Imagine working in the bustling ER of Jackson Memorial Hospital late at night. A drunk man, roughly middle-aged, was rushed in unconscious. You are unsure as to how much time he has left and what you immediately do to help stabilize him. His breathing is heavy and he is exhibiting signs of septic shock. Completely alone, you begin to examine the patient only to find the words “Do Not Resuscitate” tattooed in bold letters on his chest with the word “Not” underlined and a signature placed directly underneath. As a physician, what should you do? Do you ignore the message of the tattoo and resuscitate the John Doe or do you carry out this highly unusual DNR?
This wasn’t just a hypothetical situation, but rather a doctor’s worst nightmare come true. In 2017, at Jackson Memorial, the first plan of action was to attempt to bring the patient to consciousness. However, they failed so he was put on an IV, O2, antibiotics, and adrenaline in order to stabilize him but they did not put him on life support such as intubation or ventilation. The doctor’s first reactions were to provide all life-saving care for this man, given that letting someone die is an irreversible action. They were doubtful about the meaning of the tattoo due to a past incident with a man who came in and had the acronym “DNR” tattooed on his chest. The hospital staff confirmed that he wanted to be resuscitated and that he got the tattoo as a joke when he had lost a drunken bet.
Written DNRs take a long time to be recovered from the dusty, locked drawers of the State Department of Health. It could also be argued that the John Doe had gone to extreme lengths to have his wishes heard for a scenario just like the one he was in. The tattoo was his insurance policy– a way of assuring that his wish to not be resuscitated was honored. An ethics group including Dr. Ken Goodman, the Director of the Institute for Bioethics and Health Policy at the Miller School of Medicine and the Co-Director of the UM Ethics Programs, was consulted for the case and said that the instructions of the tattoo should be carried out because they believed that they expressed the real wishes of the patient. John Doe died later that evening and a written DNR order that was filed with the Florida Department of Health was later found.
The major controversy over this case regards the legal value of the tattoo, if it conveyed a medical message at all and if it was representative of his current wishes. When contemplating such an issue, it is important to consider some of the ethical implications of the decision of the physicians. Did the physicians make the correct decision in honoring the tattooed DNR order? In future cases, what evidence should physicians weigh in deciding whether to honor non-traditional DNR orders, such as jewelry or tattoos? And should the physicians have waited to act until hearing from the Florida Department of Health before making a final decision?
Given this specific case, the physicians did make the correct decision in honoring the tattoo. In the end, the patient’s wishes were honored. The tattoo was placed directly on his chest, the immediate area for compressions during resuscitation. The fact that a signature was placed after DNR written, NOT was underlined for emphasis, and the DNR was written in large bold letters shows that the patient very much wanted to not be resuscitated. In other cases with a DNR tattoo, the patient should be resuscitated if there is ambiguity in their DNR statement because the decision to accidentally let someone die is irreversible.
In the situation where the man had “DNR” tattooed as a joke, his tattoo was ambiguous and had minimal effort. Our John Doe took the initiative to show what he really wanted and he put in the effort. He also followed the formal means and went a step further to tattoo “Do Not Resuscitate” on his chest and place his signature underneath the tattoo to act as a pseudo-DNR order. The man clearly stated his wishes by tattooing it for immediate sight.
A major problem we are faced with in the field of medicine is that patients are not required to not refresh written advanced directives and as a result it is hard to understand what a person’s current wishes are if they are unable to communicate. Dr. Ken Goodman, the Director of Institute for Bioethics and Health Policy and Co-Director of the UM Ethics Programs stated that the man had ample opportunity to remove the tattoo and he went through a lot of trouble to get it so that he was not rescuitated. Therefore, he communicated in the way he thought best for his doctors to understand by taking that extra step to get a tattoo.
Unusual DNR orders are more common in the ER than they seem. With regard to tattoos, they should be honored if they lack ambiguity, meaning that the words “do not resuscitate” are spelled out fully. The acronym DNR would not be sufficient because ambiguity and no effort in stating the person’s wishes.
Physicians should wait to hear from the Department of Health because confirmation of the existence of a DNR and what it says is important if there is ambiguity. However, if there is no ambiguity, then they can take immediate action to follow through with the DNR. The hospital would be held liable if he did not survive or if the DNR was not in place. The state’s interest is in preserving life and in order to override the state’s interest the DNR must be posted clearly.
The status of the patient and whether or not the emergency is a time sensitive matter should be taken into consideration. This specific case was highly time sensitive so if the physician had waited to hear back from the department, the patient’s legal and medical wishes would have been denied and he would have been put on life support. He later could not be taken off life support because a DNR does not mandate removal from life support, only that the patient is not resituated. Though the physicians honored his wishes in the end, the clarity of a DNR order and time-efficient access to written DNR orders are vital to avoiding situations like this in the future. In future cases similar to that of our John Doe, the best solution is to call the next of kin and provide hospitals immediate access to important records such as DNRs by having a registry for advanced directives. Not everyone has an advanced directive in place so it is important to have that discussion with your doctor and family so that your wishes are clearly understood and not misconstrued.