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An Unconscious Patient With a 'DO NOT RESUSCITATE' Tattoo (nejm.org)
A real-life case study, published on New England Journal of Medicine, documents the ethical dilemma that a Florida hospital faced after a 70-year-old unresponsive patient arrived at the hospital. The medical staff, the journal notes, was taken aback when it discovered the words "DO NOT RESUSCITATE" tattooed onto the man's chest. Furthermore, the word "NOT" was underlined with his signature beneath it. The patient had a history of chronic obstructive pulmonary disease, diabetes mellitus, and atrial fibrillation. Confused and alarmed, the medical staff chose to ignore the apparent DNR request -- but not without alerting the hospital's ethics team, which had a different take on the matter. From the report: We initially decided not to honor the tattoo, invoking the principle of not choosing an irreversible path when faced with uncertainty. This decision left us conflicted owing to the patient's extraordinary effort to make his presumed advance directive known; therefore, an ethics consultation was requested. He was placed on empirical antibiotics, received intravenous fluid resuscitation and vasopressors, and was treated with bilevel positive airway pressure. After reviewing the patient's case, the ethics consultants advised us to honor the patient's do not resuscitate (DNR) tattoo. They suggested that it was most reasonable to infer that the tattoo expressed an authentic preference, that what might be seen as caution could also be seen as standing on ceremony, and that the law is sometimes not nimble enough to support patient-centered care and respect for patients' best interests. A DNR order was written. Subsequently, the social work department obtained a copy of his Florida Department of Health "out-of-hospital" DNR order, which was consistent with the tattoo. The patient's clinical status deteriorated throughout the night, and he died without undergoing cardiopulmonary respiration or advanced airway management.
I'm starting to wonder if my Digital Noise Reduction tattoo was a bad idea in hindsight.
Takes you to a webpage with various forms of authentication and contact info for ultimate authority if there's any question.
For all they knew, the tattoo could have been an artifact of previous poor life choices, and nothing more than a joke. A tattoo is not a legal document. Imagine if it HAD been a joke, and the family sued the pants off the hospital for denying treatment to their family member without a formal DNR request?
It sounds like they did pretty much everything right, and ultimately obtained the legal documentation that stated he definitely was a DNR.
This story was posted while I was watching the House M.D. episode called "DNR".
The medical staff made what I feel to be, while possibly incorrect in the long right, a rational choice. Going the way of "Let's err on the side of the choice we can reverse, rather than risk death." That seems like an unusually well considered and sane choice.
I would do exactly what they did. When you're in a gray area touching on malpractice, negligence, and homicide... well, you don't take chances.
It's also possible for people to change their minds. Apparently, in Florida you file DNR orders with the state. It's good to have an official, documented process when you're making decisions about someone's life. In the article, they even referenced a case where the patient's DNR tattoo did not reflect his current wishes.
If they are terminal and wish to pass, there will be plenty of opportunities to end their care. Case in point, this patient died later that night.
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According to the latest ruleset, this post should be modded as Vorpal Flamebait +5.
I better make sure that the G in my GNR (Guns n Roses) tattoo cannot be mistaken for a D, and I hope the red bandana on Axl's head looks like a red bandana.
When I received ERT training in Oregon, we were told explicitly to *not* honor DNR tattoos, as a tattoo was not considered a legal DNR order in this state. As always your mileage may vary.
I associate with relatively hardcore motorcycle crowds, and DNR tattoos are ...if not common, at least not unknown. But I wonder how many of them are misguided bravado? (I'm guessing, many.) According to my own training (admittedly a few years ago), the tattoo would not be honored in my state. But ride into a different state and then spill your bike, and EMTs might just let you pass. Wouldn't that be a stupid way to die.
Oliver's law of assumed responsibility: If you're seen fixing it, you will be blamed for breaking it.
This was fairly unambiguous, had a copy of the man's signature, and was pretty much completely unmissable.
In this case it sounded like it was pretty plain. Maybe he should have had it notarized and dated or made a notation to an actual document on file some place ... but it bore the man's signature, so it's not like you would assume it isn't real. This was about as unambiguous as you get.
