The names of things often greatly affect our perception. In end of life lexicon, there is a movement underway to change the name of the medical order DNR (do not resuscitate) to AND (allow natural death). No change in the medical reality of what occurs, but a radical change in our emotional reaction to the each term.
DNR: “They withholding a medical intervention” (evoking negative feelings).
AND: “They are giving care that allows death to occur naturally.”
I certainly feel more comforted and assured by the latter, positive wording, although both phrases constitute the same medical pathway.
Now I am ready to take this a step further, I would like to rename the “full code” pathway for those who are in the final stages of a terminal illness or at the end of a long life. Instead of offering “artificial life support” to these patients, I will be offering “artificial death extension.”
Yikes! Who in their right mind would want that? Or even say such? Now before you think that I’m an insensitive brute let me explain.
Ventilators, central lines, defibrillators. These are all ethically neutral technologies, but how we use them and how we speak of them carries great power.
When a 30-year old young mother falls over dead in a grocery store from a heart arrhythmia, me and my EMS and intensive care colleagues will use all of the mentioned technologies and more to try to revive this woman back to her middle-of-life, meaningful existence. Make no mistake about it, we will be applying all forms of artificial life support to try to get this young mother’s heart and lungs restarted.
Now in contrast, when a 90-year old great grandmother is brought to my emergency department, and I find her to be paralyzed, unable to speak, covered in bedsores, with a feeding tube taped to her abdomen — for this poor woman, any medical interventions given with the intention of reviving her is really nothing more than artificial death extension.
Does this mean that I care for this great grandmother less than I care for the young mother?
In many ways, I might be more moved by her plight. Frequently, I feel a deep grief and almost a love for my frail and elderly patients whose well-meaning families have made choices that have allowed them to enter such a state of prolonged suffering. I want to give these patients my best comfort-focused care. I want to clean their wounds and apply soft bandages, to wet their dry lips and to give them pain medications for their stiff limbs and open sores.
What I do not want to do to these patients are medical procedures which will create more suffering or to prolong that which already has gone too far. For these great grandmothers, ventilators, central lines and defibrillators will not bring them back to a comfortable and meaningful end-of-life experience: they only will make matters worse.
So now, when speaking to the families of the very frail, elderly and those with advanced terminal illness, I talk about two end-of-life pathways from which to choose:
1. Allowing natural death. Focusing on medicine that creates comfort and peace when active dying begins.
2. Artificial death extension. Medical interventions which could create unnecessary suffering and prolong the dying process for an already dying loved one
Changing from DNR and artificial life support to AND and artificial death extension doesn’t make me a brute. I think it means that I actually care.
Monica Williams-Murphy is an emergency physician and author of It’s OK to Die.