddlers notwithstanding—can agree on what ‘‘do not’’ means.) Defined as ‘‘to revive a person or animal from a moribund state by medical treatment,’’8 ‘‘resuscitate’’ can refer to a variety of procedures. (For example, the standard response to hypovolemia is ‘‘fluid resuscitation.’’9) As part of DNR, however, the word refers specifically to cardiopulmonary resuscitation, which has a much narrower meaning: ‘‘An emergency procedure for life support, consisting of artificial respiration and manual external cardiac massage.’’10 Since the same word is used in different ways, it’s easy to see why DNR is often misunderstood and misapplied. This is particularly true for modalities that are commonly used in tandem with cardiopulmonary resuscitation in the inpatient setting, such as epinephrine and endotracheal intubation. Such interventions are certainly invasive and intensive—and thus might feel like they should be withheld from someone who is DNR—but they’re not intrinsically resuscitative in the
cardiopulmonary sense. For instance, epinephrine is used to prevent anaphylaxis, and patients can be intubated electively for procedures. One would never, however, refer to the prophylactic use of an Epi-Pen or intubation for scheduled surgery as ‘‘resuscitation.’’ The ambiguity inherent in that word—and, thus, by extension, in the abbreviation DNR—can lead to both underand overtreatment. Physicians might assume that a patient who is DNR doesn’t want more broadly resuscitative interventions, when in fact he or she might simply want to ‘‘die in peace’’ if his or her heart were to stop. Conversely, a patient who consented to DNR under the false impression that it was synonymous with comfort care may be subjected to unwanted treatments by a physician with a more precise understanding of the term. In order to avoid such misunderstandings, it’s critical to recognize that CPR refers less to a particular set of procedures than to a specific context. By definition, CPR ‘‘is used in cases of cardiac arrest or apparent sudden death.’’10 Therefore, as long as a patient has a pulse, the fact that he is ‘‘DNR’’ has no clinical relevance, and certainly doesn’t preclude the use of even rather intensive modalities such as pressors or mechanical ventilation. Following cardiac arrest, however, DNR precludes all medical interventions, even those that might seem rather benign. Over the years there have been many attempts to modify or improve the term DNR. Some—such as ‘‘Do Not Attempt Resuscitation’’—rightly emphasize that CPR is unlikely to be successful, yet still rely on an ambiguous term. Others—such as ‘‘Allow Natural Death’’— shift the focus from procedures to overall goals of care, in so doing providing little practical guidance in emergent situations. Left unanswered is how medications such as benzodiazepines and synthetic opioids—mainstays of end-of-life care, and presumably desired by patients who are A.N.D.—can be considered ‘‘natural.’’6 It’s time to admit that ‘‘DNR’’ cannot be resuscitated. We need another term, one that clearly means what it says and implies nothing more. It should emphasize what will be provided in the context of cardiac arrest—such as respect— rather than focusing on what will be withheld. Finally, it shouldn’t demonize CPR, a procedure that has saved many lives and one that many patients thoughtfully choose. A term that meets all these requirements is ORACA: Only Respect After Cardiac Arrest. After Cardiac Arrest makes it
Department of Pediatrics, University of Vermont College of Medicine, Burlington, Vermont.
747
748
absolutely clear that the term does not apply to any patient who has a pulse, thus preventing inappropriate limitation of treatment. Respect emphasizes that our obligation to a person who will soon be declared dead is not limited to resuscitative interventions, and also avoids the negativity of DNR and DNAR. Only acknowledges that providing CPR to a patient struggling to survive can also be an act of respect, not to mention potentially beneficial. The term thus reassures patients they will be allowed to ‘‘die in peace’’ if their heart were to stop, while also making it clear to clinicians that as long as a patient’s heart is beating, the-code-status-onceknown-as-DNR is irrelevant. Ultimately, though, any abbreviation will have limitations. A patient’s hopes and dreams can’t be reduced to a handful of letters, and a ‘‘code status’’ can never replace a thoughtful description of a person’s goals. The term ORACA—like DNR before it—encompasses patients who have accepted their impending death, as well as those who hope to live longer but want to avoid the burdens and uncertainties of CPR. Perhaps, then, the greatest flaw in our approach to resuscitation isn’t the term we’ve chosen to decline it, but relying on a single term in the first place. Viewed in this light, Montoya’s response to Vezzini is particularly apt. Much like the common misunderstanding of DNR, Vezzini’s use of ‘‘inconceivable’’ is close enough to its true meaning to not arouse suspicion. Nobody dared question him because he was, like today’s medical establishment, in a position of power and considered—at least by himself—to be brilliant. (A few pages later he refers to Plato and Socrates as ‘‘morons.’’) The observation of Inigo Montoya might just as easily be directed at physicians and our (mis-)use of DNR: ‘‘You keep using that term. I don’t think it means what you think it means.’’ It’s time to heed those immortal words and stop using an ambiguous and oft-misunderstood term, especially when the stakes are so high.
LETTERS TO THE EDITOR References
1. Billings JA, Block SD: The demise of the Liverpool Care Pathway? A cautionary tale for palliative care. J Palliat Med 2013;16:1492–1495. 2. Fink S: Five Days at Memorial: Life and Death in a StormRavaged Hospital. New York: Crown, 2013. 3. Beach MC, Morrison RS: The effect of do-not-resuscitate orders on physician decision-making. J Am Geriatr Soc 2002;50:2057–2061. 4. Berger JT: Ethical challenges of partial do-not-resuscitate (DNR) orders: Placing DNR orders in the context of a lifethreatening conditions care plan. Arch Intern Med 2003; 163:2270–2275. 5. Curtis JR, Burt RA: Point: The ethics of unilateral ‘‘do not resuscitate’’ orders: The role of ‘‘informed assent.’’ Chest 2007;132:748–751; discussion, 755–756. 6. Breault JL: DNR, DNAR, or AND? Is language important? Ochsner J 2011;11:302–306. 7. Goldman W: The Princess Bride: S. Morgenstern’s Classic Tale of True Love and High Adventure. Orlando, FL: Harcourt, 2007. 8. Oxford English Dictionary. Oxford: Oxford University Press, 2002. 9. Perel P, Roberts I, Ker K: Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev 2013;2:567. 10. Concise Colour Medical Dictionary, 5th ed. Oxford: Oxford University Press, 2010.
Address correspondence to: Robert Macauley, MD, FAAP, FAAHPM University of Vermont College of Medicine 111 Colchester Avenue, Smith 266 Burlington, VT 05401 E-mail: [email protected]
