In their Letter to the Editor, Clarity or Confusion? Variability in Uses of ‘‘Allow Natural Death’’ in State POLST Forms, Dan Chen, MD, and Daidre Azueta, MD, discuss the pros and cons of the phrase “Allow Natural Death (AND)” versus “Do No Resuscitate (DNR)” on POLST Forms.
The authors explain that AND was proposed as an alternative to DNR in 2000 that might be “more acceptable” and “impact resuscitation decisions,” but that critics point out AND is not a well-standardized term.
The study involved an analysis of all POLST Paradigm Forms the authors could find from Developing, Endorsed, and Mature POLST Paradigm Programs listed on the National POLST Paradigm map web page in December 2016 (the webpage has since been updated more than once); three non-conforming programs were excluded, and in one instance, authors were unable to obtain one state’s POLST Form. In total, 43 POLST Forms were analyzed for their terminology.
Most (28 or 65.1%) states used “Allow Natural Death” in the title of the medical order on the POLST Form, and, of these, most (24 of 28, or 85.7%) used “AND” in conjunction with the terms “DNR,” “Do Not Attempt Resuscitation (DNAR),” and/or “No Code.” Among these, most (79.1%) specifically prohibited defibrillation in the order, whereas the others (5 states, or 20.8%) did not specify.
The four (14.2%) forms that did not couple AND with DNR instead coupled “AND” with the phrases “Comfort Measures Only,” “Comfort Measures,” or “Comfort Care.”
Most (21 or 87.5%) forms with AND/DNR orders were applicable to patients lacking both a pulse and respirations. The remaining (3 or 12.5%) forms with AND/DNR orders were applicable to patients lacking either a pulse or respirations (or both).
States that used AND as a comfort order did not all include the same description of comfort care; some included mention of pain, wound care, dyspnea and hospitalization preferences in their definitions, but others were less specific.
In summary, the study authors concluded that while sometimes considered more acceptable, the term “AND” is not well-standardized, which may create confusion, especially if POLST Forms from one state were to be interpreted in another. In conclusion, Chen and Azueta state, “Institutions and providers introducing AND into their practice should exercise caution. For all its merits, we believe that AND remains imperfect language.”
Original Article: Chen D and Azueta D. (2017). Clarity or Confusion? Variability in Uses of “Allow Natural Death” in State POLST Forms. Journal of Palliative Medicine. March 2017, ahead of print. (limited access).