If You Ink It You Better Mean It

This happened in Florida, but it isn’t your usual Florida Man story:

There’s  a letter in The New England Journal of Medicine, faccompanied by this photograph of the ink in question (h/t Ars Technica):

What would you do, faced with an unconscious, unaccompanied and unidentified person with this on their chest?

(ETA: I guess the tattooed signature is an identifier.  But I’m guessing they mean formal ID, and one that might lead them in a timely fashion to the necessary records.)

The Florida hospital staff seems to me to have got it right this time.  Here’s how the patient came to them:

Paramedics brought an unconscious 70-year-old man with a history of chronic obstructive pulmonary disease, diabetes mellitus, and atrial fibrillation to the emergency department, where he was found to have an elevated blood alcohol level. The staff of the medical intensive care unit evaluated him several hours later when hypotension and an anion-gap metabolic acidosis with a pH of 6.81 developed.

Remember: no ID, no family to ask, and a patient unable to speak on his own behalf.  The ER tried to get him to the point where he could tell them his intentions, but he never reached that point. What to do?

We initially decided not to honor the tattoo, invoking the principle of not choosing an irreversible path when faced with uncertainty. This decision left us conflicted owing to the patient’s extraordinary effort to make his presumed advance directive known; therefore, an ethics consultation was requested.

While they deliberated, the patient received not-terribly intrusive treatment, but treatment.  Then…

After reviewing the patient’s case, the ethics consultants advised us to honor the patient’s do not resuscitate (DNR) tattoo. They suggested that it was most reasonable to infer that the tattoo expressed an authentic preference, that what might be seen as caution could also be seen as standing on ceremony, and that the law is sometimes not nimble enough to support patient-centered care and respect for patients’ best interests. A DNR order was written.

The patient died that night.  Later (after his death, I think, though the letter isn’t entirely clear) the patient was identified and his written DNR order was found in Florida Dept. of Health files.  The takeaway?

This patient’s tattooed DNR request produced more confusion than clarity, given concerns about its legality and likely unfounded beliefs1 that tattoos might represent permanent reminders of regretted decisions made while the person was intoxicated. We were relieved to find his written DNR request, especially because a review of the literature identified a case report of a person whose DNR tattoo did not reflect his current wishes.2

In other words:  Don’t Get The Tat If It Ain’t Where You’re At!

Open thread.






35 replies
  1. 1
    dmsilev says:

    a review of the literature identified a case report of a person whose DNR tattoo did not reflect his current wishes

    I’m going to assume, just because I can, that they resuscitated someone who didn’t want to be, which at least gives you the opportunity to come back and fix your mistake, Old-Yeller style.

  2. 2
    dr. bloor says:

    That hospital’s ethics counsel should be fired immediately. S/he is going to cost them a fuckton of money someday spitballing like that.

    If it ain’t on paper with a signature, it ain’t shit.

  3. 3

    Don’t Get The Tat If It Ain’t Where You’re At!

    Mine says “‽” so I’m good then.

  4. 4
    beergoggles says:

    This just indicated to me that doctors can take a simple situation and complicate it enough so that they can do whatever the fuck they want and completely ignore my wishes.

  5. 5
    the Conster, la Citoyenne says:

    We might want to start a new open thread on Flynn’s indictment.

  6. 6
    OzarkHillbilly says:

    I was listening to a RadioLab episode some years ago. It was asserted in an interview of a person in the medical field that getting a DNR tattoo is a not uncommon practice among doctors.

  7. 7
    chopper says:

    I’m sure the dude is in heaven right now getting another tattoo under it that says “no regerts”.

  8. 8
    Gin & Tonic says:

    @the Conster, la Citoyenne: There’s one downstairs.

  9. 9
    Timurid says:

    Michael Flynn might need that tattoo soon…

  10. 10
    Tom Levenson says:

    @Timurid: And here I thought that we wouldn’t get our news dump till the afternoon.

  11. 11

    @Tom Levenson: Maybe this isn’t the news dump.

  12. 12
    Mark says:

    To me a tatoo signals more serious intent than a piece of paper.

  13. 13
    Sergio Lopez-Luna says:

    Maybe “Mom” is the only safe Tat

  14. 14
    Yarrow says:

    @Major Major Major Major: Was thinking the same thing. More news dump to come?

  15. 15
    Spanky says:

    @Mark:

    To me a tatoo signals more serious intent than a piece of paper.

    There’s a booming business in tattoo removal. Easy to do if you can afford it. If you’re roaming around drunk with no ID, you might not have the resources.