Now, one might argue that if some night one of your friends tattoos that on your chest while you're drunk it could lead to your death, and then from there you argue that you can never take such a thing seriously.
But that's an exercise for lawyers and philosophers to try to play with to find examples of where it clearly didn't mean what it said.
You mean I can tattoo my DNR on my chest WITH MY SIGNATURE, and that is still not clear in the eyes of doctors?
What the hell does it take, then?
Unless a female serves you with a signed, notarized, legitimized DO NOT BANG order, you're good to go...
Got it..
Will be billed and the estate likely will have to court to fight the bill.
Is it unfortunate that he never knew all the work that he put into getting that tattoo paid off?
Also, assuming it was his actual signature tattooed on, does that make his skin a legal document?
If I tattoo "DO NOT RAPE" and sign it on my ass will that save me at the local 'pound me in the ass' prison?
Seriously, this does not belong on /.
They're lucky he died. If he lived, he could have sued the fuck out of that hospital, and he would have won, easily.
Huh?
Is it too much to RTFS? Because if you RTFS you'd see that they stabilized him long enough to confirm his DNR status, and then let him die. They did not resuscitate. "he died without undergoing cardiopulmonary respiration or advanced airway management"
You can register an Advanced Directive with a Living Will and/or Health Care Proxy at the U.S. Living Will Registry. The forms for all 50 states can be downloaded from the site or obtained for your state at your local hospital (and perhaps doctor's office). There is a fee to register the forms yourself, but many hospitals will register them for you for free or at a reduced cost. You can create an account the site to manage your registered forms. They will send you a card to carry in your wallet (which can also be downloaded) Health care providers can access your documents when needed to confirm your wishes. Registration is permanent, subject to your management.
I know this because... My wife Sue was diagnosed with a fatal brain tumor the day before Thanksgiving 2005 and died seven weeks later. We both completed Advanced Directives at that time, so I have one registered. She named me as her Health Care Proxy and specified no extraordinary measures -- I had to sign the local order DNR several weeks later when her brain stem was damaged and she fell into a coma. She wasn't expected to live through the night, but died a week later. I kept her feet warm (she always liked that) and I slept by her side in the space between her and the bed rail. I heard her last breath and felt her last heartbeat as she died in my arms.
Remember Sue...
It must have been something you assimilated. . . .
Always resuscitate them, explain what happened, and then if they protest that they didn't want that, just kill them.
"DNR"?!
"Born to Die" isn't edgy enough for ya?!!
As told by Michael Crichton during his MD training in his book Travels:
--
Dr. Z was a seventy-eight-year-old physician who entered the hospital in a near coma, in end-stage cardiac and renal failure. His son was also a physician, but not on the staff of the hospital, so he could only visit like any other relative, and he had nothing to say about his father's care. He did, however, state that he wanted his father to die peacefully.
The old man was on the critical list for nearly a week. He had a cardiac arrest one night, but he was resuscitated. His son came in the next day and asked, with a certain delicacy, why the staff had resuscitated the old man. Nobody answered him.
Later that day, old Dr. Z suffered sudden massive congestive heart failure. The hospital staff was making rounds; they all rushed to his bedside. In a moment he was entirely surrounded by white-jacketed interns and residents, working on the old man, sticking needles and tubes into his body.
In the midst of all this, he somehow emerged from his coma, sat bolt upright in bed, and shouted clearly and distinctly, "I refuse this therapy! I refuse this therapy!"
The residents pushed him back down. He got the therapy anyway. I turned to the attending physician, and asked how such a thing was possible. This man was, after all, a physician, and he was unquestionably dying-if not today, then tomorrow or the next day. Why had the house staff contradicted his wishes, and those of his family? Why was he not being allowed to die?
There was no good answer.
Dr. Z finally died on the weekend, when hospital staffing was light.
Which should be an insanely easy win since he did have a lawful DNR order files with the state
Normal people worry me!
The acronym DNR is not registered by any medical institution however if spelled out in plain English and signed then it would constitute a legal basis of recognition.
