Hos­pi­tal thrown into panic over un­con­scious man's 'do not re­sus­ci­tate' tat­too across his chest

Sunday Times (Sri Lanka) - - INTERNATIONAL - By Natalie Rah­hal

Aman's ' do not re­sus­ci­tate' tat­too forced Miami emer­gency doc­tors to con­front the eth­i­cal con­flict be­tween a pa­tient's wishes and a doc­tor's duty.

The 70- year- old man was un­con­scious and pre­sum­ably drunk, given his el­e­vated blood-al­co­hol level, when paramedics brought him to the emer­gency room. His pulse slowed to a wor­ry­ing rate, and the doc­tors de­cided to try to save him any way, but were get­ting no re­sponses, ac­cord­ing to a case study pub­lished in the New Eng­land Jour­nal of Medicine.

After con­sult­ing with ethi­cists, the doc­tors de­cided to re­spect the man's tat­too, but the quandary made them aware of the need for an up­dated sys­tem of track­ing pa­tients' end of life wishes.

Paramedics brought the se­nior to the Univer­sity of Miami hos­pi­tal emer­gency room after find­ing him on the street. The man had al­co­hol in his sys­tem and couldn't be roused, but none of that was ter­ri­bly un­usual.

'Un­for­tu­nately, we get a lot of that kind of pa­tient at my hos­pi­tal,' says Dr. Greg Holt, one of the doc­tors who treated the man.

The man's tat­too was, how­ever, unique enough to draw Dr. Holt, who was the at­tend­ing physi­cian that night, and his en­tire team of eight down to the emer­gency to see what the fuss was all about.

The man had a signed 'do not re­sus­ci­tate' on his chest, with a line un­der the 'not' for em­pha­sis. ' We al­ways kind of joked around about do­ing that. A lot of physi­cians say "Boy, I'm go­ing to have that tat­tooed on my chest so ev­ery­one knows my sta­tus." Then you see it and... holy crap,' says Dr. Holt.

The team's first con­cern was le­gal­ity.

Tat­toos are not legally-bind­ing DNR or­ders. In fact, says Dr. Holt, there are very spe­cific re­quire­ments for le­gal or­ders in Florida. 'It has to be on yel­low pa­per, both the doc­tor and the pa­tient have to have signed it...it doesn't say any­thing about tat­toos.'

DNR or­ders are pro­tected by med­i­cal pri­vacy laws, so it's un­clear how many peo­ple have them, but about 80 per­cent of Amer­i­cans with chronic ill­nesses re­ported that they did not want to be hos­pi­talised or put into in­ten­sive care if they were dy­ing.

Peo­ple who want DNRs have to fill out stan­dard forms with their doc­tors, then DNR is writ­ten on the med­i­cal chart, and they can get bracelets or wal­let cards show­ing their sta­tus. These wishes are usu­ally re­it­er­ated in a will.

Dr. Holt's pa­tient blood pres­sure dipped dan­ger­ously low. Dr. Holt and his team de­cided that it was bet­ter not to risk the out­come that could not be un­done: death.

Walk­ing a fine line, they gave the pa­tient IV flu­ids, an­tibi­otics, and 'some med­i­ca­tions to keep his blood pres­sure up, which some peo­ple would con­sider re­sus­ci­ta­tion,' says Dr. Holt. 'If I knew that he was no code, I would have put him on a breath- ing ma­chine,' Dr. Holt adds.

But with a tat­too, ' I al­ways kind of thought peo­ple might re­gret it later on, you get drunk, you get it when you were a kid, you wish you didn't, but what can you do?' says Dr. Holt.

In fact, in an­other case study, doc­tors dis­cov­ered a tat­too read­ing 'D.N.R.' on the chest of a di­a­betic man in the hos­pi­tal for a leg am­pu­ta­tion. When his doc­tors asked about the ink, the man said that it was the op­po­site of his wishes.

The pa­tient, a hos­pi­tal worker had lost a bet when he was younger, agreed to the tat­too but, ac­cord­ing to the case study, ' did not think any­one would take his tat­too se­ri­ously.'

Dr. Holt says his pa­tient's tat­too seemed quite dif­fer­ent. The hos­pi­tal's ethics team came to con­sult with the doc­tors, and to­gether they de­cided that the tat­too most likely did rep­re­sent the pa­tient's true wishes. For one, the man's ap­par­ent sig­na­ture was in­cluded.

Dr. Holt also says the place­ment of the tat­too mat­tered. 'It was ex­actly where you would have to do chest com­pres­sion, the guy had to have had some knowl­edge of the med­i­cal sys­tem,' he says.

But really, the team was con­fronting a deeper ques­tion. ' One way is to say "we don't know [his wishes] so for­get [the tat­too]". The other way is to say we are be­ing too dog­matic,' says Dr. Holt.

He says that 'it's really hard for pa­tients to have their end of life wishes known,' and this man, he and the ethics team con­cluded, had taken mat­ters upon him­self, lit­er­ally.

Luck­ily, two hours later, they found doc­u­men­ta­tion con­firm­ing that the tat­too was cor­rect and the man had signed a DNR or­der. The pa­tient took a turn for the worse, and the doc­tors let him go, but it was a wake up call to Dr. Holt.

DNR or­ders are still on pa­per, and just as the man could have changed his mind after get­ting his tat­too, pa­tients may change their minds be­fore hav­ing an op­por­tu­nity to change their re­sus­ci­ta­tion sta­tus.

'It’s a con­cern for both physi­cians and pa­tients be­cause you want to do right by some­one and if you don’t know, you do ev­ery­thing you can think of be­cause we al­ways pick the re­versible choice, not the one you can’t take back when faced with uncer­tainty,' he says.

A 70-year-old un­con­scious man with 'do not re­sus­ci­tate' tat­tooed on his chest (pic­tured) along­side what ap­peared to be his sig­na­ture. He had no other iden­ti­fi­ca­tion or next of kin, so doc­tors had to de­cide whether or not to re­spect the man's inked wishes

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