    And speaking of which:

    Paramedics brought an unconscious 70-year-old man with a history of chronic obstructive pulmonary disease, diabetes mellitus, and atrial fibrillation

    IANAD, so tell me how you can determine a history if the patient is not IDed?

  16. 16
    JCJ says:

    While they deliberated, the patient received not-terribly intrusive treatment,

    “not-terribly intrusive treatment” is not at all incompatible with DNR. DNR does not mean no treatment of any sort.

    If his state has community DNR bracelets and he did not have one I would disregard the tattoo

    Also, what dr bloor said @ #2

  17. 17
    Humboldtblue says:

    Read this story last night. Fascinating.

  18. 18
    Gravenstone says:

    @dr. bloor: It looks like you can get medic alert jewelry that includes DNR instruction. Would you also find that inadequate?

  19. 19
    OzarkHillbilly says:

    @Spanky: The history of it came about after he was IDed but was written into the beginning of the story.

  20. 20
    The Moar You Know says:

    That hospital’s ethics counsel should be fired immediately. S/he is going to cost them a fuckton of money someday spitballing like that.

    If it ain’t on paper with a signature, it ain’t shit.

    @dr. bloor: Agreed. That to me was by far the most disturbing part of the story.

    Don’t fucking tattoo it. Get it on paper, file it with the state, and put it in your wallet/purse.

    It looks like you can get medic alert jewelry that includes DNR instruction. Would you also find that inadequate?

    @Gravenstone: Is it signed with a verifiable legal signature? Is it something that somebody who can’t read that well might have just picked up off the ground? Hell yes it is inadequate. DNR is easy to do – but it must be done right.

    I speak as one who is adamantly in favor of your right to die and your right to refuse treatment under any and all circumstances. But you can’t put medical people in a position of having to guess what you want.

  21. 21
    nonynony says:

    @beergoggles:

    This just indicated to me that doctors can take a simple situation and complicate it enough so that they can do whatever the fuck they want and completely ignore my wishes.

    It really isn’t that simple of a situation. It’s a really weird corner case and you’re talking about someone’s life. Doctors are supposed to save people’s lives, and DNR is a very specific legal framework designed to tell the doctors explicitly that yes, this person really does want you to back off and let them die counter to everything in your training.

    This is a guy with a random tattoo. This is not the same as a legal signature on a legal contract telling the doctor the patient’s wishes. For all anyone knows it could be the result of a horrible prank (people are awful) or a decision that he now regrets. Absent the paperwork the default behavior of the hospital staff should be to try to save your life because they cannot know what’s in your head and letting a patient die by accident isn’t the kind of mistake you can fix after the fact.

  22. 22
    JCJ says:

    @Gravenstone:

    @dr. bloor: It looks like you can get medic alert jewelry that includes DNR instruction. Would you also find that inadequate?

    Is it legal in the state? If it is not legally recognized then it is not adequate. I just looked – Florida does NOT recognize DNR bracelets. Wisconsin has had them for several years.

    From a google search: “Florida does not recognize a metal DNR bracelet or necklace. Instead, they have what’s called a “patient identification device”, which is a miniature version of DH Form 1896. It is a perforated section of the form and can be detached. It can be used as a wallet card or it can be hole-punched, attached to a chain and visibly displayed on the patient. It should be laminated for protection after the information on it has been completed. Please note that this device must also be signed by the patient’s physician and the patient or patient’s healthcare proxy.”

  23. 23
    AnonPhenom says:

    Don’t Get The Tat If It Ain’t Where You’re At!

    Or make sure the Tat references the Health Dept. file number of your written instructions also…

  24. 24
    cynthia ackerman says:

    AEMT here, with two restarted hearts in a small rural community.

    Here in Oregon this tattoo would not affect my patient care.

    We have a simple form called a POLST (Physician Order for Life Saving Treatment). Once completed, signed by a physician, and registered with the state, the POLST is a gold standard. It can be updated easily if preferences change. Absent documented physician orders, my legal obligation is to do everything possible, with exceptions for certain clearly defined circumstances (traumatic cardiac arrest, rigor mortis, etc.).

    A tattoo of one’s POLST registration number would do the job, but not a “DNR”.

  25. 25
    Another Scott says:

    Dunno. I feel that if the language on the tattoo is clear (and it certainly was clear here), has a signature reproduction (as this one apparently did?), and has a date (dunno if this one did, and the elapsed period of time isn’t too long (maybe annual date updates?)), then the law should be that it’s as good as a formal paper DNR.

    The law exists to serve man, not the other way around. People’s clearly expressed wishes should be honored when possible – is my bottom line. A tattoo like that couldn’t be more clear, IMHO, and he had medical conditions and age that would be consistent with the expressed wish.

    My $0.02.

