06 November 2011

A "Do Not Resuscitate" tattoo


It should be emphasized that this is not a substitute for a proper living will.  Additional information about this lady (who also has a PTO ("please turn over") tat over her scapula)  at The Mirror.

Addendum:  A sad observation by TheReaperD:
I've encountered multiple EMTs and organizations that openly defy DNR orders, even if they have been given an advanced legal copy and have it on file. They believe it is morally wrong not to do everything to try and save somebody and no amount of patient's wishes or legal paperwork is going to stop them. I have real issues with this that I cannot seem to put into words at the moment.

25 comments:

  1. I've been planning one of those since nursing school, get it when I'm in my 60s.

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  2. I hope that readers will be interested in Physician's Orders for Life Sustaining Treatment (POLST) to help honor treatment wishes. Paraphrasing from http://dying.about.com/od/ethicsandchoices/f/POLST.htm and POLST.org:
    The POLST is a relatively new document designed to ensure that a person’s end-of-life wishes are followed in every situation, from home through hospital. It would protect from unwanted emergency medical care like chest compressions, electrical shocks, ambulance transfer to hospital, etc. Both doctor and patient (or legal representative) sign the form; and the physician must also certify that the decision the patient is making is consistent with his/her current medical condition. The POLST complements (but does not replace) an Advanced Directive or DNR order, particularly in an emergency at home, giving paramedics clear authorization on which actions are desired by the patient. Without this, full treatment is the automatic default.

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  3. Old ICU nurse here... like Zhoen, I'm going to get "DNR" tattooed on my sternum when I hit 60... There have been way too many "G.O.M.E.R.s" through the years...
    (And yes, I have a Living Will, POLST, and DPAHC!)

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  4. I've encountered multiple EMTs and organizations that openly defy DNR orders, even if they have been given an advanced legal copy and have it on file. They believe it is morally wrong not to do everything to try and save somebody and no amount of patient's wishes or legal paperwork is going to stop them. I have real issues with this that I cannot seem to put into words at the moment.

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  5. Thanks, TheReaperD. I've added your comment to the post because I think it deserves further consideration by readers.

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  6. I was told by my EMT instructor back in the day that if you knowingly defied a DNR you could be held liable for the patient's medical expenses. I frankly like that idea.

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  7. Baylor's research has shown that feed tubes and successive resusitations obstruct the body's own ability to shut down 'gracefuly' CAUSING more suffering for the patient as faculties are still being provided nutrients that would otherwise be unavailable.
    There is a huge cash crop that is the rows within the wards of our hospices. Strange that when the insurance ends so too does the patient's care.

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  8. I think this is a relevant passage from the hippocratic oath:
    "I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism."

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  9. As a first responder, I wonder about the necessity of the scapula tattoo. I'm not being sarcastic, either: pretty well any treatment (except perhaps one exacerbated by entrapment or entanglement) would neccesitate the patient being turned onto their back.

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  10. In Australia, ambulance and paramedics are not empowered to honour Advanced Directives and could be sued if they -don't- do "everything" in the pre-hospital phase. Unfortunately that means I've seen an elderly terminal cancer patient who attempted suicide brought into the ER on a ventilator. Once there, we (ER doctors) were able to honour his wishes and allow him to die.

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  11. A related personal experience -- in 1990 my mother was at the end stages of a long drawn out bout with lung cancer that we all knew she was close to losing. She had excellent hospice care in her own home and my father was there to help in any way he could. At some point the hospice nurse said that my mother would be dying very soon and cautioned us about how to deal with the police and the EMTs since she would be dying at home and someone would need to be called. She simply said that when she was obviously dead, we should wait another 30 minutes or so and then call 911 saying that someone had died in our home. Then we were told to stand on the front porch and wait for the EMTs, barring the way and saying very clearly that my mother had died and has been dead for at least 30 minutes. We did so and it took a valiant effort to keep them at bay. Eventually they did enter the house (with all their equipment in tow!)and only performed the necessary examinations to confirm death. Someone from the funeral home arrived during all this and supported our efforts. Trying to leave this world with a little dignity is a lot more difficult than most would think.

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  12. Thanks, anon, for your comment. The experience probably varies quite a bit from place to place and time to time. When my father was dying about 20 years ago, I went down to Texas to stay with him in his trailer for the last few weeks so he wouldn't have to be institutionalized. He died at night, and as I remember I waited until the morning to call a funeral home and they came to pick up the body without any fuss. But that was "snowbird" territory in the Rio Grande Valley where death may be accepted a little bit more casually.

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  13. I am a reincarnationist, and have been my entire adult life. Our society gives no standing to non-Judeo-Christian POVs on most everything, and evidently this one, too.

    To me, the process of dying is a passage, nothing more - one we all contracted to do the day we decided to come into this world.

    Reading these comments it appears I will have to fill out all those acronym-ic forms, so I can die in peace, like humans were meant to do. I have long since instructed my children that don't they DARE allow ER people or EMTs revive or try to sustain my life. When my time comes, it is my time. It is not the place of a stranger to dictate to me how I go. The very thought enrages me, of being violated.

