Monday, January 8, 2018

DNR tattoos

Hi. I'm Art Caplan. I'm the head of the Division of Medical Ethics at the NYU School of Medicine. You may have heard about this case. A 70-year-old man showed up at an emergency room in Florida. He had a very elevated blood alcohol level. People intervened and found that he had a big tattoo that read, "Do Not Resuscitate."

He had a long history of many medical problems. He had chronic obstructive pulmonary disease and diabetes. He had many other medical complications. He was definitely difficult to revive, and the question became, should they try to do that? Do you have to follow instructions that are tattooed in large print on someone?

My view is that it's a tough decision because, clearly, somebody who puts "Do Not Resuscitate" across their chest is trying to send a message about their values. On the other hand, there are no reasons to think that a tattoo is in any way legally binding. We don't ask people to honor a contract if they tattoo on their bodies that they're going to love Joe, Rosie, Suzanne, or whomever forever; it's just a decorative, aesthetic choice, and it's not a legal document. No state is going to enforce that tattoo. If you chose to resuscitate him on legal grounds, you'd be okay.

What about ethics? Ethically, I think it isn't enough to rely on a tattoo. Why? You don't know how impulsively the tattoo was put on. You don't know whether he had it put on 12 years ago or within the past month. You can't get information—about whether he changed his mind or not, about the whole thing. Tattoos are not something to be encouraged as a way to communicate values. If there was a chance to resuscitate this man with a high degree of likelihood, then I probably would have done so.

The medical team did ask for an ethics consult, which was fine, and I think that's a good thing to do too, just to get a second opinion. As my view goes, the tattoo isn't binding. What would be binding is if you had the tattoo or, for that matter, a medical bracelet, and then in your wallet or your purse you had an advance directive.

Remember, in talking to patients, that they ought to be encouraged to carry an advance directive, and they certainly can be encouraged, if they have strong views, to wear a bracelet or get a tattoo. That's fine. They need to understand, though, that the tattoo isn't the last word. It's a signal to check something, ask relatives, ask friends, look for that advance directive, and get a confirmation.

A tattoo is no substitute for conversation with your loved ones, friends, and others who are going to be present if you get into trouble or become unconscious, as this man was. You have to have had that conversation so that they know what you want and can back up any bracelet or tattoo that you might have.

Sure, tattoos are interesting, and they're important, but they're signals saying that we have a situation where we had better make sure that we're not doing something that this individual didn't want. The best way to make sure of that is to tell your patients to keep a copy of their advance directive, even if it's a short one that just says, "I don't want to be resuscitated" and it is witnessed and dated.

That's very much confirmatory for what the tattoo says. Most important, have that conversation with them, making it explicit that they need to talk to family, friends, and others. The best way to get your wishes respected is not to tattoo them on your body; it's to talk about them with family and friends….

Some healthcare professionals contend that some people get a DNR tattoo because they are afraid that their choices will not be respected. According to the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT), physicians understood only 46% of hospitalized, seriously ill patients' preferences to forgo cardiopulmonary resuscitation (CPR)…

Some healthcare professionals contend that DNR orders, like all medical orders, need to be reversible. They contend that if patients are permanently committed to preferences expressed at one time, they may be reluctant to express any interest in forgoing interventions. These professionals cite studies that show that a substantial percentage of patients change their minds regarding preferences for attempted resuscitation…

Some healthcare professionals feel that a DNR tattoo expresses "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."

1 comment:

  1. Holt GE, Sarmento B, Kett D, Goodman KW. An Unconscious Patient with a DNR Tattoo. N Engl J Med. 2017 Nov 30;377(22):2192-2193.

    We present the case of a person whose presumed code-status preference led him to tattoo “Do Not Resuscitate” on his chest. Paramedics brought an unconscious 70-year-old man with a history of chronic obstructive pulmonary disease, diabetes mellitus, and atrial fibrillation to the emergency department, where he was found to have an elevated blood alcohol level. The staff of the medical intensive care unit evaluated him several hours later when hypotension and an anion-gap metabolic acidosis with a pH of 6.81 developed. His anterior chest had a tattoo that read “Do Not Resuscitate,” accompanied by his presumed signature. Because he presented without identification or family, the social work department was called to assist in contacting next of kin. All efforts at treating reversible causes of his decreased level of consciousness failed to produce a mental status adequate for discussing goals of care.

    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.

    This patient’s tattooed DNR request produced more confusion than clarity, given concerns about its legality and likely unfounded beliefs1 that tattoos might represent permanent reminders of regretted decisions made while the person was intoxicated. We 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. Despite the well-known difficulties that patients have in making their end-of-life wishes known, this case report neither supports nor opposes the use of tattoos to express end-of-life wishes when the person is incapacitated.