Cardiopulmonary resuscitation — time for a change in the paradigm?

To the Editor: Levinson and Mills are to be lauded for their article on the need to rethink our approach to cardiopulmonary resuscitation in hospitalised patients.1 They outline the barriers to open discussion at an individual and a society level. However, they have omitted a key barrier: the language that we use to discuss the topic.

Negatively worded terms such as “not for resuscitation” (NFR) and “do not resuscitate” (DNR) are common in the medical lexicon. In part, such negative language makes discussion so challenging for clinicians, patients and families.

As an emergency physician, I have been involved in such conversations for over two decades. I have reversed the language and use the phrase “allow natural death” (AND). The use of positive language was described by Meyer and has been taken up in the hospice setting.2 Research suggests that AND is more likely than DNR to be endorsed by both clinical staff and lay people.3

While concerns have been raised that the use of AND may cause confusion, it has been argued that the benefits outweigh this risk in promoting high-quality end-of-life care.4 In my experience, positive language facilitates discussion when treatment is likely to be futile but death is not expected.

Changing the language would help in changing the paradigm for cardiopulmonary resuscitation. We should be having a conversation about allowing a natural death rather than about withholding largely ineffective and possibly harmful treatment.