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Medicine The Courts Science

An Unconscious Patient With a 'DO NOT RESUSCITATE' Tattoo ( 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.
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An Unconscious Patient With a 'DO NOT RESUSCITATE' Tattoo

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  • by DrXym ( 126579 ) on Thursday November 30, 2017 @03:26PM (#55652385)
    I'm starting to wonder if my Digital Noise Reduction tattoo was a bad idea in hindsight.
    • Re:Bad decision? (Score:5, Interesting)

      by ColdWetDog ( 752185 ) on Thursday November 30, 2017 @03:30PM (#55652421) Homepage

      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)

        by Bruce Perens ( 3872 ) <> on Thursday November 30, 2017 @06:01PM (#55653897) Homepage Journal

        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)

          by rahvin112 ( 446269 ) on Thursday November 30, 2017 @08:06PM (#55654661)

          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.

        • Re: (Score:3, Insightful)

          by gurps_npc ( 621217 )

          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

  • by rwven ( 663186 ) on Thursday November 30, 2017 @03:29PM (#55652417)

    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.

    • by Anonymous Coward on Thursday November 30, 2017 @03:34PM (#55652453)

      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.

    • by networkBoy ( 774728 ) on Thursday November 30, 2017 @03:37PM (#55652481) Journal

      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." []

    • Re: (Score:3, Informative)

      Combat soldiers frequently tattoo all of their medical information on their torsos. Granted, that's a military context, but those tattoos are very much treated as authentic health documents. While not a direct apples-to-apples comparison, it does provide some context and support for the notion that a tattooed DNR order should be treated as legitimate.
      • Well there's a difference between: "A- Blood type" which conveys information and a DNR which is an instruction. The problem with his particular tattoo is that other than a simple instruction it doesn't have all the legal elements that a DNR form would need including the signature of a physician/nurse or a witness. Some DNR orders specify what can and cannot be done like CPR, etc.
        • 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.

    • An anecdote (Score:5, Interesting)

      by iMadeGhostzilla ( 1851560 ) on Thursday November 30, 2017 @04:03PM (#55652729)

      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.

    • by dasunt ( 249686 )

      A tattoo is not a legal document.

      In Canadian law, which has a similar tradition to US law, a tractor fender has been considered a legal document [].

      If a fender passes, why not a signed tat?

    • by ljw1004 ( 764174 ) on Thursday November 30, 2017 @06:00PM (#55653883)

      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." - []

      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.

    • by DRJlaw ( 946416 )

      A tattoo is not a legal document.

      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'

  • Funny timing (Score:2, Insightful)

    by Anonymous Coward

    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.

    • So, how would they reverse resuscitation? By killing him?

      • by mark-t ( 151149 )
        He will die eventually anyways, regardless of their efforts.... so from that standpoint, their decision to resuscitate him is reversible.
      • Give him a gun and tell him if he still doesn't want to live, that's pretty easy to do.

      • by sjames ( 1099 )

        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.

  • by EndlessNameless ( 673105 ) on Thursday November 30, 2017 @03:34PM (#55652457)

    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.

    • Re: (Score:2, Insightful)

      by MobyDisk ( 75490 )

      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!?!?!?!

      • then what could the patient have a POSSIBLY done!?!?!?!

        Duh, that's easy: He should have had a second tattoo below the first one, from his lawyer, notarizing the whole thing.
      • by EndlessNameless ( 673105 ) on Thursday November 30, 2017 @03:53PM (#55652653)

        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.

      • Filed an actual DNR form, properly notarized and witnessed? No, that would just be ridiculous, right?

        • Umm, yeah, I really want the people in the ER checking against state records to determine if someone has filed a proper DNR form, or not, BEFORE they attempt to resuscitate that person when they arrive in the ER unconscious.
        • by XXongo ( 3986865 )

          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.

      • You are aware that you can retract DNRs?

        How exactly would you propose to do this with a tattoo?

        • by Shotgun ( 30919 )

          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.