Anyone who prefers DNR is kind of an idiot.
I WANT TO LIIIIIIIIIIIIIIIIIIIIIIIIIIIVE. \o/
AC plays at being an armchair lawyer.
Yeah, the health care industry is going to bet on your opinion.
but it bore the man's signature, so it's not like you would assume it isn't real.
But it didn't - it bore a forgery of the man's signature by the tattoo artist. Unless he took the tattoo pen himself and signed his name on his own chest (quite interesting feat, if you ask me), it's not his legal signature.
That is all.
in a CPR situation or similar (not a clinician). People are responsible for themselves - not a court. "My body, my choice." Choosing to not have the tattoo removed was obviously a conscious choice.
Then again, I'm not looking to bill $4500 for the CPR 'procedure' - I'm happy if nobody vomits in my mouth.
My God, it's Full of Source!
OUTSIDE_IP=$(dig +short my.ip @outsideip.net)
Serious comment..
Did they try to charge the man, his estate, or his insurance?
You specifically say that you don't want a service, the hospital renders the service anyway..
Did they charge?
I bet they did.
This whole setup where the hospital can do whatever they want to an unconscious person, and then charge them whatever the hell they want after is crazy.
Single Payer for EVERYONE!
> It's not a legal document because there are no signatures
Quoting TFS, 'furthermore, the word "NOT" was underlined with his signature beneath it.'
> if you start treating one tattoo as a legal document, you have to start treating ALL of them that way.
How do you figure? If you start treating one piece of paper as a legal document, you have to start treating ALL pieces of paper as legal documents?
BTW, the supreme law of the country, the US Constitution, is also written on skin.
> No, because a legal document that states they're DNR is a binding contract that they made. ...
> There's nothing to "prove." It simply is not a legally binding agreement/contract.
There are four elements that make up a contract. A DNR has none of the four. The four elements of a contract are:
An offer
An Acceptance
Mutuality (agreed understanding of the terms)
Exchange of consideration (payment)
> Does power of attorney even grant you permission to sign a document with another person's name, or does it merely grant you permission to sign a document on behalf of the other person but still using your own name?
It does whatever it says it does. Power of attorney is a rather general term, not one specific document. In general, if I say to you "you can sign my name on this type of document", you may indeed do that. Years ago I double checked the federal and Texas statutes on this issue.
News for Nurses?
I pretty sure that the patient ended up getting burned by that decision.
People have been known to do all sorts of things to impress others. This seems just like another in a long line of ill-advised attempts to make themselves part of an in-group or the like.
Not exactly shortsighted as all sorts of people have different means of being validated, but certainly it is not taking into account a myriad of situations that are likely to come to pass during one's life.
I have been considering doing this, along with a *NOT ORGAN DONOR* tattoo/stencil for when I am hoboing it in a few years.
While there are good medical staff out there, in my experience the bills as well as the quality of care varies dramatically depending on region, and should I ever been in a situation where I am unconscious due to life threatening injury, I would rather not wake up with some low quality repairs and 50-(X)00k worth of medical bills to look forward to.
I got my excellent medical care as a kid in the 80s and maybe early 90s and since then it has been all downhill decline into expensive and substandard medical work.
Instead of putting DNR on your chest... Why not provide the contact information of somebody who understands your medical history, your wishes, has a copy of your living will properly executed and has a valid medical power of attorney? Forget the tattoo and just go for the medical alert bracelet with the same information if you are serious.
Seems to me that a tattooed DNR request isn't likely to have the desired effect regardless of where you end up. What you need to provide access to is the actual legal paperwork and the faster you can get this into the ER doctor's hands, the better.
"File to fit, pound to insert, paint to match" - Aircraft Maintenance 101
invoking the principle of not choosing an irreversible path when faced with uncertainty.
That is a cop-out. Under these circumstances resuscitating is just as irreversible as not resuscitating.
Under these circumstances, after a "successful" resuscitation, the patient will most likely not be able to "reverse" that decision, he will likely be physically or mentally incapable, or both.
