An Unconscious Patient With a 'DO NOT RESUSCITATE' Tattoo (nejm.org) 454
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.
Bad decision? (Score:5, Funny)
Re:Bad decision? (Score:5, Interesting)
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.
Re:Bad decision? (Score:5, Interesting)
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.
Re:Bad decision? (Score:5, Informative)
Simple DNR orders are for people that are already sick and don't want to be put through hell and back to die. I think of my 80+ great-uncle that had severe emphysema that coded and was resuscitated and spent 6 months in a nursing home with 8 broken ribs and he could barely breathe before they broke all his ribs saving him. And this was the 3rd time it'd happened.
For the rest there are some very good forms out there that can walk you through the majority of the invasive life saving measures and allow you to apply advance directives to them. But keep in mind, your spouse/family can override your directives if you are unconscious or impaired unless they are prefiled with the hospital you are taken to (good luck guessing that one).
Just remember, saying nothing means they will do EVERYTHING, including a lot of things you may not even realize they could or would do.
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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) E
Re: Henna stencil. (Score:5, Insightful)
What's wrong with being an organ donor. It's not like you're going to miss them.
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I suspect most medical professionals would find this deeply insulting.
And they can tell your organs are shot just by looking at you.
Re:Henna stencil. (Score:5, Interesting)
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.
Europe+Canada 3 Years ahead of US (Score:5, Insightful)
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 [wikipedia.org] in Europe and Canada is about 82 years while it is only about 79 in the US (averaged over both genders).
Did the right thing... (Score:5, Insightful)
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.
Re:Did the right thing... (Score:4, Insightful)
So I should get a tattoo that says "DNR" then a QR code to scan, that links to the official DNR? Man this is getting more and more complicated by the day.
Re:Did the right thing... (Score:5, Interesting)
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... [nih.gov]
Re:Did the right thing... (Score:5, Insightful)
The patient in this case is a moron. Tattoo removal or infill is something they should look into prior to them ending up in an ER unconscious and not able to clarify the "joke" status.
Re:Did the right thing... (Score:4, Insightful)
I think it just comes down to "If you get a joke DNR tattoo, you're a moron."
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Darwin award ...
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Well, if he's THAT dumb, he might not be in favor of DNR, but I am.
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I would argue that "A- Blood type" is an instruction. It's actually even worse than DNR. DNR leaves it up to the medical staff to actually do it. "A- Blood type" translates into "don't waste time with a blood test, and instead just pump A- directly into my veins".
Well, "don't do a blood test" is an instruction. But more than that, what if I know that my blood type is "B+"? Respecting my tattoo would be killing me.
Information is just information. Acting on information makes that information a directive.
Re:Did the right thing... (Score:5, Informative)
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Any type of medical care without consent is criminal assault
You're not a lawyer. Your legal opinion means nothing.
If what you said is true, how can they even touch an unconscious person that comes into the hospital? Especially if a bystander called 911---there would be no indication of consent from the patient at all. This is supposed to be a crime? Nope, this is how it works every day.
States have rules about how to file a DNR and how to verify a DNR. And look, a quick google search shows you what Florida residents need for a legit, legal DNR order:
http://www.florid [floridahealth.gov]
Re:Did the right thing... (Score:5, Interesting)
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.
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The ONLY thing necessary for a DNR order to be valid is for it to be a true reflection of person's informed wishes. Someone getting it tattooed on themselves and then fucking signing under the tattoo is all the proof anyone with a brain needs.
Paramedic here. This is technically not true (at least in any state I've ever worked in). Though, perhaps it should be. Of the four states I've worked in, each one has required that a DNR order appear on a particular form, with particular legal-ese. Each state has required that the form be witnessed by at least one additional competent party, and three of the four have required that it be signed by the patient's primary care physician. Some states allow medic alert bracelets to signify a DNR order. The
An anecdote (Score:5, Interesting)
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.
Re:An anecdote (Score:5, Insightful)
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.
Re:An anecdote (Score:4, Insightful)
> 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.
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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.
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In Canadian law, which has a similar tradition to US law, a tractor fender has been considered a legal document [globalnews.ca].
If a fender passes, why not a signed tat?
