Published in: New York Times
Issue/Volume: September 25, 2008
Written by: Anemona Hartocollis

9/25/2008 – The goal is to prevent potentially dangerous mistakes, like giving the wrong food to an allergic child, or allowing a patient with balance problems to walk unescorted down a freshly waxed hallway. The drive was spurred, in part, by a notorious 2005 Pennsylvania case in which a patient nearly died because a nurse used a yellow band thinking it meant “restricted extremity” (don’t draw blood from that arm), as it did at another hospital where the nurse sometimes worked, when at this hospital it meant D.N.R.

While the new color-coding has been quickly embraced by at least 20 states and endorsed by the American Hospital Association, the purple bands, typically embossed with the letters D.N.R. to reinforce the message, are meeting with some resistance.

The nation’s leading hospital-accreditation agency, known as the Joint Commission, has expressed caution about the new system, citing concerns about branding patients by their end-of-life choices, or inadvertently broadcasting those choices to family and friends who have not been consulted.

The commission also said that children who do not understand the system had been prone to trade the wristbands like baseball cards.

“You need to strike a balance between the need for patient safety and accuracy and the whole privacy concern and sensitivity and compassion for the patient,” said Roxanne G. Tena-Nelson, executive vice president of the Continuing Care Leadership Coalition, a group of long-term-care providers in New York.

In most places, the new bracelets replace colored ones that have been used for decades without uniformity: a survey by the Greater New York Hospital Association last year found nine different colors used to denote patients with D.N.R. orders, five to indicate allergies and nine to highlight risks of falling. There is still some variation. Ohio has adopted the red and yellow bands but has avoided the purple ones because they conflict with a state law requiring a clear wristband for D.N.R.’s.

In New York, the Roosevelt Hospital division of St. Luke’s-Roosevelt Hospital Center, near Columbus Circle, began using the yellow and red bracelets this month, but is still debating whether to add purple. In Arizona, one hospital embossed its purple bracelets with a white dove carrying an olive branch, rather than D.N.R., while another chose the initials A.N.D., for “allow natural death,” as a gentler alternative.

Kim Miyauchi, associate nursing director at Kingman Regional Medical Center, the Arizona hospital that uses the white dove, said officials there worried that wearing the initials D.N.R. on one’s wrist was “a little bit harsh,” and also failed to convey nuances best captured in a medical chart, as with a patient who wants medication for heart failure but not to be shocked by a defibrillator.

“Sometimes people want varying levels of treatment at the end of life,” she explained. “Sometimes it’s not so clean as just don’t do anything.”

Attuned to the sensitivities, hospitals have cautioned their staffs that wearing the color-coded bracelets is voluntary, and that patients are allowed to opt for some other method instead, like colored dots — or just old-fashioned notations — on medical charts.

Some hospitals have also had problems with colored bracelets that patients bring from home, like the ubiquitous yellow Lance Armstrong “Livestrong” bracelets. Most hospitals are asking patients to cut these off, but if they refuse, the popular bangle can be covered with tape instead.

Proponents of the new system argue that standardized colors are essential to patient safety, especially since nurses and doctors often move among several hospitals.

The specifics are based both on historic precedent and the sign language of colors. Yellow, for falls, is commonly understood as a symbol for caution, whether by janitors mopping floors or by traffic engineers. Red, for allergies, is associated with a command to stop and check for danger. In the past, some hospitals have used blue to signify D.N.R., but it was ruled out on a national level, Ms. Tena-Nelson said, because the phrase “Code Blue,” is often used to call for resuscitation, the opposite of what D.N.R. patients want.

The color-coded system could be seen in full flower the other day on Yau N. Wan Gong, 77, who was recovering from gallstone surgery at Roosevelt.

Mrs. Gong was taking her afternoon promenade in the post-surgical ward wearing hospital-issued yellow slipper-socks, to denote that she was at risk of falling, along with two plastic bracelets on her right arm, one yellow, like the socks, the other pink. Pink has been adopted by some hospitals to indicate that a limb is somehow compromised and should not be used for procedures like drawing blood or inserting an intravenous line. (Mrs. Gong recently had surgery on her right side, so that arm is weak.)

Roosevelt also uses green bracelets, to mean “no blood transfusions,” usually at the request of a patient with religious beliefs that conflict with transfusions. But in Minnesota and Colorado, as in New Jersey, green indicates a latex allergy.

In Mrs. Gong’s case, the hospital staff had allowed her to continue wearing a green jade bracelet, which her son, Peter Gong, who was accompanying her on her walk, said gives his mother comfort because in Chinese culture it is supposed to ward off arthritis pain. Mr. Gong said nurses had carefully explained the color-coding system and asked for his mother’s consent, and that he was all in favor of it, hoping that “people will have a little more patience, hopefully, and understand that she is not as quick as a younger person.”

The system has made some patients more aware of the possibility for simple yet potentially fatal errors in any hospital.

When nurses at Roosevelt pointed out the yellow fall-risk name tag on his hospital room door, Tom Pineault, 74, a former merchant seaman who had just emerged from surgery for an ulcerated foot, also checked the tag for his name. “I made sure that was me that was in there,” he said. “I didn’t want to end up with somebody else’s meal.”

At Metropolitan Hospital on the Upper East Side, officials handed out red, yellow and purple pens to drive home the new color-coding system to the staff, since the hospital had previously used red bands, now for allergies, to denote “no blood transfusions,” now green.

Meryl Weinberg, the hospital’s executive director, said some employees worried that psychiatric patients would become obsessed with fiddling with the bands, but that has not turned out to be a problem.

As for the purple bracelet, “We did have one patient refuse to wear it because of the family not knowing,” said Patricia Graham, deputy director of nursing at Metropolitan. But she said the hospital had found the privacy concern less pressing than anticipated, noting that many patients who choose not to be revived are deeply committed to their decision, even proud of it.

And, she noted, most D.N.R. patients are in such poor condition that they rarely walk the hallways for all to see. To illustrate, Ms. Graham took a visitor to a room where a comatose woman was lying in bed attached to a ventilator and intravenous feeding tube. On the woman’s wrist was a green band — no transfusions, please — and a purple one.