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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.
Simple DNR orders are for people that are already sick and don't want to be put through hell and back to die. I think of my 80+ great-uncle that had severe emphysema that coded and was resuscitated and spent 6 months in a nursing home with 8 broken ribs and he could barely breathe before they broke all his ribs saving him. And this was the 3rd time it'd happened.
For the rest there are some very good forms out there that can walk you through the majority of the invasive life saving measures and allow you to apply advance directives to them. But keep in mind, your spouse/family can override your directives if you are unconscious or impaired unless they are prefiled with the hospital you are taken to (good luck guessing that one).
Just remember, saying nothing means they will do EVERYTHING, including a lot of things you may not even realize they could or would do.