Slashdot Mirror
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.
Just make sure to underline Noise.
As an ER doc, I would hate to run into this but my wife (an ER) nurse and I have talked about doing exactly this.
Except we're not much into tats.
Faster! Faster! Faster would be better!
This actually was the case for another patient. They lost a poker bet and had to tattoo DNR on their chest. Discovered during intake for leg amputation, patient clarified "he indicated that he would want resuscitative efforts initiated in the event of a cardiac or respiratory arrest."
https://www.ncbi.nlm.nih.gov/p...
whois gawk date unzip strip find touch finger mount join nice man top fsck grep eject more yes exit umount sleep dump
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.
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.
If what you said is true, how can they even touch an unconscious person that comes into the hospital?
Technically, what the OP said is true. Most (all?) legislatures have covered this by creating "implied consent" for patients who are unable to give consent in a life threatening situation. The assumption is they would consent, or the guardian would.
This is something every first aid course I've ever had over the last 30 years has taught. If you come across a conscious accident victim, you ask if you can give aid. If they say yes, you're good. If they say no, you may not touch them. This applies to professionals like EMTs, too. If you tell a firefighter/paramedic you refuse treatment, that's what treatment you'll get.
There is always one altruistic person in the group that is concerned about this. The answer to how you deal with an uncooperative conscious victim is, you wait until they pass out, implied consent kicks in, and you can help them. The fact they said "no" before was based on them being conscious. Going unconscious changes the situation.
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.
Back in the early 2000's, I started an organization called No-Code International to get rid of Morse Code tests for ham radio licenses, world wide. We succeeded.
Startlingly, "no-code" has taken on another meaning since then. Apparently doctors and laymen wear necklaces with a token inscribed with the words "No Code", which means don't resuscitate me.
I am sympathetic with the desire to avoid the almost uniform bad outcomes from CPR, etc. However, I just happen to know a man who went into v-fib while sleeping, for no known reason, in his 50's. His wife noticed him snorting in his sleep, he happened to be in a brand new hotel with a newly-trained staff who had received CPR training, and had brand new AEDs. He required 4 shocks in all and was unconscious and intubated in intensive care. He recovered fully, received a pacemaker which had some start-up issues, but has had a full decade of quality life since then with no complications. So, I don't know what to think about DNR.
Bruce Perens.
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?
This is indeed, as you say, "bullshit" because a light year is a measure of distance.
Which is why I put "light year" in quotes. I used the term from the parent post. I realize that it is a measure of distance, I assumed it was used figuratively as meaning a vast difference. I'm sure you knew that.
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).
I noticed that African nations ranked lower than average on that chart compared to the rest of the world, and European nations ranked average to above average. I see that the USA has a population of people from African descent of about 13%. Getting a good number for the percent of people in Europe of African descent is difficult, but my best guess is that it's about 2%. Similarly the percentage of those of European descent in Africa is quite small, also likely about 2%. Is it possible that this very small difference in lifespan between USA and Europe is due to genetics rather than the quality of the medical care?
Here's something interesting, a study showing that people of African descent in America live on the average 4 years less than those of European descent.
http://www.businessinsider.com...
The authors of the article linked above seem to think that this is not genetic but merely a reflection of poverty and education. But it seems Americans are highly educated.
http://newsfeed.time.com/2012/...
It also seems Americans make good wages.
https://en.wikipedia.org/wiki/...
Perhaps it's genetic, perhaps poverty, perhaps education, or maybe it is in fact the healthcare in the different countries. There's other factors too, like climate, crime, diet, accidents, and more. Placing this rather small difference in expected lifespan on the different health care systems alone seems like a pretty big leap in logic. Perhaps a leap in logic the distance of a "light year"?
I am armed because I am free. I am free because I am armed.