Re:Did the right thing... (Score:5, Informative)
A tattoo is not a legal document.
That's incorrect. Depending on the legal instrument, some of them can be written on anything. "You can write contracts on a napkin, a ticket stub, a pizza box - just about anything ink will stick to." - http://www.lawyers-plus.com/ca... [lawyers-plus.com]
Different legal instruments have different requirements for what they need to be valid. DNRs across all states (I think) require a doctor's signature (so a tattoo that included a doctor's signature would presumably be valid). Some of them require a particular state-issued form to be used as well (so a tattoo in those states wouldn't be valid). Some of them require yellow paper. In my own state of Washington, property recording instruments even have a specified margin sizes in inches for them to be valid.
In the act that introduced electronic signatures, nowhere did it say that "electronic signatures are valid". Instead it said "a legal instrument shall not be deemed invalid solely on the grounds of the signatures on it being electronic".
TLDR: "legal document" isn't a well-defined concept. "Validly executed legal instrument" is a well-defined concept. The exact requirements for validity depend on the instrument in question and on jurisdiction.
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Says who, boyo?
It's a writing that was apparently signed by the person. Florida does not require that its DNRO form be notarized. The only thing that the tattoo lacks in comparison to the Florida DNRO form is the physician's statement. If you choose to hang your hat on that, then I remind you that this patient completed a Florida DNRO form and that the hospital only chose to look for it AFTER beginning resuscitation efforts and finding the tattoo.
Even if the tattoo doesn'
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Hmmm, I am a Notary with access to a laser engraver to make notary seals...
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No, because a legal document that states they're DNR is a binding contract that they made. It's been signed and notarized. A tattoo hasn't.
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Who would be "the other party" of that "binding comtract"?
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1) Yes, getting a DNR tattoo would be insane if you didn't really mean it.
2) It's not a legal document because there are no signatures, no notarization, and if you start treating one tattoo as a legal document, you have to start treating ALL of them that way. There's nothing to "prove." It simply is not a legally binding agreement/contract.
3) No, because they did not have access to the DNR documentation at the time. In this case they had to go through unusual channels to get the document, and acting on a DN
mistakes of fact and law (Score:2)
> It's not a legal document because there are no signatures
Quoting TFS, 'furthermore, the word "NOT" was underlined with his signature beneath it.'
> if you start treating one tattoo as a legal document, you have to start treating ALL of them that way.
How do you figure? If you start treating one piece of paper as a legal document, you have to start treating ALL pieces of paper as legal documents?
BTW, the supreme law of the country, the US Constitution, is also written on skin.
> No, because a legal
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Mod up please. This is how I felt reading the article. I need to pay lawyers and notaries before someone will listen to me?
What if it doesn't reflect my current decisions? Same can be said of my lawyer's notarized copy too.
How do I change my legal DNR? I need to call lawyers and such.
How do I change my tattoo DNR? I use the sharpie in my junk drawer.
I'm fine with confusion when a permanent tattoo DNR has a ballpoint pen line running through it. That's confusion. But it really doesn't get any more cle
Permission to sign my name is permission to sign (Score:2)
> Does power of attorney even grant you permission to sign a document with another person's name, or does it merely grant you permission to sign a document on behalf of the other person but still using your own name?
It does whatever it says it does. Power of attorney is a rather general term, not one specific document. In general, if I say to you "you can sign my name on this type of document", you may indeed do that. Years ago I double checked the federal and Texas statutes on this issue.
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You've apparently never made your own tattoo artwork then. They photocopy it onto special paper, transfer the ink to your skin, then trace over it with the tattoo gun. Basically two xerox machines involved, one of which you don't want dating your daughter.
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Something like a spirit duplicator [wikipedia.org] (aka "ditto machine") could serve the purpose. User signs a ditto master, which is then rubbed onto the skin, transferring the colorant to the skin. Tattoo artist can trace the ink.
Re:Did the right thing... (Score:5, Funny)
I find it ironic to see people posting on Slashdot judging others for not being normal.
Funny timing (Score:2, Insightful)
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.
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So, how would they reverse resuscitation? By killing him?
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Give him a gun and tell him if he still doesn't want to live, that's pretty easy to do.
