When is it appropriate to allow natural death under an advance directive?

Allow Natural Death Under Advance Directives

Allow Natural Death (AND) orders are appropriate when patients with advanced, life-limiting illness have documented their wishes to forgo cardiopulmonary resuscitation and other life-sustaining treatments, particularly when they are no longer competent to make decisions and when such interventions would only prolong the dying process without improving quality of life. 1

When AND Orders Are Appropriate

Clinical Context

AND orders should be considered in the following situations:

• Advanced metastatic cancer with life expectancy less than 1 year 2
• Terminal heart failure where patients are experiencing progressive symptoms despite optimal medical management 3
• Patients so near death that any benefit from intervention would be too brief to justify treatment 4
• When life-sustaining treatments would only prolong the dying process without reducing mortality or improving outcomes 2

Key Distinction from DNR

The term "Allow Natural Death" is preferred over "Do Not Resuscitate" in palliative care settings because it focuses on what is being provided (comfort care, palliation) rather than what is being withheld 1. This framing presents palliation as the normative default rather than CPR, which is particularly appropriate for patients with far-advanced disease.

Requirements for Valid AND Orders

Legal and Ethical Framework

The advance directive must be:

• Created when the patient was competent and capable of informed decision-making 4, 1
• Written and documented in the medical record or legal form 1
• Specific enough to apply to the current clinical situation 2
• Legally valid in your jurisdiction (provincial/state variations exist) 3

Patient Capacity Requirements

The patient must have been able to:

• Understand the purpose, benefits, and risks of proposed treatments 4
• Comprehend the likely consequences of refusing treatment 4
• Make decisions based on personal values, priorities, and beliefs 1

Implementation Process

Early in Disease Course

Advance care planning should begin at diagnosis, not just at end of life 2, 3. This allows:

• Patient wishes to be upheld throughout the disease trajectory 3
• Regular reassessment as conditions change 2
• Conversion of treatment goals into actionable medical orders while patient maintains capacity 2

For Patients with Advanced Disease

When patients have:

• Advanced illness with limited life expectancy
• Progressive symptoms despite treatment
• Expressed clear preferences about avoiding aggressive interventions

The advance directive should be converted to physician orders (such as POLST/Medical Orders for Life-Sustaining Treatment) to ensure preferences are followed by all healthcare providers, including first responders 2, 5.

Weekly Reassessment

For patients under intensive care for more than one week, therapy goal discussions should occur at least weekly with patients (if possible) and families, even when written directives exist 6. This ensures:

• Current condition is accurately communicated
• Realistic therapy goals are established
• Treatment plans align with patient values 6

What AND Orders Do and Do Not Affect

What Is Withheld

• Cardiopulmonary resuscitation
• Advanced cardiac life support
• Intubation and mechanical ventilation 1

What Continues

AND orders do NOT preclude:

• Chemotherapy or other disease-directed treatments
• Antibiotics
• Surgery when appropriate
• Supportive and palliative care
• Symptom management (including opioids for dyspnea)
• Volume management in heart failure
• Maintenance of near-euvolemic status 1, 5

All treatments to relieve pain and suffering must continue 4. For heart failure patients, maintaining volume status and continuing neurohormonal therapies (ACE inhibitors, beta-blockers) palliate symptoms even at end of life 5.

Critical Pitfalls to Avoid

Common Errors

1. Assuming AND means "do nothing" - Active symptom management and comfort care are essential 4, 1
2. Applying directives that are too vague - General statements may not provide sufficient guidance for specific clinical scenarios 2
3. Ignoring directives made when competent - Well-established advance directives from competent patients should be accepted 4
4. Failing to involve substitute decision-makers - When patients cannot express wishes, designated proxies must be consulted 1

Special Considerations

For patients with implantable cardioverter-defibrillators (ICDs): Preferences regarding device deactivation should be part of advance care planning discussions. Turning off the defibrillator function may change the mode of death from progressive heart failure to sudden death, often a more preferable and less symptomatic form 3.

When Disagreement Arises

If there is disagreement between:

• Patient/family and healthcare team
• Different family members
• Written directive and current clinical judgment

Mediation may be necessary 1. However, healthcare professionals cannot be forced to provide treatments considered futile 1.

Documentation Requirements

The advance directive should specify:

• Specific interventions the patient refuses
• General principles guiding healthcare decisions
• Designated substitute decision-maker (proxy/power of attorney)
• Patient's values and goals of care 3, 1

Both instructive directives (living will) and proxy directives should be prepared when legally permitted 3.