A recent report in the New England Journal of Medicine highlighted a case of a patient who presented to the Emergency Department, unconscious, with a Do Not Resuscitate tattoo sprawled across his chest. The 70 year old man was quite ill on arrival. His blood alcohol level was high. He had COPD, diabetes, and atrial fibrillation. In the ICU he was noted to have hypotension and anion gap metabolic acidosis with pH of 6.81. “All efforts at treating reversible causes of his decreased level of consciousness failed to produce a mental status adequate for discussing goals of care.”
The staff decided initially to not honor the DNR tattoo. The words Do Not Resuscitate were inked. With a replica of his signature. This was a serious tattoo.
The staff placed the patient on empiric antibiotics, IV fluids, and vasopressors while they awaited an ethics consultation. He was also treated with bilevel positive airway pressure.
The staff did not want to commit to an irreversible path if the tattoo did not reflect the patient’s current wishes.
The ethics consult suggested that it was reasonable to infer the tattoo represented an authentic preference.
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.
The case report continued the authors were relieved to find his written DNR request, especially because a review of the literature identified a case report of a person whose DNR tattoo did not reflect his current wishes. 1
Once inked, it would be difficult to reverse the apparent intent and meaning on the patient’s chest. But, that may not be much different than a patient who has signed a DNR request (Advanced Directive) in the past and has changed his mind without changing the documentation. How is it any different? Sure, we rely on family/friends to update. But, if there is any ambiguity, the law supports honoring the directive.
The authors likely violated the intended advance directive on the patient’s chest. But, I understand why. They were not prepared to give that message the same import an Advanced Directive might have had in a past medical record primarily because of unfamiliarity.
I’m guessing, without any evidence, the patient had a negative resuscitative experience in a hospital in the past and did not want to repeat that experience. Hence, he took the extraordinary step of making a permanent mark on his body. Ironically, the steps the patient took caused the medical staff to second guess this wishes.
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When do we draw the line, if a tattoo does not suffice for DNR, would a medical alert bracelet with DNR have sufficed? Do you have to carry your Advance Directive with you at all times?
So even if a DNR is drawn in blood it is not sufficient to satisfy legal requirements? The ethics consult got this right. The patient knowing that he was an end stage alcoholic paid money to make sure that in the absence of any paperwork, conscious ability to speak, or next of kin his message was loud and clear with a tattoo on his chest.
When is common sense going to click in? Are we going to litigate these issues forever? Moreover why is resuscitation looked at as a miraculous cure for end stage disease. Resuscitation statistics are dismal out of hospital, and only slightly better in hospital.
No patient is going to tattoo DNR on their chest as a joke. If the patient had a medic alert bracelet that said the same thing, would that also be questioned as to current intent?
The patient knew what they were doing when they got the tattoo, and the meaning was as plain as the nose on your face.
How often can the paperwork for an advanced directive not be found at the hour of need. Do we need to carry legal paperwork on our persons at all times to have our wishes honored?
I am all for continuing resuscitation in ambiguous situations, but what part of this is ambiguous? Answer, no part.
Res ipsa loquitor.
The tattoo is indeed ambiguous. The patient didn’t write it, even if a facsimile of his signature was there. Watch and/or read The Girl With The Dragon Tattoo.
It would have ben a lot easier for the patient to wear a bracelet or dog tag with instructions written on them, yet he did not do that. Rather he came to the ER wearing a tattoo, which has no legal precedent as an advance directive, the provenance of which is entirely unclear.
He was an alcoholic? Maybe in a fit of drunken poor judgment he got tattooed, as happens with a lot of people in our militaries of old. People sober up and regret things they’ve done; maybe he did, but then got drunk again and didn’t think anything of it.
Davening over whether it’s ethical to resuscitate someone based on a tattoo they’re wearing is a waste of time. finding relatives is time better spent.
If you are the type who would tattoo DNR across your chest and change your mind, you should spend a few more bucks and have the N crossed out or covered. Or put a note in your wallet stating “ignore DNR”.