Thoughts on Cairns, Advanced Directives, and DNR Orders

Cairns are ancient, human-made stacks of rocks indicating a landmark or memorial site.

Cairns by jparadisi

Cairns by jparadisi

Modern-day hikers use cairns as directional markers for those following their trail. Not long ago, I came across a group of cairns while walking along the Willamette River. Most likely, they were merely an artistic expression, but only the person who left them knows for sure.

In a way, Advanced Directives and DNR orders are healthcare cairns, marking directions for end of life journeys. Also like Cairns, without an understanding of the patient’s intent, their meanings become open to interpretation, and subsequently, misinterpretation.

Misinterpreting Advanced Directives and DNR orders is a common occurrence among physicians and nurses.

A series of surveys by QuantiaMD, an online physician learning collaborative, found that nearly half of health professionals misunderstood the components of living wills — 90 percent of those surveyed were physicians.¹

The survey findings provided characteristics of a patient who had a living will, and asked respondents to identify the patient’s code status. Of about 10,000 respondents — 44 percent incorrectly identified the patient as having a DNR, and 16 percent did not know the code status. About 41 percent correctly identified the patient’s status as a full code.¹

The majority of survey respondents wrongly said patients with DNRs should receive significantly less medical care and interventions than designated by such an order. A DNR means that a patient should not be resuscitated if found with no pulse. About 20 percent said they would defibrillate a patient who had a clear DNR order.¹

Much confusion stems from the lack of a national standardization of end of life directives, and their communication to a patient’s healthcare providers. One article describes a hospital using yellow armbands to indicate that a patient has DNR orders.²  Oncology nurses will especially appreciate the problem created for that hospital’s oncology unit, where many patients arrive wearing yellow Livestrong bracelets in support of finding a cure, not as a declaration of DNR status!

Terminology also contributes to confusion. Many physicians and nurses wrongly interpret DNR (Do Not Resuscitate) to mean Do Not Treat. Reviewing a patient’s Advanced Directives, DNR orders, or POLSTs (physician orders for life-sustaining treatment), and making them readily available to a patient’s healthcare team, helps prevent unwanted treatments, while providing comfort care per the patient’s wishes.

In March 2012, The ANA Center for Ethics and Human Rights revised their position statement, “Nursing Care and Do Not Resuscitate (DNR) and Allow Natural Death (AND) Decisions,” defining the responsibilities of nurses following end of life orders.

What are your experiences with end of life orders? What is your institutions’ policy?


In the Absence of Clouds, Artists and a Nurse Discuss Death and Dying (or The Art of the Death Panel)

Bones oil on canvas by jparadisi

Outside, it was a rare, January day of cloudless sunshine. Instead of enjoying it, I sat on a bench towards the back of an art gallery in a vacant storefront, where I estimate thirty artists sat in a circle talking about death and dying. I was there because the artist moderating the discussion is a friend of mine, and because I wanted to hear what people who are not health care professionals have to say about death and dying. Their ages ranged from twenty-something to seventy-something. Some had family members who are terminally ill. Some had lost parents, grandparents, siblings or friends. No one said they were battling life-threatening illness themselves, or had in the past. A couple of the artists were studying physics. As far as I know, I was the only artist working in health care. Because of that, I decided to listen without participating in the discussion. As an oncology nurse, I get to talk about death and dying all the time.

People shared their experiences of death, and then quickly shifted to ideas about their own deaths. One thirty-ish looking man admitted that he thinks about it all the time, and is saving money for cryogenics. He wants his body frozen when he dies. Another person, older than middle-aged, said he hoped to convince a friend or family member to drown him should he be a victim of dementia. Dementia seemed more feared by the group than pain. Another person thought you couldn’t really know when you’ll wish to die until it happens to you. Several people said they have signed POLST forms.  I found it interesting that no one brought up physician-assisted suicide, which is legal in Oregon and Washington states.

The topic of caring for dead bodies was lively. Most of the group couldn’t imagine washing a dead body, and a few insisted that they don’t care what happens to their own remains. This was the part of the discussion I found keeping my silence difficult. I have lost count of how many bodies I have washed and dressed. All of them have been infants or children. I was a pediatric intensive care nurse during that period of my life. While it was always sad, I feel that washing and dressing those small patients for their parents and families to hold and say good-bye to was the most sacred service I have provided my patients.

A young woman said that she learned in an anthropology course there’s a culture “I can’t remember the name of,” which believes each of us dies three deaths: First, we die physically. Secondly, when the last person who knew us dies, and lastly, when our name is no longer spoken. I’m not surprised I heard this for the first time in a room full of artists.

There was one statement I considered profound. An artist said she doesn’t know if there’s an after life or not. “If there isn’t, there’s nothing to be afraid of, but if there is, I am not afraid of that either, because in that case, I have already been there.”

I came away from the conversation believing that the people who know the most about death and dying are the dying themselves. Now that I work in outpatient adult oncology, I no longer attend at the bedside of the dying like I did as a PICU nurse, but many of my patients share their thoughts about their impending deaths with me. Most are at least a little frightened of the unknown. Some have said it all went by so quickly. I have heard young patients say that their bodies have become burdens of maintenance and they look forward to being done with them.  The last time I saw him, an elderly patient said to me, “My Juliette, parting is such sweet sorrow,” and he made me cry.