Recently, medical professionals were stumped when an elderly gent presented to America’s Miami University Hospital drunk and in a bit of a state. No next of kin could be found, and no patient identification was to hand. For all intents and purposes, he was a John Doe. A very poorly, very unstable John Doe. During the course of his medical review, a very important tattoo was discovered etched onto his chest: Do Not Resuscitate, along with a blurry signature.
Would doctors and nurses charged with his care take a risk on allowing his to die? Or should they respect the man’s tattoo, and hope it was a reflection of his healthcare wishes?
It’s had us student nurses slightly confused and ethics of treatment are a topic covered in my student nurse blog frequently. In the UK, according to NHS guidelines, the only official way a patient can request a DNR is if they have had it written down, signed it themselves with a witness countersigning. This is called an advanced legal directive. It must also expressly state which treatments are being refused (for example, CPR, antibiotics, blood transfusions, or intubation and tracheostomies, to name a few) and acknowledge the risk to life where such treatments are refused. If a patient doesn’t have the capacity to make a decision, perhaps an elderly patient with dementia, a multidisciplinary team meeting can be held whereby a decision is made in the patient’s best interests. While family are able to have input into the patient’s wishes they’re unable to make a decision for the patient themselves.
So, the tattoo. At first, medical professionals tending to the elderly gent with his tattoo DNR decided to ignore it. Perhaps it was a bet. Perhaps it was the name of his favourite band. Maybe it was a joke. Maybe his views had changed as he got older. As they couldn’t be sure it was in the patient’s wishes, they decided to treat him and disregard it. However, after the ethics of the situation were called into question, the man’s tattoo was upheld and he passed away during that night.
As students, we’ve wondered what would happen here in the UK if such a situation occurred. If we were asked to give someone lifesaving treatment and then discovered a DNR tattooed on a patient, what would we do? With nurses losing their PINs over not performing CPR on patients in the late stages of rigor mortis, the ethics behind the intent are something we need to be wary of.
Zoe, a student nurse, questioned whether the tattoo was ‘just for banter’ and if so, not resuscitating due to a joke tattoo could cost a patient their life. Many students echoed the same thought: a tattoo isn’t a legally binding document and therefore it should be ignored. One major line of reasoning was whether the person could have changed their mind - does an advanced directive as indelible as a tattoo really mean it still applies perhaps years after it was applied?
Some students noted that while it’s extremely unlikely the tattoo was intended as a joke, they would still perform resuscitation. Kerry mentioned that, from a nurse’s point of view if there is no documentation, despite any ethical issues, CPR is still likely to be required even if the nurse was under no doubts as to the genuine nature of the tattoo.
Eventually the patient was identified and legal documentation confirming his DNR was found. However this entire issue has left the medical world in an ethical dilemma - should tattoos be used as the basis for lifesaving treatment decisions? While the patient has now passed away, the legacy of his tattoo will be one discussed in nursing circles for years to come.