Does Changing the Name, Influence Patients’ Code Status choice? Changing DNR (Do Not Resuscitate) to AND (Allow Natural Death)

Topic: Quality Improvement


Context:  Per the Patient Self Determination Act of 1990, upon admission to the hospital, patients are provided written notice of their decision-making rights, and policies regarding advance health care directives.  As a result, all patients when being admitted to the hospital are asked about their code status choice. There is scant evidence that suggests changing the terminology “Do Not Resuscitate” (DNR) to “Allow Natural Death” (AND) could have an impact on a patient’s code status choice in a theoretical situation. There is no evidence, however, that changing the language will affect a patient’s code status choice upon admission.

Objectives: To determine if using standardized language including the phrase AND during the admission process will affect patient choice of code status.

Methods: Chi-squared test was used to compare code status of patients meeting criteria (age >70 or those of any age with a chronic disease or cancer) admitted to the family medicine inpatient service in Westminster, CO (metro-Denver area) using a standardized script incorporating AND to those admitted with normal, standard of care admission language, DNR. Intervention took place for 6 weeks, with historical control group from preceding 7 months.

Results: In the intervention group (n=77) 37.7% chose AND.  In the control group (n=304) 21.7 % chose DNR. Using a standardized script including “Allow Natural Death” made a statistically significant difference (p = 0.004) in code status choice among all patients.

Conclusion:  Using the phrase "Allow Natural Death" makes a difference when discussing code status with patients.



  • John Miller, MD
  • Shane A. Lieberman, MD

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