    Cheers,
    Scott.

  26. 26
    Karla says:

    @Spanky: Tattoo removal is pricey, but a new tattoo crossing out the order, should someone change their mind, shouldn’t be that expensive. (I’m not saying I’m sure where I stand on this whole situation, but there is more than one way to back out of the message communicated by the tattoo.)

  27. 27
    beergoggles says:

    @nonynony: A tattoo with his signature is way more of a commitment than a piece of paper or a bracelet which can both be lost. Why do you call it random? It’s actually very specific. Quite the opposite of random actually. Tattoos can also be removed or cheaply covered up with other tattoos or struck through if it no longer relevant. It looks healed indicating it’s been there a while without any attempt to change it, so there is absolutely no indication this was prank. People are just reaching for absurdities in order to support poor decisions by doctors.

  28. 28
    VincentN says:

    Perhaps he got the tattoo because he was worried about a situation in which his wallet with his DNR paperwork would be missing or stolen? If so, he might have considered having his personal identifiers tattooed as well to make it easier for the medical staff to find his written and filed DNR.

  29. 29
    Another Scott says:

    I’m a little concerned about some of the reasoning here.

    We’ve all heard stories about the wrong leg being amputated and that many (most? all?) hospitals have protocols now that have big magic marker writing on legs saying things like “THIS ONE” on the correct leg to be removed. Would surgeons follow that if the paperwork said the other one, or would they say – “well the paperwork says this, so that’s what I’m going with…”??

    What about people who go on vacation to a different state, or country? Or swimming and don’t have the paperwork in their trunks? Should their clearly expressed wishes be ignored if they don’t have the paperwork (regarded as valid in that particular place) handy?

    I recognize this is a corner case given the variations in the laws as they exist now. But it shouldn’t be a difficult decision at all in this man’s case, IMHO. Common sense should apply.

    FWIW.

    Cheers,
    Scott.

  30. 30
    satby says:

    @Another Scott: Agreed.
    Also, he was unidentified, meaning even if he carried a wallet or ID it had been lost. He did the most clear thing he could to ensure that if he was found in the condition he was, that his wishes would be carried out.

  31. 31
    JCJ says:

    @Another Scott:

    Should their clearly expressed wishes be ignored if they don’t have the paperwork (regarded as valid in that particular place) handy?

    There ya go.

    regarded as valid in that particular place

    If I have a valid DNR bracelet in Wisconsin but a medical event happens in Florida I would suspect that the DNR bracelet might not be considered valid.

    As far as clearly expressed wishes, if someone has a tattoo with “Angela, love forever” and is married to Angela but then the relationship sours for whatever reason could the person file for divorce if Angela says no to this? The tattoo is a clear statement. Would it be required that the tattoo be removed or altered?

  32. 32
    Another Scott says:

    @JCJ: Expressing love is not a life-or-death decision.

    The over-riding main point of DNR laws is to allow people to be treated with dignity and to respect their clearly expressed wishes when they are near death. It’s not to protect doctors (otherwise, protect doctors by forbidding DNR laws and remove the potential ambiguity), or to create work for lawyers. That dignity and respect should not depend on where one happens to be when one is near death.

    There should be sensible, uniform, national standards about DNR, and tattoos like this one should be valid, IMHO. Add sensible standards about what such tattoos need to say, if you want. I recognize that such uniform national standards do not yet exist, but it doesn’t change my opinion about what should have happened here.

    My $0.02.

    Cheers,
    Scott.

  33. 33
    John says:

    @dr. bloor:

    I don’t know what the solution is, but the way things are currently set up almost EVERYONE gets the fully invasive monty because nobody carries their DNR paperwork with them. DNR tattoos should be valid.

  34. 34
    sempronia says:

    This guy wasn’t going to survive anyway, with a pH of 6.8. But if he had rolled into my ER, we would not have honored the DNR tattoo either, because it’s not a legally recognized way to designate your wishes; it’s POLST, expressing your wishes to family/friend, or nothing. (Or DNR bracelets, in those states.) We don’t need new standards – we just need people to make their own decisions and then make it known through already established channels. Who knows how old the tattoo is, and whether you still feel that way. As for the DNR bracelets, if your state doesn’t recognize them, get one anyway and engrave the contact info of whoever holds your POLST form. As someone said above, don’t make your medical team guess what you were thinking. I love it when families walk in waving their person’s POLST forms – it means they’ve really thought about what they want, and everyone’s on the same page.

  35. 35
    dr. bloor says:

    @John: What should be the case is an open question. What the hospital did in this case, circumstances being what they were, is the legal equivalent of taping a “Sue Me” sign on the hospital’s back.

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