What to Do When a Patient Has a 'Do Not Resuscitate' Tattoo | Hacker News Reader

What to Do When a Patient Has a 'Do Not Resuscitate' Tattoo

theatlantic.com

38 pointsjansho53 comments

It's a trivial legal question. The answer is that you resuscitate right now, without any hesitation.

You don't want to explain to the judge that you let someone die because of a stupid tatoo, that may very well come from 10 years ago.

A 10 year old tattoo can be easily covered up or altered if the person changes their mind. This tattoo was clear and explicit and contained a signature. There wasn't any ambiguity.

Would you say the same thing about a 10-year old signed card in their wallet?

Yeah.

You can assist them to suicide in certain jurisdictions, if they want to end it.

It's pretty hard to resuscitate back to life after they've been dead, and put in the freezer for half a day.

The ugly fact is this comes down to a pure legal choice: Was the appropriate legal work done for the DNR? If not, ignore and save them. A live person dealing with legal is better than a dead person's family dealing with legal.

[let's ignore the specific case from this article for a minute]

Let's say that you are unconscious and stopped breathing.

Your brain is deprived of oxygen. Within 3 minutes, the brain cells will start dying and you will suffer irremediable permanent damage, within 10 minutes, you will be effectively dead all things considered.

What do you do? Do you look for a wallet and the cards inside it?

I know I guy who has "Rape Me" tattooed on his chest. It's his favorite Nirvana Song. For the most part, tattoos are a form of art and expression. Phrases such as "death wish" or "kill me" are pretty common, and are absolutely not meant as instructions. The idea of DNR is pretty popular in certain artistic circles. There is an incredible amount of ambiguity in this situation.

Actions often have consequences. I don't see this situation any differently.

You don't see the difference between the aesthetics of a "Rape Me" tattoo and explicit instructions?

Of course I do. I'm talking about the consequences of getting the words "DO NOT RESUSCITATE" applied to your body along with your signature.

That said, there are lots of situations where I think it would be stupid to have "Rape Me" tattooed to my body. It might have lots of calligraphic merit, but if it's on your face, you probably aren't going to be working the customer service counter at Target.

Unfortunately (as per the article), there is precedent for someone getting a DNR tattoo as a joke after losing a bet in poker.

https://link.springer.com/article/10.1007%2Fs11606-012-2059-...

This implies that people getting tattoos do not treat them as legal documents.

The doctors in this more recent case were justifiably cautious - they did the sensible thing, which is to consult an ethics/legal specialist ASAP, and then follow their advice.

The majority of suicide attempts are driven by temporary situations. Postponing a suicide attempt usually means the person will reconsider. http://www.nejm.org/doi/full/10.1056/NEJMp0805923 Are there any such studies on people reconsidering their DNR?

I believe there was at least one person that had a tattoo but "didn't think people would considerate it serious because he wasn't". I would side on "be cautious" when a life is at stake. If you're serious...fill out the damn paperwork.

But it's a similar problem even with paperwork - someone might realize, while they're in a life-threatening situation, that they'd rather not have the DNR. I was just wondering if it's really any different from suicide.

  “Paper gets lost, and some people do not trust paper. This
  man may have been trying to safeguard against that

He was wise to distrust, as it turns out, given that they decided to temporarily ignore the tattoo despite the fact there was a valid form on file for him.

...while they were unsure that the paper existed.

Given that he was "He was alone and had no identification.", I don't find that particularly malicious on their part. If I _was_ stupid enough to get a DNR tattoo without being totally serious (like the 2012 fellow mentioned in the article), I would hope they take the time to find out who I am and where my file is first.

Taking the time means killing people, though.

I wish that these tattoos carried as much weight as a paper DNR. People that prefer DNR currently have no way to express their wishes when outside of a health care facility.

It looks like a bracelet is enough depending upon the jurisdiction in the United States. For example in New York - https://www.health.ny.gov/professionals/ems/policy/99-10.htm

Did you read the article:

> And there’s good reason to be cautious. Back in 2012, Lori Cooper at the California Pacific Medical Center was caring for a (conscious) patient who was going to have a leg amputated, when she noticed a “DNR” tattoo on his chest. The man revealed that he got the tattoo after losing a poker bet many years ago, and actually, he would very much like to be resuscitated if the need arose. “It was suggested that he consider tattoo removal to circumvent future confusion about his code status,” Cooper wrote. “He stated he did not think anyone would take his tattoo seriously and declined tattoo removal.”

Well that guy's an idiot then. That one guy is an idiot shouldn't prevent anyone else from declaring a near-permanent DNR...

He should have it covered up if he doesn't mean it.

I agree he's an idiot.

I'm just saying there are some reasons to consider tattooed DNRs invalid. While the guy, in this case, could have obviously covered up his tattoo prior to his scheduled surgery (permanently or temporarily), what if he had been in an unexpected accident?

I don't have any tattoos but a quick google says removal is expensive too. I guess you could have someone tattoo over it, but, in the article, they mention a man who had come from a nursing facility. I'm not sure how practical it is to suggest he should have had it removed/covered up prior.

I like the basis of killjoywashere's suggestion, but, in a more centralized way that would allow you to register your intentions in a way that hospitals could easily check on your desires and status.

It's hard to think of a better example of a candidate for the Darwin Awards than the guy who gets a DNR tattoo and thinks "no one will take it seriously."