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I presume that would be up to the patient, but yes. In a medical context, it's easy to reverse living. Death not so much.
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We're all born to die. There is little certainty in life but that it is finite.
Better safe than sorry... (Score:5, Insightful)
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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When you're in a gray area...
How the heck is that a gray area!?!?!?! If THIS isn't good enough, then what could the patient have a POSSIBLY done!?!?!?!
Re:Better safe than sorry... (Score:4, Funny)
Duh, that's easy: He should have had a second tattoo below the first one, from his lawyer, notarizing the whole thing.
Re:Better safe than sorry... (Score:5, Insightful)
If THIS isn't good enough, then what could the patient have a POSSIBLY done!?!?!?!
From the very comment you are replying to:
In the article, they even referenced a case where the patient's DNR tattoo did not reflect his current wishes.
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States have different rules on what is necessary for a legally binding DNR order.
Most states require a patient signature and a witness signature. In some states, the document must be notarized or filed with the Department of Health. Some states actually do recognize DNR tattoos.
Would be nice to have a consistent standard though.
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Filed an actual DNR form, properly notarized and witnessed? No, that would just be ridiculous, right?
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Filed an actual DNR form, properly notarized and witnessed? No, that would just be ridiculous, right?
As the summary states, he did have a proper DNR form filed with the state.
It takes time, however, before the DNR form can be located and sent to the hospital and then forwarded to the hospital social work staff to write a hospital DRN order.
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You are aware that you can retract DNRs?
How exactly would you propose to do this with a tattoo?
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My wife removes tattoos for a living. The laser is tuned to color of the pigment, so it selectively "burns" out just the tattoo. Dark skinned people take it on the chin in this case, because the laser has to be used on a lower setting or burn out the skin pigment.
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Filed a proper DNR order. It turns out he did that, and they found the order. Then he died and they honored that properly filed order.
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Sure, just as it's possible to tattoo over the "not" in DNR.
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They'll make up for it by making future treatments more expensive.
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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.
If you sign a DNR then death is obviously not what you're afraid of. It's being trapped in some sort of half-dead state where you may have extensive brain damage and experience prolonged pain and suffering without actually dying. And he could very well have gone into such a state where he'd be incapable of making that choice again. That's why DNR orders exist in the first place.
another data point (Score:5, Insightful)
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.
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So, written and signed DNRs aren't legal? Weird.
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"as a tattoo was not considered a legal DNR order in this state" So, written and signed DNRs aren't legal? Weird.
It has to be notarized as well. Think meat tenderizer, but with a seal imprint on the head.
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So, written and signed DNRs aren't legal? Weird.
Except it isn't one.
Tattoos are usually applied by a third party. Tattoos are usually categorized as art rather than official documents. Thus, a tattooed signature will probably not be a legal signature.
You do realize people get DNR tattoos to show off how badass they are, right? I would never do it, but it's a thing. Decorative DNR tattoos may be stupid, but the hospital cannot be sure a patient wants to die as long as the decorative ones exist.
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- source [thefreedictionary.com]
Artwork is also commonly created from paper and ink. People wear bracelets and necklaces most commonly as jewelry, but sometimes as medical alerts. The medium doesn't determine whether it's art or a document
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Wouldn't that be a stupid way to die.
No more so than any other in which a person chooses how they want to go out.
Re:another data point (Score:5, Funny)
Wouldn't that be a stupid way to die.
If someone goes to the trouble of actually tattooing the spelled-out Do Not Resuscitate instruction, then it's not stupid - it's what that person wanted. Why the hell would anyone tattoo themselves with something they don't want? Another poster refers to losing a bet; taking this as the stakes of a bet sounds pretty shortsighted.
It's about being edgy, I bet (Score:4, Interesting)
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.
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"Why the hell would anyone tattoo themselves with something they don't want?"
Like I said, bravado.
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If only there were a registry of DNR orders available to medical personnel on demand. If only we had the technology to file something online securely and have it retrievable at a hospital on a computer. Alas, this is completely impossible with today's meager technology.
