Could these words change the way we care for frail elders at the end of life?
Allow Natural Death (AND) is the formal designation given to a model of care that acknowledges aging and death as a natural part of life; one that foregoes aggressive technologies that treat aging as if it were a disease necessitating treatment and cure. The words themselves reflect the intention of care that follows, but there is much deeper meaning here. AND places the highest value on providing kinder and gentler care to frail elders in the short term – even if it means that life will be shortened when the emphasis is on quality of life rather than quantity.
Hospitals have become environments where medical intervention is meted out to those who are elderly and moving closer to the time of death. Tremendous suffering and wasted resources accompany this approach to advanced aging. The current medical model denies dignity and peace to those who are trying to die in the setting of rising costs and diminishing resources. Institutions that are bound by social imperative, do so within complex systems that are no longer able to acknowledge the value of those precious last days, weeks, and months of a long life. The AND designation carries with it the promise of changing the way we care for frail elders at the end of life.
The AND mindset may have remained limited to a minority of individuals were it not for the historic times in which we find ourselves. There are sufficient drivers of this change to create a sense of urgency. Medicare costs are impossible to sustain. Baby boomers, demanding a voice in their own care, have begun to change the formerly patriarchical system of healthcare. Living Wills have not afforded control of the dying process as Americans hoped that they would. The numbers of Americans over the age of 85 will triple by 2050. Caregivers are insufficient in number to fill this growing need. Bernardine Healy M.D., a past Director of the American Red Cross, predicts a “Healthcare Armageddon.” Urgency has been established. AND will assist those who seek to diminish reliance on the medical model of healthcare as it seeks to support comfort, dignity and relationship at the end of a long life.
ORIGINS OF AND
The basic concept of allowing natural death is not a new one. Adherents to the Hospice philosophy have always advocated the principles of AND without consciously naming them. Scott and Helen Nearing sought a complete divorce from medical management at the time of death. AND’s basic tenets are supported by the writings of Ira Byock, Stephen Kiernan, and Dennis McCollough who advocate a lessening of medicalization while humanizing and maintaining the dignity of our dying elders. During the 1990’s, Chaplains Amy Donahue-Adams and Chuck Meyer formalized processes at end of life at Round Rock Medical Center in Texas by introducing the Allow Natural Death order as an alternative to DNR (Do Not Resuscitate). Interest in AND is increasing in medical ethics circles and in gatherings of members of the nursing community. Facilities in Texas, Florida, Minnesota and California have replaced the Do Not Resuscitate (DNR) order with AND, or added AND to the patient’s choices for care. Attention to AND is spreading as answers are sought to questions regarding the best use of scarce resources and how care is restricted.
AND ON THE FRONTLINE
Patients and families who find themselves in the midst of a health crisis are asked to decide if they wish to enact a DNR order each time the patient is hospitalized. The perceived meaning of the DNR has been skewed as Americans maintain inappropriate optimism regarding resuscitation outcomes. The language of DNR is negative while AND is seen as positive. It is preferable to that of DNR for the majority of those surveyed. The option to AND necessitates conversation between physicians and family members that define desired goals of care at the end of life. AND makes it more possible that preferred outcomes will be achieved as planned. The choice to AND would allow the process of dying for frail elders to be a time of comfort and palliation during final precious days rather than an invasive and often futile path to lengthen the road to the inevitable end of life.