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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.
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.
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. . . .
Always resuscitate them, explain what happened, and then if they protest that they didn't want that, just kill them.
As told by Michael Crichton during his MD training in his book Travels:
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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.
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.
What's wrong with being an organ donor. It's not like you're going to miss them.
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.
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?
First, a lot of people in the UK don't consider themselves a part of Europe. Second, there was no evidence that the US could have done anything for that baby and the doctors were of the opinion that the experimental treatment would prolong suffering. There was no murder involved.
As related to the topic of this original story, being kept on life support unnaturally is often not in the well being of a patient. Many doctors have their own DNR orders because they know the torture that these actions can bring. The same doctors however are forced to rescuscitate patients in the US if there is no DNR order. This issue is not about dying with dignity, but dying without torture.
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).