In other words: chances are he will end up in the exact situation he was trying to avoid. And I am fairly sure none of the people who performed the resuscitation in the first place will be volunteering to actively pull the plug at that time.
This is not a sneer, moral decisions like these are extremely difficult and stressful, that is why such simplifications do not belong in the discussion. It is also why DNR whishes should have a strong legal position. It takes some of the difficulties away from the medical staff and puts it where it belongs, with the patient himself.
And yes, that may be a difficult decision to make for yourself. Though, freedom does not equate easy.
When I recently got CPR training, I was told to do what I felt was right when encountering such a tattoo. However, I was also told that trained medical personnel should definitely honor such signs as they are legally binding in the Netherlands. We also have official badges specifically for this purpose.
This should not be an ethical dilemma in developed countries. It should not even be a legal dilemma....
0x or or snor perron?!
Dead, alive, persistent vegetative state... whatever. THIS is the important one. https://i.pinimg.com/originals...
Dear Slashdot: next time you want to mess with the site, add a rich-text editor for comments.
My dad was chronically ill for years, one organ after another failing. Towards the end, he wanted nothing more than for it all to be over. The miracles of modern medicine - they just wouldn't let him die. He had registered a DNR - the hospital even f*cking knew about it - and when his heart gave out, they revived him anyway. He suffered on for another year or more. Gee, thanks for that.
We initially decided not to honor the tattoo, invoking the principle of not choosing an irreversible path when faced with uncertainty.
What uncertainly. Seriously, what does a guy have to do in order to be allowed to die in peace? Filing a piece of paper in some government office somewhere is useless: the paramedics show up, or someone takes you to the ER, and no one has time to find out whether that paper exists. That's what the tattoo is for.
Look, I read the other comments about drunken idiots getting DNR tattoos. They probably also enjoy playing the odd round of Russian Roulette and do drunken dares with running chainsaws. There's no cure for stupid. Believe the tattoo, don't make other people suffer because of a few idiots.
Enjoy life! This is not a dress rehearsal.
Unless he gave power of attorney to the tattoo artist to sign his name...
It seems that he forgot the second part of the tatoo that should have read " because you won't get paid"
It seems to that the consequence a hospital should face for failing to honor a DNR is that the hospital assumes financial responsibility for the patient's health care from the time the patient entered their facility until the patient's natural passing, including subsequent nursing home or hospice that may have become necessary as a result of their actions.
Maybe more, but this seems like a decent starting point.
I remember reading some article long ago about men in the army or such signing DNRs if something were to happen to their penis or testicles, a concept I personally couldn't understand. On the other hand, I recently started HRT, so perhaps I was never supposed to ;).
Everyone who has aging parents or is concerned about how they might end up after a catastrophic accident should know about these issues.
For anyone interested, I recommend the book "Extreme Measures" by Jessica Nutik Zitter, but there are many others out there.
Here in the middle east, he would be revived whether he likes too or not, because allah/jehova said so. You are lucky to be living in a civilized place, try not to fuck it up.
Sincerely, Lucas from Israel.
Avantgarde Hebrew science fiction
I can't think of any another reason for the weasel word justification other than they didn't.
Doctors can do what the patients want.
Even if the have to first consult with a ethics coach.
Here's a few examples of real situations I've personally been in, to give you an idea of just how much of a gray area this can be, and how challenging it can be to do the moral and ethical thing.
A 40 year old man is diagnosed with terminal pancreatic cancer. While currently in good health, he is expected to have less than 4 months of good health left, and 6 months at most to live. He gets stung by a bee, to which he is severely allergic, and develops an anaphylactic reaction. His airway is swelling shut, his blood pressure is dropping, he is losing consciousness and can't talk nor follow directions. He needs an administration of Epinephrine, along with multiple other drugs and interventions, to reverse the allergic reaction. He has a valid DNR bracelet on his wrist, which he has not removed. What's his intent? Did he intend for the DNR to prevent you from treating a life threatening allergic reaction?
