The following story from The New England Journal of Medicine illustrates the importance of not just creating an Advance Healthcare Directive and a Do Not Resuscitate (DNR) order, but making sure your family and healthcare providers are advised of and committed to your decisions.
An unconscious man with a DNR tattoo on his chest
A Miami medical team faced a legal and ethical dilemma when an unconscious patient was wheeled into the emergency room with “Do Not Resuscitate” tattooed on his chest–the tattoo seemed to be the patient’s way of identifying his end-of-life wishes. It didn’t end there: “Not” was underlined, and the tattoo included a signature. Not surprisingly, none of the team had encountered this situation before, and there was no way to validate the DNR or determine if it was legally sound.
The tattoo was created to provide clarity; what it actually created was confusion
The tattoo produced more confusion than clarity—fueled by the common belief that tattoos are the result of regrettable decisions made while intoxicated. While in theory this tattoo may have been a great idea, without any context, it backfired.
This patient had a history of pulmonary disease, lived at a nursing home but was found intoxicated and unconscious on the street and brought to the hospital. He arrived without identification, family or friends. The doctors had no idea what his end-of-life wishes were, but an infection had led to septic shock, which causes organ failure and extremely low blood pressure. When his blood pressure started to drop, the medical team gave him intravenous fluids, antibiotics and blood-pressure medication, buying time to decide whether to try to save his life or manage his pain and let him die, as per his DNR order.
A cautionary tale helps explain medical team’s dilemma
Doctors referenced a case published in 2012 in The Journal of General Internal Medicine about a 59-year-old patient who had a DNR tattoo on his chest. In this case, however, the patient wanted lifesaving measures to be taken if he needed them. The reason for the tattoo? He’d lost a bet playing poker. In his case, the tattoo was a joke, but the medical team couldn’t assume that the tattooed man in their own ER was also the butt of a joke.
In Florida, when outside of hospitals, DNR orders are printed on yellow paper and signed by a physician and the patient, or a surrogate. Inside the hospitals, doctors can talk to a patient or the patient’s family or friends to determine end-of-life wishes. Since this patient remained unconscious, the doctors consulted an ethics expert to discuss the legal and ethical issues. He determined that the doctors could assume that the tattoo reflected the patient’s wishes.
The tattooed man died the next morning
The patient died the next morning. Thankfully, social workers were later able to track down the man’s proper DNR paperwork which supported the DNR order, assuring doctors they had acted according to the patient’s wishes.
A DNR tattoo: No substitute for an Advance Healthcare Directive or Living Trust
The lesson we can take from this? A tattoo is not the best way to alert medical staff to your wishes. A better methodology is to keep the actual document in a pocket or wallet, and it does not replace a properly executed Advance Healthcare Directive.
Inform families, friends and doctor of your end-of-life wishes
If a family member or friend who is unaware of a patient’s DNR wishes calls the local emergency response team (EMT) via 911 or other system, it’s likely that this team will work to resuscitate the patient; EMTs are trained to save lives, not interpret DNR orders.
While we can all appreciate the humor in this story, it alerts us to the importance of making sure our family and doctor are aware of and support our decisions.
CDP’s Living Trust package includes both a Power of Attorney and Advance Healthcare Directive, where you name an Agent, the person who will make healthcare decisions for you if you’re no longer able to do this yourself. An important part of this document is a Do Not Resuscitate (DNR) order—which means you do not want a medical team performing Hail Mary efforts to keep you alive when you are clearly near the end.
Do you need to create or update your Living Trust?