    I have read many Near-Death-Experience accounts, and I see passing as something to look forward to, when the time comes that it needs to happen. We come here for a while, then we go there for a while, back and forth.

    As I see it, only those whose hubris tells them that they "know what is best" makes them intrude on what is a necessary passage in life. Do they think they are stemming the flow? That this person they are pounding on is going to live forever? Their belief that life must be clung to, no matter what - who died and made them God?

    I will go when it is my time. No later and no sooner.

    P.S. As a kid, I was in several hospitals for extended stays, for a problem the doctors did not (and still don't) know a thing about. I was probed, tested, held under false pretenses (they faked diagnoses just to keep me in the hospital), and X-rayed to the point people wondered why I didn't glow. From that early experience, I found out something many never learn: Doctors often are just guessing. I see them at best as mechanics, and will go to them with a broken ankle or some such. I will NOT let them interfere with my bodily functions.

    I was given lessons to work through in this life, and if some of those are physical ailments, then that is what my karma is about, and I accept it - including the one the doctors couldn't figure out (they never did). When the time comes for my body to start to fail, then it will be my time. Why should I ask for more time - especially time in a hospital bed, enduring a long, slow, painful - and above all, frustrating - leaving of this Earth.

    I see dying as a dignified affair. Just as life is.

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  14. I take the sentiment, however.....

    If a patient arrived in front of me at the hospital unconscious and I had no information other than that tattoo on their chest I would certainly ignore it.

    On the face of it this is callous and disrespectful to the patient. However, I have no idea the history of the tattoo. They may have been drunk; done it as a joke; they may have changed their mind - removing a tattoo isn't a quick job; they may have been in an unfit state to make that very important decision at the time of the tattoo; I have no idea if there was coercion and they were forced into it. I would hope all the above were unlikely and it was a well thought out decision.

    I would undoubtedly resuscitate first and ask questions (a very quick) second. You can gather information, in most circumstances, very quickly. In the split second decision between someone's life and death, I will choose life where possible - you can't undo death if you were wrong.

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  15. Additional to the above:

    Please note I would not ignore a legally valid advanced directive/living will etc.

    I believe in dying with dignity. I certainly do not agree with medical intervention for the sake of it and I definitely try to act in all circumstances in the way that the patient would wish me to.

    If there is any doubt - act in the way that is the least harmful and leaves the possibility of 'undoing' your decision. As I said before, you can't undo death.

    (Before I scare anyone though - by 'undoing' I don't mean actively killing the patient if you later find out resuscitation was against their wishes, you can withdraw active treatment etc - acting in an ethically and legally permissible way)

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  16. @Paula
    The second sentence of your comment does nothing but clarify why so many people think doctors are arrogant know-it-alls with a god complex. You offer some not-very-likely (ie. lame) reasons why someone "might not really mean it" about a DNR tattoo. (Do you seriously believe a tattoo artist would knowingly give someone who didn't want it a DNR tattoo? And any tattoo artists who value their license will not work on an intoxicated person.) Those unconvincing reasons why you would ignore a DNR are pretty weak cover for your 'doctor knows best' attitude. I can only hope your arrogance doesn't cause someone harm. Doctor, heal thyself indeed - of hubris!

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  17. anon, you're being too hard on Paula. Her comments do not reflect physician arrogance; they reflect the brutal reality of the everyday practice of medicine and the risks of major malpractice lawsuits when proper guidelines are not followed.

    If you read the link, it specifies that "Joy made a living will." Her tat is a supplement to that, not a substitute for it.

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  18. Stan, with all respect, this is one instance where I think we'll have to agree to disagree. I have had far too much personal, firsthand experience with arrogant, condescending doctors to take @Paula's comments at face value. One of my best friend's daughters graduated from medical school last year, and I can barely stand to be in the same room with her now. Before she went to med school she was one of the most open-minded, engaging young people I know. Now you can't tell her anything because she knows it all, and her general air of bored condescension makes that attitude abundantly clear. I don't know what they do in med schools to turn otherwise nice, normal people into such smug, arrogant a**holes, but I sure wish they'd stop!

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  19. Are you sure she didn't go to law school?

    :.)

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  20. Ha-ha! A good question, but no - her parents would've disowned her!

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  21. I shall try not to be personally offended by what amounts to a personal attack.

    A tiny bit harsh to say that because you know a doctor who is an arrogant arse you can conclude I am also closed-minded, arrogant or condescending. It is a false conclusion to say that because we have the same qualifications we share the same personalities.

    Ok, so you may not like me, you don't have to. But to make an ad hominem attack on the integrity of an argument based on your feeling for me is a bit crap!

    I know someone with an english degree who has no sense of humour, could I conclude that therefore no english graduate is ever funny?

    I know doctors who are arrogant, I also know many who are not.

    Is it not arrogant to suppose that by reading a few lines of something I have written that you know my personality, my attitudes and beliefs, that you can be sure if you met me in a hospital that your abiding memory of me would be that I was an arse.