You are called for an 80 year old woman who is unconscious on the floor of her kitchen. She has a valid DNR order. Her husband tells you she choked on her soup, and needs the Heimlich. You don't see any food in her mouth or upper airway. Performing the Heimlich, chest compressions, or inserting an advanced airway would violate the DNR. What do you do?
An elderly man arrives in the ER with fresh bruises. He is unconscious with critically unstable vital signs and inability to maintain an airway. A woman identifying herself as his daughter says that she can't find a DNR, but she is certain he had said that the doesn't want anything heroic measures done at the end of his life. You suspect foul play given his apparent injuries, but then again, old people bruise easily. You have no ID on the man, and haven't yet been able to ID the alleged daughter. Do you begin resuscitation, at least long enough to verify the pretense or absence of a DNR?
You get called to do a welfare check on someone who hasn't been seen in several days. You force entry into his house, and find him unconscious on the floor, surrounded by blood. There's a scrap of paper next to him that says "Don't bring me back" with a signature. You can't tell whether this is the natural progression of some terminal illness, an accident, an attempted suicide, or an attempted murder. You also can't tell the extent of the patient's injuries and whether they're obviously incompatible with life. Do you begin resuscitating the patient?
The case of my own grandfather, who had terminal lung cancer and a valid DNR. His dying words were "Please save me." He specifically asked to be saved. Do we start performing resuscitation?
In each of these cases, you need to make an initial decision within seconds. You don't have time to do a lot of research, interview witnesses, search for evidence. And, if you guess wrong, the patient could die - which is kind of a lot for us to live with.
I'm not trying to defend or blame any particular party here. I'm just asking for a little sensitivity to the fact that, most of us in emergency health care are decent people doing the best we can to serv
How many slashes would a slashdot dot, if a slashdot could dot slashes?
What's nerdy about this?
Oh that must be why Americans have lower life expectancy, all the extra care and money spend trying to keep them alive...
Dr McDougall (Of The McDougall Diet fame) says he has "DO CATH I WILL SUE" tattooed on his chest. Seems like it should be on his upper thigh or groin since that is where they insert the catheter.
I'm surprised this hasn't been mentioned; just last week RadioLab/NPR ran a segment on this subject.
"As part of the decades-long Johns Hopkins Precursors Study, Gallo found himself asking the study's aging doctor-subjects questions about death. Their answers, it turns out, don't sync up with the answers most of us give."
http://www.radiolab.org/story/...
The UK did not have the ability to treat this child's condition, but people in the USA could. Or at least they claimed they could have.
The important part of your statement is "they claimed they could have". The quack in the US claimed this without ever having examined the patient and the UK doctors were appalled at the irresponsible nature of the US doctor's claims. After the baby's condition became clear to him he was forced to admit that there was absolutely nothing he could have done for the child. All he did was act is a grossly unprofessional manner and made things a lot worse for everyone else.
European health care "light years" ahead of the USA? I call bullshit.
This is indeed, as you say, "bullshit" because a light year is a measure of distance. However, it is very accurate to say that European and Canadian healthcare is about 3 years ahead of healthcare in the US because the average life expectancy in Europe and Canada is about 82 years while it is only about 79 in the US (averaged over both genders).
A QR code won't work for more than a decade. Use something that can be read well, even 60 years later, when it looks like a CAPTCHA.
This is a US thing, as far as I can tell.
Nobody in all of Europe would understand "No code", let alone that it "must" mean that, or that the ham tadio usage would be invalid.
So keep your arrogant god-complex snobbery to yourself. You sound like a doctor.
Reminds me of Trevor Philips tattoo on his neck of lined dashed and "CUT HERE".
https://vignette.wikia.nocookie.net/gtawiki/images/2/28/TrevorPhilips-GTAV.png
"No Code" would be understood in Canada as the codes are pretty much the same from hospital to hospital in North America short of a few department/region-specific codes for disaster scenarios:
Code Red: Fire
Code Blue: Cardiac Arrest
Code Orange: Disaster or Mass Casualties
Code Green: Evacuation
Code Yellow: Missing Patient
Code Amber: Missing or Abducted Infant or Child
Code Black: Bomb Threat
Code White: Aggression
Code Brown: Hazardous Spill
Code Grey: System Failure
Code Pink: Pediatric Emergency and/or Obstetrical Emergency
Code Red and Blue are universally understood for Fire and Medical emergencies. Code Amber is based off "Amber Alert", which is also pretty much universal in North America. All the Doctors and Nurses carry a card that has these listed on them. In a Hospital, Code Blue overrides elevators, so during such emergencies, you may get stuck on a floor if you're not staff.
could easily have got a second tattoo, a nice black one, all over the first.
