Do Not Resuscitate Tattoos

As pre-hospital medical providers we see a lot of patients in all sorts of medical disrepair. The public and patients expectation is that we put a full effort into doing the best we can with our limited field resources and either take the patient to a medical facility, leave at home, send the patient to their primary care or specialist physician or call the coroner.

We have seen terminally ill patients with Do Not Resuscitate (DNR) orders on paper at the patient’s home or at a nursing home and if the staff, patient or family member can produce the paper in a timely manner, we honor that request. Generally these patients are terminally ill and sent home under Hospice, in care of a hospice specialist, a family member or nursing home staff.

We also see cardiac arrest patients whose family states they have a DNR order, but if they cannot produce one, most of you know the local protocol for those events is to not honor the verbal order and do your thing related to providing excellent patient care. Anything less and you could find an attorney knocking on your department’s door.

It has been the prevailing belief that DNR orders are generally hospital or nursing home documents that found their way into the patient’s home and we have honored those requests generally to the satisfaction of the patient and surviving family. I have been on calls where DNR means DNR enforced by the family threatening physical violence against the responder if they attempt treatment although the patient was not suffering from the medical condition for which the DNR order was written. The patient was sent home for a terminal disease such as cancer but suffers from pneumonia and respiratory distress. In reality, it was not a good document for prehospital responder.

Over the last several years, there has been a big change in the paperwork related to DNR orders with the newer Physician Orders for Life Sustaining Treatment form (POLST) that clearly outlines the patient’s intent signed by the patient and the physician in an eye catching color of lime green and the patient is issued a wrist band to wear consistently in case they do not have the actual document with them.

This is a legally sanctioned form to provide certainty for the patient and emergency responders who must be decisive about attempting or forgoing an attempted resuscitation. An example under Washington Law, RCW 43.70.480; the POLST document was created for “emergency medical personnel responding to injury or illness for the treatment of a person who has signed a written directive or durable power of attorney requesting that he or she not receive futile emergency medical treatment.” The document generally outlines the patient’s wishes for resuscitation, medical interventions, antibiotics and artificial feedings and every State has either this form or something very similar.

Scenario - you respond to a patient in cardiac arrest and in the process of uncovering the chest for application of the pads or paddles, you see “DO NOT RESUSCITATE” tattooed on their chest. Most EMS responders continue with the resuscitation due to the fact the tattoo may have been a joke or a whim of the patient many years ago and when a potential or actual terminal event occurs, the EMS responder must ask the question, does this tattoo reveal the actual intent of the patient?

A best practice is to think about the established rule of “Implied Consent” (consent that is inferred from signs, actions, or facts, or by inaction or silence) and not honor the tattoo as the patient is not in a position to agree or protest the action by the responders and go with the resuscitation. That places you in a legally defensible position if the family members sue the department or provider for a “failure to resuscitate.”

The actual answer is a legal and ethical dilemma. EMS responders are trained to seek or inquire about POLST (or DNR) documents and they will generally follow direction and protocols for patient care. In my experience, prehospital medical providers are generally conservative and will offer the basic prehospital care while actually determining the presence of a medical directive.

The legal perspective is that people continue to have the right of self-determination when it comes to health care issues. Look at the laws regulating Physicians Assisted Suicide for terminally ill patients in several states where the courts have ruled in favor of patients taking their own lives under a physicians originated prescription of a narcotic or barbiturate, therefore declining lifesaving procedures based on their competency to make such determinations.

There is a legal presumption that patients are mentally fit and competent to make those decisions until a court determines otherwise.

These situations are ethically unique in nature and each one requires a through ethical evaluation. Most fire or EMS departments do not have an ethics officer on staff or on call, so the question continues as to your medical procedures and response during these situations. In an in-hospital situation, many ethics consultants would advise you to honor the patient’s do not resuscitate (DNR) tattoo, suggesting that it was reasonable to infer that the tattoo expressed an authentic preference as the law is sometimes not nimble enough to support patient-centered care and respect for patients’ best interests.

The patient’s tattooed DNR request will produce more confusion than clarity, given concerns about its legality and likely unfounded beliefs that tattoos might represent permanent reminders of regretted decisions. Despite the well-known difficulties that patients have in making their end-of-life wishes known, this neither supports nor opposes the use of tattoos to express end-of-life wishes when the person is incapacitated. Emergency responders are unlikely to miss seeing a DNR tattoo on the chest prior to attempting resuscitation.

