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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.
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.
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.
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. . . .
" Why had the house staff contradicted his wishes, and those of his family? Why was he not being allowed to die?"
Answer:
$70,000+
That simple. In the seven 'extra' days he 'lived' he was billed for doctors, specialist, anesthesiologist, nurses, tubes, IV bags, catheters, meds, rubber gloves, and many other things.
https://www.debt.org/medical/hospice-costs/
How much is end of life care?
Costs for End-of-Life Care. In 2009, Medicare paid $55 billion for doctor and hospital bills incurred during the last two months of patients' lives. Hospital inpatient charges exceed $6,200 per day, and costs to maintain someone in an ICU can reach up to $10,000 per day.Mar 22, 2016
That simple. In the seven 'extra' days he 'lived' he was billed for doctors, specialist, anesthesiologist, nurses, tubes, IV bags, catheters, meds, rubber gloves, and many other things.
Or, maybe it's because people don't like seeing other people die if they can help it. We can break this down to a profit motive but that's not likely on the minds of the people working on that shift or that patient. If you are going to put a profit motive on it then it's more like to them they get paid to not let people die.
Perhaps put that in your profit motive perspective. These are people getting paid to keep other people alive and healthy. If they are shown to be "compassionate" and letting the sick die in peace then they could find themselves no longer employed. This can be seen as being incompetent, uncaring, or even malicious. This gets to my next possible answer.
Maybe hospitals don't want to be seen as allowing people to die. This can affect their profits. Even if it's a charitable hospital that lives on donations a history of not attending to people can diminish donations. Taken too far and a hospital can be sued by a grieving family for malpractice, or even murder, for not attending to people's needs, or what they perceive as a need. The costs of the rubber gloves and meds used in any given case have to be tiny compared to the costs of defending a lawsuit and the investigation of the care provided.
This is a complex issue and calling this just a tactic to gain more money in billable services is simplifying the issue into the absurd.
I am armed because I am free. I am free because I am armed.
What's wrong with being an organ donor. It's not like you're going to miss them.
> Or, maybe it's because people don't like seeing other people die if they can help it.
Once a patient has made their wishes true IT'S NO LONGER UP TO YOU. Your "feels" are entirely irrelevant. This is what we get from all of this statist nanny crap. A guy can't even have his own wishes in this matter honored and most of the peanut gallery is willing to make excuses to IGNORE the individual.
A Pirate and a Puritan look the same on a balance sheet.
This is a complex issue and calling this just a tactic to gain more money in billable services is simplifying the issue into the absurd.
Nope, it's pretty simple. It's about the money.
If someone expresses their desire to not be treated, either directly or through documentation or representation, you don't treat them.
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).
You need to understand the concept better.
DNR's is not a suicide law being forced on everyone.
Instead it is the legal option for people that have previously thought it out and decided that they do not want to spend the rest of their lives on machines.
Frankly, you would be pretty stupid to just get one for no more reason than the risks of a standard CPR.
Instead, there are three typical reasons to get one:
1) Religious. Just as some people do not want to get blood transfusions, some don't want to get CPR
2) Extremely Fragile. You already know that your health is so fragile that should you get CPR, chances are you will never wake up. Not never be as healthy again, simply never wake up. 80 year olds are prime examples for this, not 50 year old people. Someone that is already has severe organ damage are other examples.
3) Quality of life. Your body is not fragile per se, but is severely disabled. For example if you have Alzheimer and do not want to end up being stuck in bed and also unable to think or talk.
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