Making it invisible.
Why do we want the stupid to survive?
It looks like you are married to your work.
If something is so important that you feel the need to post it on the internet... It probably isn't that important.
why existing and official DNR order could not be obtained immediately just because it as "out of hospital" in XXI century?
I do not believe in karma. "Funny"=-6. Do good and forbid evil. Yours, Oft-Offtopic Flamebaiting Troll.
There was no good answer.
That's because the real answer is money.
There's only one industry that's even more corrupt and self-serving than the financial industry -- and that's healthcare.
He'd have had more luck if the tattoo read 'my medical insurance has lapsed.'
Requiem for the American Dream
The sad truth is that when there's money involved (especially BIG money which is obviously the case with healthcare in the US), you can bet your house that money is at the bottom of every single decision.
Simple rule of thumb regarding any human interaction: Is money on the line? Then there is absolutely no need to look any further for motive or incentive. When money is on the line, money explains everything.
You've clearly never had to deal with the affairs of either multiple amputees, the very elderly, major stroke victims, or the otherwise-incapacitated. There is no legal requirement for you to take a pen and sign your own name for it to be a valid signature. In legal terms, the signature is affirmation of consent to whatever is being signed. You don't have to sign your name, you can draw a tiny house. You can have someone else sign your name for you, though in that case it helps if there are witnesses on-hand who could testify that you clearly expressed intent and permission to sign on your behalf. Really, you don't even need to sign, just have several people who could testify that you appeared to be of sound mind, and made your intent perfectly clear verbally. There's even an entire legal framework (Power of attorney) in which you give another person the legal authority to make decisions and sign documents to which you will be held accountable as though it was you who made these decisions and signed them. You don't need to be unable to sign or make decisions to give someone else POA, you can do so just because if you like.
So, point is that the tattooed signature isn't legally a forgery and is perfectly valid as it's pretty obvious the man assented to the tattoo artist signing it on his behalf.
But never mind me. I'm sure you're a lawyer or some such with as confident as your assertion was.
Most people die in hospitals and most healthcare is done on people who will never get well enough to enjoy any marginal life extension. A rational attitude is to invest in healthy lifestyle and simple drug treatments for diabetes, blood pressure and cholesterol first. Of course, if you get one of those rare illnesses that are both curable and serious enough to require treatment, it's worth the expense. But other than that? I would rather travel the world for a year while I am still healthy enough to enjoy it than linger on for 3 years in hospitals. I will get the same tattoo if things go South.
What part of "DO NOT RESUSCITATE" seemed unclear?
(And if you're stupid enough to get a tattoo with the words "DO NOT RESUSCITATE" on your chest, you deserve whatever happens as a result.)
âoeRebuild Him. Better. Faster. Stronger.â
You have one life to live, even in pain Iâ(TM)d prefer being alive. Even if the experience is torture Iâ(TM)ll take that over no experience at all.
For starters, the patient DID file the appropriately notarized legal documents and the hospital staff DID look them up and honor them.
Reading between the lines in the article, it also appears the hospital staff wouldn't have bothered to look up the legal documents if the tattoo wasn't there; so, the tattoo definitely did its job. And that's definitely something to think about if you ever file a DNR. "DNR filed with ..." would probably work better...
The real dilemma would have occurred if there were no backup documents. The tattoo probably wasn't legally binding because it wasn't notarized. And I don't think you could get it notarized because that would required the notary's seal (at least everywhere I know of). I guess you could get the seal tattooed or branded as well, but they seems a bit extreme...
An engineer who ran for Congress. http://herbrobinson.us