Doctors in Miami faced an unusual ethical dilemma when an unconscious and deteriorated patient was taken to the emergency room with the words "Do not resuscitate" in his chest.
The 70-year-old man was taken earlier this year to Jackson Memorial Hospital, where the doctors made his surprising discovery: a tattoo on his chest that seemed to convey the patient's life's longing wishes. The word "No" was underlined, and the tattoo included a signature.
He left the medical team to deal with a myriad of ethical and legal questions.
Was it an accurate representation of what the patient wanted? Was it legally solid? Should they honor him?
The case was detailed Thursday in the New England Journal of Medicine, in a report that described the medical team's struggle for answers.
"The request for tattooed DNR from this patient produced more confusion than clarity, given concerns about its legality and probably unfounded beliefs that tattoos could represent permanent reminders of regrettable decisions made while the person was drunk," wrote the authors of the article.
Gregory Holt, critical care physician and lead author of the article, said in an interview that "I think many people in medicine have joked about getting a tattoo like that, and then when you finally see one, there's a kind of surprise and surprise on your face, then the impact hits you again because you actually have to think about it. "
Holt said the patient, who had a history of lung disease, lived in a nursing home but was found intoxicated and unconscious on the street and taken to the Jackson Memorial.  He arrived without identification, without relatives or friends, and without a way to tell the doctors if he wanted to live or die.
Holt said the man had an infection that caused septic shock, which causes organ failure and extremely low blood. Pressure.
When their blood pressure began to drop, emergency room doctors called Holt, who specializes in lung diseases, and first agreed not to respect the tattoo, "invoking the principle of not choosing an irreversible path to uncertainty , "according to the case study.
Men were given intravenous fluids, antibiotics, and blood pressure medications to buy more time to make the life or death decision.
The medical team used a breathing mask on the man, Holt said, but he struggled more with the decision to connect it to a machine that would breathe for him.
"We had a man I could not talk to," Holt told the Washington Post, "and I really wanted to talk to him to see if that tattoo really did reflect what he wanted for his end-of-life wishes."
Physicians who treated the elderly patient knew of "a cautionary tale" published in 2012 in the Journal of General Internal Medicine. That document spoke of a 59-year-old patient who had a "D.N.R." tattoo on his chest, but he said he wanted to take measures to save lives, if he needed them.
When the patient was asked why he had the tattoo, he told the doctors he had "lost a bet playing poker", according to the report.
Florida requires that no-resuscitate orders be printed on yellow paper and signed by a doctor, so doctors at Jackson Memorial called an ethics consultant to discuss the legal aspects of the tattoo.
Holt said the consultant determined that doctors did not need to be totally "dogmatic" and could presume that the tattoo was a true reflection of the patient's wishes.
According to the case study:
"After reviewing the patient's case, the ethics consultants advised us to respect the patient's non-resuscitation (DNR) tattoo, suggesting that it was more reasonable to infer that the tattoo expressed an authentic preference, that what could be seen as a precaution could also be considered a ceremony and that the "Sometimes it is not agile enough to support patient-centered care and respect for the best interests of patients".  In any case, the social workers were able to trace the DNR documentation itself, leaving doctors relieved, Holt said 19659002] The man, who was never publicly identified, died the next morning.
"It seemed very I'm serious about this, "Holt said of the patient's tattoo." But he also did not seem to trust that his end-of-life desires would be properly transmitted. So, for me, it means that we need a better system.
"We need a better system so that people are able to transmit their wishes, if these are their wishes, so that we do not do things they do not want, such as in the middle of an emergency when a man like this enters the unconscious emergency room " – – –
History of Lindsey Bever
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