Perhaps the time has come to replace the concept of "do not resuscitate" (DNR) with the gentler, but more definitive, approach - "allow natural death" (AND).¹

This concept, developed by Rev. Charles Meyer, chaplain at St. David's Medical Center, Austin, TX, before his death in an auto accident in 2000, is supported by the Hospice Patients Alliance and the New Jersey State Nurses Association.

Explaining The Acronyms
DNR is often viewed in a negative way. But DNR does not mean "do not treat." It does not mean "abandon the patient, nothing more can be done" and it does not mean "give up hope."

A DNR order does not give permission to end someone's life; it gives direction not to start CPR if a person dies.

An AND order recognizes the patient is dying and allows for patient autonomy, and supports aggressive symptom management with the goal of comfort for patient and family.

Establishing a palliative-care supportive treatment plan assures symptoms are anticipated, prevented and managed with a team approach that includes the patient and family. Withdrawal of life-sustaining medical treatment and unnecessary procedures allows death to occur naturally in an as comfortable and stress-free environment as possible.

No two patients or family units are the same, and developing an aggressive comfort treatment (ACT) plan is often a challenge. The nursing team only has one chance to get it right.

Most people are not afraid of dying as much as they are afraid of dying in pain, distress and with a lack of control. The goal of ACT is a peaceful end, with comfort and dignity.

In 'ACT': Taking a Positive Approach to End-of-Life Care, Patricia Murphy defines ACT as "a concept that frees yourself of the constraints of the care-oriented medical model," allowing you to "better focus on caring for the whole person."²

Palliative Care In Acute Care
The World Heath Organization defines palliative care as "total care of the patient whose disease is not responsive to curative treatment. It includes control of pain and symptoms and addresses psychosocial and spiritual problems."³ It is a transition from hope for cure to hope for comfort. When a patient and/or family choose palliative care and allow AND, a team approach is used to anticipate and meet patient and family needs.

A hospital's palliative-care team will advocate for the patient and family to assure their wishes are being honored that pain and non-pain symptoms are managed effectively.

Spiritual and cultural issues are addressed and patient/family values and beliefs/burdens are discussed. The goal is to better prepare people for the dying process through a care plan that's sensitive to change and providing quality end-of-life care.

Symptom Management
One analogy defines the art of symptom management very well. Think of a really good spa treatment, how it manipulates your senses to achieve serenity - the lighting, music, aroma therapy, therapeutic touch and guided imagery. You always leave feeling much better than when you arrived.

I am not advocating we convert hospital rooms into spas, but similar principles work. Transform the noisy hospital environment, play music the patient likes, turn off alarms and call bells, and move the patient away from the nurses' station (preferably to a private room) to give the family more personal space.

You don't need bright lights, but there should be some light as dying patients may become fearful. Tell the family it is OK to speak and touch the patient, but explain that dying extremities may become cold and change color.

Tell the family what it looks like to die. The Hospice and Palliative Nurses Association's Web site (www.hpna.org) offers an education sheet on this.⁴ Remember you don't have to say much; the most precious gift you can give is your presence.

Even with all the best nonpharmacological methods, we probably still need drugs. The pharmacist is integral to the symptom management team and knowing how to do equal analgesic conversion is something nurses interested in palliative care can learn from them.

A key concept to remember is there is no ceiling for opioids; follow the rule "start low and go slow," but make sure you keep going if you need to. Another overlooked issue: if a patient has been experiencing pain and becomes cognitively impaired or unresponsive, assume they still are in pain and need treatment.

Martha Chambers is CCU case manager at Cape Regional Medical Center, Cape May Court House, NJ.

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