    However, on the point of the tattoo - it is a very complex an emotive ethical and legal quagmire. What is ethically seen as right is not what is always legally right. Given the current legal state, I would defend my actions as stated previously - if I had to stand up in court and defend my actions, I would far rather for myself and the patient/family defend trying hard to save that patient then having to apologise afterwards for making the wrong decision (and yes, if I make a mistake, I apologise) than standing back, doing nothing and having to explain to a grieving family why I didn't bother trying to treat their relative.

    cont...

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  22. As said previously - I do not assume I know what is right for any particular patient. I carry out what I think, in my professional experience and judgement, will be the LEAST HARM option whilst ascertaining what the PATIENT wants. Medicine requires split-second decisions. You can not sit around debating the merits of any particular action before acting.

    I always, in every way, every day try to act in the way that the patient wishes (if legally permissible), and if they are unable to express a wish either themselves, via an advanced directive/living will or a relative (and with this you assume all relatives tell the truth all the time) I try to act in what, my judgement tells me is in the best interests of the patient. But you don't just stop there, rub your hands together and pat yourself on the back for a job well done, you gather as much information as possible to ascertain what the patient would want if they were able to express it. I am unsure where the arrogance lies in this aim.

    The arguments of "Anonymous" make several significant assumptions.

    1) "Do you seriously believe a tattoo artist would knowingly give someone who didn't want it a DNR tattoo?" - what guarantee do I have that a tattoo artist did ascertain the persons mental state and the certainty of their wishes at the time of giving them the tattoo. I have absolutely no doubt that there are tattoo artist with that level of skill, training and conscience. However, you are assuming that not even one single person who could do a tattoo (including someone with a biro and a needle) all conform to those same standards.

    2) "And any tattoo artists who value their license will not work on an intoxicated person". See argument above. You are making an assumption that the tattoo was done by someone with a license. I don't have sufficient skill to ascertain the professionalism of the artist from the artwork.

    I do have to point out this is all academic as the lady in the original article had a living will. I would not have resuscitated her given there was a legally defensible document stating her wishes. ie I would have done exactly what the patient wanted because I could be 100% sure of what her wishes were.

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  23. @Paula
    I'm glad to hear that you at least sound like "one of the good ones", and therefore apologize for the portion of my comment that was indeed directed at you (ie. the "physical, heal thyself" quotation. I do, however, stand my my assertion that medical schools seem to do something to far too many med students that makes them believe they are practically god-like. I don't just know ONE arrogant, condescending physician (I wish that was the case!), but as I stated in my original post, I know far too many.
    I am a volunteer MFR myself, and was on one occasion actually shouted at by a doctor for honoring a DNR tattoo. She called me everything from unprofessional to a 'f***ing idiot', in front of many shocked witnesses. Even after we handed her the patient's valid, current DNR order, she still refused to admit her mistake. Instead, she screamed "those things aren't worth the f***ing paper they're printed on!" and threatened to have my "license" taken away.
    So I'm afraid you'll have to excuse me if I'm a little touchy about doctors and their reputations.

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  24. Thank you. Good reply.

    I would agree that very often the product of a medical school is arrogant and too self-assured. You don't need to tell me, I went to medical school! A little humility and self-doubt goes a long way. To me being a good doctor is not just about how much you know (although clearly knowing stuff really helps) but also how you behave.

    Calling any of your colleagues “unprofessional” or “f*****g idiot” in private, let alone infront of colleagues and patients is incredibly unprofessional. It also doesn’t make you a nice person! Everybody is human, and every human makes mistakes, the mark of a good person is how you handle that. Putting your hands up and saying “I’m sorry, I genuinely believed I was acting in the right way, but I can see I was wrong” is appropriate. Screaming at your colleagues is not. I don’t care how much you know; if you think those are appropriate ways to act you are a bad doctor.

    However, I would not say that everyone is going to agree all of the time. Because I’m a doctor does not always make me the one that is right. The appropriate way to tackle a difference of opinion is to communicate. In my experience, once everyone appreciates all aspects of the situation, there is much better understanding from both sides and a reasonable, more informed conclusion can be had. My opinion is that every person in the team matters, doesn’t matter whether you are a doctor, nurse, pharmacist, cleaner etc if one of you doesn’t turn up to work, everyone is affected. The point of a team is that everybody matter in different ways, but all equally. You just ask the nurse who recently tried to tell me that she was "just a nurse" - we got into a complete mess of me trying to prove that there was no such thing as "just a nurse" because we'd all be screwed if she wasn't there.

    I would suspect we practice in different countries (spelling a dead give-away, but I’m afraid I also don’t know what MFR stands for). However, whatever country you practice in, the same things make you a good person make you a good doctor or any other type of healthcare professional.

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  25. @Paula
    "the same things make you a good person make you a good doctor or any other type of healthcare professional."
    Amen to that, doctor - I couldn't agree more. Which makes it all the more frustrating to see people like my friend's daughter turned into self-satisfied, smug wretches I'd just as soon strangle as help! (only partly kidding!) ;)
    Thank you, too, for elucidating your position. Keep up the good work!
    PS: I live in Canada, and MFR stands for Medical First Responder. I'm also a volunteer firefighter in a rural area, where the nearest ambulance is a good half-hour away. That's why many of our firefighters are also MFRs.

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