In these situations, it is advisable to provide basic patient care, contact base station to obtain the medical director’s advice to provide some solace that you did the right thing places you in a sound legal and defensible position.

Discussion - Ethic experts opine that some individuals do not trust paper so they tattoo end of life desires on their bodies with forethought. One issue to consider with a paper POLST is that there is an opportunity to rescind the order and remove the wrist band that will reset the desires of the patient.

Pre-hospital providers are morally, ethically and legally obligated to respect the preferences of patients to decline life-sustaining treatment. The use of a tattoo originates from a fear that such choices will not be respected if the paper document cannot be found.

In a report from a Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT), physicians only understood 46 % of hospitalized, seriously ill patients’ preferences to forgo cardiopulmonary resuscitation (CPR). In qualitative interviews, emergency physicians described the emotional and moral distress caused by resuscitating a patient, only to learn later that the patient had a legal and signed Do Not Resuscitate document that was not accessible in the emergency department.

Actually tattooing DNR on one’s chest is intuitively appealing, but flawed as policy. From a legal perspective, emergency responders and clinicians in health care settings are not obligated to respect a DNR tattoo.

For an unresponsive patient, a tattoo might provoke emergency providers to search for a legally binding document, such as a Physicians Order for Life Sustaining Treatment (POLST) or a locally sanctioned pre-hospital DNR order — if there is time. But in a cardiopulmonary arrest, and in the absence of such official documentation, the responding emergency provider or clinician should proceed with attempted resuscitation.

By imprinting the letters DNR on their body, a person obtaining a tattoo may wish to increase the certainty that their decision will be respected. Paradoxically, however, such a tattoo may exacerbate the uncertainty of emergency responders at a critical time. A DNR tattoo, however, may cause confusion at the very moment when certainty is needed. First, its meaning may be ambiguous. The emergency responder may wonder: do the letters stand for Do Not Resuscitate? Or Department of Natural Resources? Or someone’s initials? Second, the tattoo may not result from a considered decision to forego resuscitation. Errors in interpretation may have life and death consequences.

A DNR order needs to be legally recognized in order to provide a legal safe harbor for first responders who implement it. In this case, if the emergency personnel had withheld CPR, they might be legally liable for an erroneous interpretation of the tattoo. 

Finally, DNR orders, like all medical orders, need to be reversible. If patients are permanently committed to preferences expressed at one time, they may be reluctant to express any interest in foregoing interventions. Changing a POLST form or removing a POLST bracelet is fairly straightforward and free. Removing a tattoo, in contrast, is an expensive and time-consuming process.

What can we learn from the DNR image or bracelets in this case?  

Several things. First, DNR tattoos, and other forms of non-legally binding advance directives, are not to be trusted.

Second, for those individuals who do hold strong preferences against resuscitation, there is a need for a form of legally binding documentation that is inseparable from the body hence a POLST bracelet. Twelve states recognize the POLST form as legally binding orders to forego CPR and other resuscitation measures and other states have some type of similar document. These orders apply in all circumstances, including out-of-hospital, in skills nursing facilities, in clinics and in hospitals.

Local jurisdictions may have their own DNR forms that are legally recognized. Oregon addressed the problem of POLST orders not being available to emergency responders and clinicians by creating a registry so that when the physical form cannot be located, emergency responders and clinicians have 24-hour-a-day telephone access to POLST information.

In the case of a cardiopulmonary arrest, first responders need to devote immediate attention to resuscitation efforts unless there is unambiguous evidence that the patient would not want CPR. Taking time to ascertain if the patient has a POLST order in a registry or searching the patients home may decrease the likelihood of a successful resuscitation.

The bottom line with DNR tattoo or bracelet is to act in the best interest of the patient, get your base station Doctor on the phone or radio for advice as they have a better resource obtaining a legal and ethical decision faster than you can in the field.

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Endnotes

Picture 1 obtained from s.weasel.com site

Picture 2 obtained from HuffPost – Protecting Yourself from Hero Doctors December 6, 2017. Jessica Nutik Zitter, MD, MPH

https://www.nejm.org/doi/full/10.1056/NEJMc1713344

https://www.theatlantic.com/health/archive/2017/12/what-to-do-when-.... Author Ed Yong 12/2017

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3445688/

http://polst.org/programs-in-your-state/