Advance Directive: Allow Natural Death

The more I practice emergency medicine, the more I think about end of life care and the futility of much of what we do as patients try to complete their time on this earth. Many emergency physicians have been faced with the reality of “coding” an elderly nursing home patient because the family insists that everything be done for their loved one when many would agree that this prolongs natural death at a minimum and at a maximum could be considered torture. Two recent events reinforce a changing of the status quo in this regard.

I heard a recent talk by Delegate Dan Morhaim, who is a Senior Delegate in the House of Representatives in the Maryland General Assembly. Morhaim is not only a long term legislator but also a fellow emergency physician. He recently published a book called “The Better End,” a reasoned and practical discussion about end of life care and how we can prepare for an event we will all face (

During his remarks Morhaim mentioned a local healthcare organization which has changed its advanced directive order sheets  from DNR (Do not Resuscitate) to AND (Allow Natural Death). I think this change is a remarkable way to encourage better discussions with a family. Would you want your doctor to sign paperwork for mom stating Do Not Resuscitate or Allow Natural Death? One withholds something from a patient. The other provides a path that is expected and natural to occur. Words can have a huge impact.

A recent post from the blog It’s OK to Die highlights a similar shift on CPR (also cited in a recent JAMA article). As the article states, “This is a change from the present expectation (or default) of CPR no matter what (even if is unquestionably ‘your time’), to a set of recommendations that incorporates the question of whether CPR ‘harms or helps’ individuals.”

As I have progressed in my career I have become more aggressive with not burdening the family with the classic question, “What do you want us to do for your loved one?” I am much more forceful in stating that they are in the process of dying and I will make them comfortable. I have stated to families that performing CPR and aggressive resuscitative measures would be considered cruel and painful. Most (but not all) families, when hearing this description, are relieved that I am removing that burden from them.

I am always perplexed at why this is a difficult conversation when we know the likelihood of survival is slim or the patient has suffered a catastrophic event. Some families force the issue by insisting that everything be done, while not realizing what they are asking us to do. In what other medical situations can a family insist on care which a physician believes to be futile? Are surgeons required to take a patient to the operating room when a family requests it and the surgeon disagrees? Of course not.

The shift on CPR is a step in the right direction. Using the term, Allow Natural Death instead of Do Not Resuscitate is also a step forward, for physicians and the patients whose care we are entrusted to provide.  Even when that means limiting aggressive care at the end of life.