Really though, how hard would it be to have a medical records registry where you file legally binding orders for your medical health? Then, all someone would need to do would be to tattoo something like: "STANDING DNR ORDERS FILED WITH REG
Ambiguous? Not so much? (Score:2, Informative)
This was fairly unambiguous, had a copy of the man's signature, and was pretty much completely unmissable.
In this case it sounded like it was pretty plain. Maybe he should have had it notarized and dated or made a notation to an actual document on file some place ... but it bore the man's signature, so it's not like you would assume it isn't real. This was about as unambig
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but it bore the man's signature, so it's not like you would assume it isn't real.
But it didn't - it bore a forgery of the man's signature by the tattoo artist. Unless he took the tattoo pen himself and signed his name on his own chest (quite interesting feat, if you ask me), it's not his legal signature.
Will be billed and the estate likely will have to (Score:2)
Will be billed and the estate likely will have to court to fight the bill.
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Which should be an insanely easy win since he did have a lawful DNR order files with the state
His intent was pretty clear (Score:2)
Is it unfortunate that he never knew all the work that he put into getting that tattoo paid off?
Also, assuming it was his actual signature tattooed on, does that make his skin a legal document?
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This at least invites, as evidence in some of the comments: critical thinking, exploration of various theories such as what if the tattoo was a joke or someone else's prank or a stupid frat hazing.
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U.S. Living Will Registry (Score:5, Insightful)
You can register an Advanced Directive with a Living Will and/or Health Care Proxy at the U.S. Living Will Registry [uslivingwillregistry.com]. 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... [tumblr.com]
Re:U.S. Living Will Registry (Score:4)
I lost my sister in much the same way (but due to lupus, not cancer). At one point the doctor asked those of us gathered around - me, sis's husband, my mom, and my other sister - how we'd like to proceed. It got quiet. I asked, "doc, if she were to wake up right now, what would her prognosis be?"
He thought for a moment, then replied: "she is gone. Her body is here, but the person you knew left before the ambulance arrived. She was a nurse, so I'm certain you had the 'oh God please don't leave me lingering as a vegetable' conversation at least once. This... today... is the situation she didn't want." That's when we made the final decision to end her suffering much as you and your wife had chosen.
Bless you and your family, friend.
Does it get better?
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Wow! Sounds like you had a good ride while it lasted. Sorry for your loss. Keep close to the ones you love. Especially around this time of year.
Solution (Score:5, Funny)
Always resuscitate them, explain what happened, and then if they protest that they didn't want that, just kill them.
I would definitely honor it (Score:2)
in a CPR situation or similar (not a clinician). People are responsible for themselves - not a court. "My body, my choice." Choosing to not have the tattoo removed was obviously a conscious choice.
Then again, I'm not looking to bill $4500 for the CPR 'procedure' - I'm happy if nobody vomits in my mouth.
How about this... Forget the Tatto (Score:3)
Instead of putting DNR on your chest... Why not provide the contact information of somebody who understands your medical history, your wishes, has a copy of your living will properly executed and has a valid medical power of attorney? Forget the tattoo and just go for the medical alert bracelet with the same information if you are serious.
Seems to me that a tattooed DNR request isn't likely to have the desired effect regardless of where you end up. What you need to provide access to is the actual legal paperwork and the faster you can get this into the ER doctor's hands, the better.
Odd (Score:3)
When I recently got CPR training, I was told to do what I felt was right when encountering such a tattoo. However, I was also told that trained medical personnel should definitely honor such signs as they are legally binding in the Netherlands. We also have official badges specifically for this purpose.
This should not be an ethical dilemma in developed countries. It should not even be a legal dilemma....
Whatever (Score:5, Funny)
Dead, alive, persistent vegetative state... whatever. THIS is the important one. https://i.pinimg.com/originals... [pinimg.com]
WTF does it take? (Score:3)
My dad was chronically ill for years, one organ after another failing. Towards the end, he wanted nothing more than for it all to be over. The miracles of modern medicine - they just wouldn't let him die. He had registered a DNR - the hospital even f*cking knew about it - and when his heart gave out, they revived him anyway. He suffered on for another year or more. Gee, thanks for that.
We initially decided not to honor the tattoo, invoking the principle of not choosing an irreversible path when faced with uncertainty.
