DNR TATTOO & Advance Care Directives

An unconscious 70-year-old man was admitted alone with no identification to a Miami hospital he had breathing problems and signs of septic shock. When the doctors took off his shirt, a tattoo running along his collarbone said DO NOT RESUSCITATE with a signature under the final word.

Doctors were conflicted as to whether or not they should follow the patients’ tattooed request as it is usual that unless otherwise notified medical staff will do everything possible to prolong a patients life. The Doctors decided that in the face of uncertainty they would take the path that’s not reversible; to give the man basic treatments—antibiotics, an IV drip, an oxygen mask to help him to breathe, and adrenaline for his plummeting blood pressure.

In Florida, legally valid DNR requests are completed on an official yellow form clearly this precludes a tattoo. However at some stage the patient had unequivocally made his wishes known although through unusual means – a tattoo.

Although tattoos are permanent the desires they express maybe fleeting, a tattoo may be ambiguous as the letters may stand for something other than Do Not Resuscitate? There are examples of patients who have had DNR tattooed for various reasons. Medical staff became aware of a DNR tattoo on a patient who was going to have a leg amputated. He had got the tattoo years before following a loss at poker, importantly it did not reflect his wishes. When it was suggested that he consider having the tattoo removed to prevent confusion he declined, as he did not think anyone would take his tattoo seriously.

Errors in interpretation may have life and death consequences therefore DNR orders need to be legally recognised in order to protect medical staff who withhold treatment importantly DNR orders need to be reversible as people change their minds; Circumstances change, and people adapt to illness and disability. Advance care directive forms can be withdrawn or a DNR bracelet removed easily. Having a tattoo removed is an expensive and time-consuming process.

The Florida patient hadn’t regained consciousness so hospital social workers used his fingerprints to track down his identity. He was a resident of a local nursing home and had completed an official DNR form. The man’s condition deteriorated, and he passed away in the night

Examples of DNR tattoos are not limited to the United States with many people substituting advanced care directives outlining their final legally binding wishes with a tattoo. In some cases they believe the tattoo is a definitive reflection of their decision to not be resuscitated. In most jurisdictions medical practitioners have an obligation to preserve life and a tattoo is not sufficient to meet the requirements of an advance care directive.

Without the appropriate legal paperwork or the consent of the next of kin no matter how detailed a tattoo is no substitute for an Advance Care Directive which outlines your preferences for future health care, end of life, and appointment of one or more Substitute Decision-Makers to make these decisions if you are unable to do so yourself.

In a case discussed before a patient was admitted to the emergency department of a hospital, and despite the best efforts of the medical staff, he developed renal failure and was being kept alive by mechanical ventilation and kidney dialysis.

At this stage the hospital became aware of an advance care directive the preparation of which included notes indicating that the patient did not wish to have dialysis. As the patient was unconscious and unable to give instructions as to his medical care the hospital took steps to preserve his life whilst seeking the Court’s decision.

The hospital sought a Court declarations to the effect that the notes were part a valid “Advance Care Directive” and that it would be justified in complying with his wishes expressed in that directive.

The Court made orders recognising the patient’s right to refuse dialysis treatment as set out in the worksheet even though medical evidence suggested it would hasten his death.

If the patient had not completed the Advance Care Directive it would have been difficult for the hospital to follow his wishes. An Advance care directive is an important part of planning for your future and should be discussed with your loved ones at the time it is prepared.

 

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