An unconscious 70-year-old man arrived at a Miami, Florida, hospital early this year with no family, friends, or other identification. When doctors were about to treat him, they realized that the man had tattooed “Do not resuscitate” on his chest – with the “not” underlined, and joined by an inked signature that seemed to be his. This made the staff enter into a medical and ethical debate: to decide whether or not they should proceed to revive this man.
The Jackson Memorial hospital doctors wondered about the legal consequences they could face if they brought the unidentified man back to life, but also felt confused after seeing his health record, and the high levels of alcohol in his blood.
They practically asked themselves: did this man get this tattoo consciously? If he did when he was young, could he still feel the same way about it? Should we respect his wishes? What would happen if we don’t?
The author wrote on the study published Tuesday in the New England Journal of Medicine that the medical team first decided not to follow the inked words after invoking the principle of “not choosing an irreversible path when faced with uncertainty.” However, they later asked for an ethics consultation with a team, which told them they were in total disagreement with them.
Ken Goodman, co-director of the University of Miami’s ethics programs, told the Atlantic Journal that – no matter how “unorthodox” it could sound -, doctors get a “dramatic” point of view of what the patients “would want” when facing similar situations.
Doctors said that these events typically happen in movies. However, they never thought about the possibility of living one of them themselves.
According to the critical-care physician and lead author of the paper, Gregory Holt, a “lot of people in medicine” have joked about getting a similar tattoo. But when they saw that the 70-year-old man had one, their faces rapidly changed with “surprise and shock.”
Holt also said that those feelings hit them for twice when they had to think what to do about it after seeing him.
“This patient’s tattooed DNR request produced more confusion than clarity, given concerns about its legality and likely unfounded beliefs that tattoos might represent permanent reminders of regretted decisions made while the person was intoxicated,” the study’s authors wrote.
How to decide what an unconscious person wants?
Holt informed that the man had a long history of pulmonary diseases and that he used to live in a nursing home. However, he was found unconscious and intoxicated on the streets before being taken to the Miami hospital by people who didn’t know him.
After the man reached the medical center, according to the paper, the staff treated the patient with “antibiotics and other life-saving measures.” The author wrote that the man’s organs were failing and that his blood pressure was low. He was suffering from an infection that led him to septic shock.
The patient had no papers and no one by his side to tell the staff who he was. The only thing that could tell about his personality was the tattoo on his chest. However, the doctors didn’t want to honor the inked words because they weren’t entirely sure of what he wanted.
Laws about reviving people are very complicated and vary depending on the state the patient is. According to an article in the Journal of General Internal Medicine, every doctor is “morally and legally obligated” to respect any patient choice to “forgo life-sustaining treatment.”
“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,” the authors wrote on the Journal of General Internal Medicine article.
However, tattoos aren’t legally binding because they cannot exactly represent what the patient wants at the moment. This should come with some agreement like a Physician Order for Life Sustaining Treatment signed by authorities.
The final decision
The doctors decided to follow the ethics consultants’ advises of not doing anything. But then, they find another paper that gave more weight to this late decision.
“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,” the study reads.
At the end of the ethical debate, the authorities from the hospital’s social work department found something related to the unidentified patient. It was a copy of the man’s Florida Department of Health “out-of-hospital” order that specifically told them not to resuscitate him if he was found unconscious again.
This supported the words on his chest. The authors of this study said that they felt relief after having found “his written DNR request.” The man died the next morning.