      • by sjames ( 1099 )

        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.

    • by msauve ( 701917 )
      "It's also possible for people to change their minds."

      Sure, just as it's possible to tattoo over the "not" in DNR.
    • Whatever happens I hope the hospital eats the cost.
    • by Kjella ( 173770 )

      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)

    by roc97007 ( 608802 ) on Thursday November 30, 2017 @03:35PM (#55652471) Journal

    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.

    • by msauve ( 701917 )
      "as a tattoo was not considered a legal DNR order in this state"

      So, written and signed DNRs aren't legal? Weird.
      • by Nidi62 ( 1525137 )

        "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.

      • 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.

        • by msauve ( 701917 )

          An individual satisfies the signing requirement when someone who has been duly authorized to sign for him does so. In the event a statute mandates an instrument be signed in person, the signature must be made in the signer's own hand or at his request and in his presence by another individual.

          - source []

          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

    • 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.

    • by DutchUncle ( 826473 ) on Thursday November 30, 2017 @03:45PM (#55652559)

      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.

      • by H3lldr0p ( 40304 ) on Thursday November 30, 2017 @04:48PM (#55653211) Homepage

        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.

      • "Why the hell would anyone tattoo themselves with something they don't want?"

        Like I said, bravado.

    • If they are not resuscitated why would they care? (Not meant to be funny by the way)
    • 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

  • by Anonymous Coward

    the words "DO NOT RESUSCITATE" tattooed onto the man's chest. Furthermore, the word "NOT" was underlined with his signature beneath it

    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

    • 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 court to fight the bill.

    • Which should be an insanely easy win since he did have a lawful DNR order files with the state

  • 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?

  • Seriously, this does not belong on /.

    • This is far more interesting than Microsoft Edge browser available on Android. Really? Who cares.

      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.
    • by meglon ( 1001833 )
      It's certainly better than all the political bullshit that gets posted.
  • by fahrbot-bot ( 874524 ) on Thursday November 30, 2017 @03:57PM (#55652675)

    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... []

    • 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?

    • 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)

    by religionofpeas ( 4511805 ) on Thursday November 30, 2017 @03:58PM (#55652685)

    Always resuscitate them, explain what happened, and then if they protest that they didn't want that, just kill them.

  • 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.

  • by bobbied ( 2522392 ) on Thursday November 30, 2017 @04:58PM (#55653321)

    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.

  • by zmooc ( 33175 ) < minus poet> on Thursday November 30, 2017 @05:12PM (#55653445) Homepage

    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)

    by sootman ( 158191 ) on Thursday November 30, 2017 @05:15PM (#55653491) Homepage Journal

    Dead, alive, persistent vegetative state... whatever. THIS is the important one. []

  • by bradley13 ( 1118935 ) on Thursday November 30, 2017 @05:36PM (#55653673) Homepage

    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)

    by denbesten ( 63853 ) on Thursday November 30, 2017 @06:00PM (#55653891)

    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.

  • by ilctoh ( 620875 ) on Thursday November 30, 2017 @09:26PM (#55655115)
    A lot of cynical responses here, and glib references to assumptions that the hospital chose to treat the guy so they could bill his insurance. As a paramedic, let me assure you that 1) cases of ambiguous DNR orders are among the most difficult decisions we have to make in our career, 2) no health care provider involved at the point of delivering emergency care has any idea how or if the patient can pay for treatment 3) most health care providers, especially emergency health care providers, are in fact huge advocates for DNR, hospice, and patient's right to determine the extent of health care they receive at the end of their lives. We don't get a kick out of resuscitating people for fun. A resuscitation is ugly, painful, and fails far more often than it succeeds. We know, as well as anyone, that resuscitation is so often futile, and that even a successful resuscitation rarely results in a return to a real quality of life.

    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

    • by slimjim8094 ( 941042 ) <.slashdot3. .at.> on Friday December 01, 2017 @12:20AM (#55655819)

      (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.)

No amount of careful planning will ever replace dumb luck.