Why is he an idiot?

The tatoo is not legally binding. It never was. As stated in the article, it can't even give the kind of reassurance that is required by law (indication of rational descision)

Why should he have expected that it works?

Regardless of whether it's legally binding, what we see here is an anecdote where there was a delay in treatment. Why should he expect that it would be ignored? People get serious tattoos all the time: https://www.google.com/search?q=medic+alert+bracelet+tattoo

Because, at least, it's going to confuse medical staff and delay treatment. In a critical care situation, seconds matter.

As a Firefighter/EMT, protocols are very clear in on what’s considered a valid DNR. This would cause zero confusion on scene.

I'm not so sure. How does one authenticate the tattoo? How can one be certain that the tattoo really does represent the patient's wishes?

A paper DNR has a paper trail that permits authentication. A tattoo does not.

Paper DNR is easier to fake than a tattoo DNR.

Well, in one interpretation of the article, if you want the tattoo to be taken seriously you have to have it done on a yellow background. :-)

However, carrying a POLST form on you at all times would seem easier, even if you wore it in a locket around your neck.

If you really don't want to be resuscitated in the US, you should instead tattoo a notice that you will not assume financial responsibility for any medical procedure performed under the aegis of implied consent.

Make sure to inform your friends and family, so they can record any interactions between hospital administration and the physicians and nurses, in order to post the fruit of your epic trolling to the public network.

There are probably some people who go with the DNR route because the healthcare system isn't that great in the US. They might prefer being 6 feet under over being crushed by debt.

https://en.wikipedia.org/wiki/Medical_debt

> 70 million Americans either have difficulty paying for medical treatment or have medical debt.

Depending on age, its always possible to just skip and start over? Preferable to being dead.

The main reason to go DNR is for quality of life concerns. Once an elderly person has already been impaired by a stroke or some other chronic condition, adding more "medicalized" life-extension on top of that is cruel.

24-7 skilled nursing care is a miserable way to exist, regardless of who pays the US ~ $10K/month bill.

RadioLab did an interesting podcast on DNR orders:

http://www.radiolab.org/story/262588-bitter-end/

I think people don't go the DNR route because their understanding of outcomes (from something like CPR) comes from television. Reality is much worse.

I think I might get a similar tattoo, but with a URL, QR code, and a chip. The url and QR code will point to a github repo with my DNR. Which I will sign with a "No really, I mean it" statement that is cryptographically signed, maybe once a day, once a week, something like that. The chip will also have the key to authenticate the git signatures. And, in the DNR, I will have directions to contact my pre-paid attorney, with further direction to summon them to the ICU and make sure my wishes are carried out.

That sounds completely intractable in an emergency situation.

Perhaps it could be an embedded computer with a small display just under his skin that asks each morning whether he'd like to be resuscitated that day and records his response.

If it detects that he has become unconscious (because his pulse has stopped?) it could display a bold "DNR" on the display, and possibly play some audio to that effect as well.

It actually seems like it would only take an order of magnitude or 2 of miniaturisation before this is an easy weekend project...

Or you can just file a normal DNR through the normal process like a normal person.

But I'm a doctor, and know how eager my colleagues are to blow past a DNR. The attorney thing has actually been deployed in practice.

So when someone is in cardiac arrest and they have a URL and QR code tattoo you're going to stop treatment while you debug their shitcode to figure out whether it's even relevant to what's happening?

It's not the ER that I'm worried about. It's the ICU.

For curiosity's sake, if you're comfortable telling me, why would you not want to be resuscitated?

Depending on the type and level of resuscitation there is a very small chance of returning to 100% normal function and a significant chance of spending the last days/weeks/months of your life in a hospital.

The people who go to the trouble to get a DNR usually have pretty poor quality of life. Given the trauma of a resuscitation with broken ribs, possible brain damage from a minute or two without oxygen, they think that their quality of life might be even lower post-resuscitation, and frequently they're not even buying that much additional time. They might think that dying with some dignity and less pain is better than holding on for a couple more miserable days.

"Nurse, bring the crash cart!" "Hang on, this guy's got a... some kind of weird tattoo?" "No time to worry about that, he's flatlining! Now start compressions, and break a few ribs if you have to!"

This is satire, right?

That's mental.

I know you're kidding, but really, the only reliable way to ensure DNR wishes are carried out in the USA is by having a notarized "health care directives" document drawn up by an elderlaw attorney and have it filed with your hospital in advance by you or a loved one that has power-of-attorney over you (which itself requires a document from an elderlaw attorney).

And what if you are hospitalized by another hospital? Seems like that's what happened to this guy. If he didn't have that tattoo they wouldn't have even bothered to figure out if he had a valid DNR document before resuscitating him.

Well, if you can't get the DNR document filed at the hospital (or a loved one isn't there to provide it immediately upon arrival)... the hospital will resuscitate, AFAIK.

Tattoos are really great signalling for motorocycle gangs and hipsters, but the nuances that one can use to discern satire, hubris, or seriousness just don't work well in an emergency room.

It's a statewide database

[If I put a do not resuscitate tatoo on my blind friend is that a paddling](philosoraptor.gif)

So, if I work in a tatoo parlor and don't like someone, I can just tatoo DNR on their back and let things sort themselves out?

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