What uncertainly. Seriously, what does a guy have to do in order to be allowed to die in peace? Filing a piece of paper in some government office somewhere is useless: the paramedics show up, or someone takes you to the ER, and no one has time to find out whether that paper exists. That's what the tattoo is for.
Look, I read the other comments about drunken idiots getting DNR tattoos. They probably also enjoy playing the odd round of Russian Roulette and do drunken dares with running chainsaws. There's no cure for stupid. Believe the tattoo, don't make other people suffer because of a few idiots.
Consequence (Score:4, Interesting)
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.
Some more case studies (Score:5, Interesting)
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
Re:Some more case studies (Score:5, Interesting)
(BLS here, not ALS)
Oh man, you put it much better than I could. And then there's the not-even-ethically-ambiguous situations. We went to an extremely elderly woman in a hospital bed at home once and asked the family, everyone around, whether the patient had a DNR and nobody knew what I was talking about and certainly didn't produce it. ALS showed up and said "does this patient have a DNR" and the family was like "oh, here you go" - meanwhile we'd been coding her for 5 minutes! We stopped and medics pronounced and we left, but we weren't doing anybody any good in the meantime.
When resuscitation is required, there are literally seconds to act. Doing CPR sucks, it rarely works, and even if you "get a pulse back" the odds of them having any decent quality of life or even leaving the hospital is small. But the only thing worse than doing it is not doing it, and the only thing worse than doing it right away is doing it too late. If we delay CPR hunting for a DNR, we know that each second is making it less and less likely it'll work. Unless someone is literally blocking our way presenting some official form, we are we are more likely to begin CPR. We can't go on an easter egg hunt, we don't have the time or manpower to spare. Honestly if the patient is alone I'm not looking further than their chest/shirt (you can pin it to your clothing) or bedside table, unless it's posted prominently on the front door or similar. If family is around I'll ask them and if they don't have it immediately, it's CPR time. I just can't justify reducing someone's chances with each second of hunting around - what if they *do* want to be resuscitated and I've wasted what little chance they had?
Honestly the "tattoo on the chest" being questionable surprises me. It's pretty much the simplest case I can imagine for a valid DNR. We've been taught that a valid DNR can be written on a napkin or - indeed - a tattoo, and a chest tattoo makes it impossible to miss when about to perform CPR. And its placement on the chest makes intention to signal unambiguous. I'd imagine I'd honor it without question, unless I have *any* reason to suspect that wasn't your current desire (e.g. family member). You can tattoo an "X" over your tattoo if your wishes change and you don't want to get it removed.
I find the presumption of profit motive insulting. DNRs are largely an emergency medical concern, for the most part hospitals are for people in a position to make their wishes known more clearly. There's no profit for us - we're volunteers, we don't get paid, and we don't bill anybody. The residents of the town donate money for us to buy equipment. We're not in the business of resuscitating anybody who doesn't want it (did I mention it's miserable?), but just think about how you'd convince someone you've never met of your intentions within 15 seconds of seeing you when they're not looking around for paper - oh, and you're unconscious. It's really hard, and we always will err on the side of life since the alternative is not what we're here for.
The easiest thing to do is set it up so that people around you don't call 911 if you end up requiring resuscitation. If you're to a point, hospice can help with end-of-life palliative (pain reduction, etc) care that's not lifesaving. When my grandfather died, he was at home in bed and we were all around, and when the time came nobody called 911 because there was no emergency. He had a DNR, but it was never used.
Oh, and don't get a "DNR" tattoo because you lost a bet - I don't know the joke, and I might just honor it. (And it'd probably stand up in court, too.)
Re: (Score:3)
They're lucky he died. If he lived, he could have sued the fuck out of that hospital, and he would have won, easily.
Huh?
Is it too much to RTFS? Because if you RTFS you'd see that they stabilized him long enough to confirm his DNR status, and then let him die. They did not resuscitate. "he died without undergoing cardiopulmonary respiration or advanced airway management"
Re: (Score:2)
what are they going to do give some lifer more time?
Re: (Score:2)
No, they'll just rip off the "NOT" and have at it...
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You assume 2 things: They can read and they care.
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