Thursday, May 23, 2013

What Is A "Natural" Death, Anyway?



by: Alex Smith, @alexsmithMD

Eric kicked off the week posting about a study comparing use of the phrase "Allow Natural Death" with "Do Not Resuscitate."  Surrogates were far less likely to opt for CPR if the physician used the phrase Allow Natural Death.

But here's the thing - what is a natural death, anyway?

I get it - death is part of the cycle of life. Seasons change.  The moon waxes and wanes.  We are born. We die.  Death is natural.

But what is a "natural" death?  Seriously, what comes to mind when you think of natural death?  Here is a video of a natural death, taken from the Planet Earth series by the BBC's NATURAL History unit (you can skip the add after a few seconds):


Death in nature is often violent, brutal, and messy.  The same adjectives could be used to describe a code.
If the video doesn't make the point, perhaps a story will.  (Thanks to Amber Barnato for this story, I'm anonymizing it).

A man pressured his pregnant wife into trying a "natural" birth, without an epidural for pain.

Years later, the man started experiencing crushing chest pain.  His wife brought him to the emergency department.  He was diagnosed with a heart attack.

The nurse prepared to give him some morphine for the chest pain.  The man's wife stopped the nurse, and said, "I think we should let him have a 'natural' heart attack.'"

Who decides why one things is natural, and another isn't?

OK, now I'll fess up. I use the words.  Or something like it.  I say, "This is about how your father is going to spend the remainder of his time.  I suggest we don't prolong his dying, and let nature take its course." It helps with framing.

There is something more natural about dying in our hospice unit than in the ICU with a big team of residents thumping the chest.  For many, including myself, the idea of a natural death is something more like a peaceful death, free from invasive medical interventions.  While peoples conceptions of "natural" death will vary, most people don't think of sharks eating seals.

But do I worry about it?  Sometimes.  It's hard for people to refuse to do the "natural" thing, right?  That's one reason there is all this angst and guilt among women who plan to have a "natural" birth, but then relent and ask for an epidural.

There is an ethical line between persuasion (the use of facts to make a reasoned argument) and coercion (threat with injury).  Persuasion is ethically permissible, coercion is not.

CPR could be described as pounding on the chest, cracking the ribs, and electrocuting the patient.  On the one hand, that sounds like battery, and seems "un-natural" to me.  On the other hand, does the word "natural" attribute desirable qualities to a death without CPR, and undesirable qualities to death with CPR, without clear justification?  Is it too judgmental?  Do we cross that line from persuasion to coercion by using the term"natural?"

NOTE: This is the fourth in a series of posts this week for "Code Discussion Week." Come back everyday this week for a new post focused on CPR AND DNR Discussions.

Here is a list of the rest:

4 comments:

Stacy Fischer said...

I love our field that we can reflect on the most subtle meanings and nuances of the language we use.

When I think about the analogy of "natural" childbirth and "natural" death one important distinction that comes to mind is where is the focus. When it comes to childbirth-the focus has to be all about the outcome. The process takes a distant second to the outcome of a healthy baby and mother.

For death-the outcome is less influenced. For example, talking about CPR in the setting of an advanced cancer-the outcome is likely to be death regardless of the process (natural or CPR). Therefore, focusing on the process is where I tend to start the conversation. What do you want your passing to look like-home, family, music etc. Then exploring how we can create a plan that supports and promotes this end of life plan. Granted there are many times when the outcome of CPR is less certain and then we start exploring and balancing those preferences-wishes for more time versus importance of having a quality end of life experience.

I have enjoyed this discussion-thanks Geripal!

Patrice Villars said...

Great conversation. This idea of allowing a "natural" death has me perplexed as well. What is it we are offering? Is giving someone with a brain tumor steroids supporting a 'natural' dying process? Is it treating symptoms? Prolonging life? Prolonging dying? How about diuretics for heart failure? When was the last time you offered to let someone with heart failure die of fluid overload because it was more in keeping with a'natural' dying process? I agree with Stacy, it's about the intention and focus. The choice of "allowing a natural death" vs CPR seems like a false dichotomy, leaving me with more questions than clarity..

Earl Quijada said...

Perhaps "natural" is a contextual term in what "normally" happens.

My is uncle is a farmer in Iowa who raises soy bean, corn, and cattle for meat. Last summer he was telling me a story of a calving death. In my naiveté I asked how he sells a dead calf. He looked at me funny and said no one buys meat unless slaughtered naturally. Needless to say I didn't venture into conversation of the dissonance (plus I had to tend to my child who was shocked by the electric fence that I guess is normal but didn't seem very natural).

Cohen Ilan said...

Interesting topic. I think as many answers exist, as many people live on this earth. For me, natural death means dying old in my house with my family around me.