Living Will Tattoo

Meriwhen, ASN, BSN, MSN, RN · Dec 6, 2017

Guy in Babyland said:

From a legality standpoint, how do we know the patient had it tattooed on his chest? He could have had a long night of drinking with his friends and passed out. His buddies could of thought "Hey, Fred is really passed out, he looks dead. Wouldn't it be funny if we get DO NOT RESUSCITATE tattooed on his chest?" Fred never bothers to get it changed or removed and then this happens.

Agreed. People get tattoos all the time while drunk and then regret it. Perhaps if there was a way to get the tattoo notarized (a tattoo of a notary stamp and sig below it?) to determine that this is indeed the patient's wishes...

And if he really did mean it then, how do we know he hasn't changed his mind? It's not as though a tattoo could magically be erased overnight, though I suppose a strikethrough and "never mind" could be added to it.

brillohead, ADN, RN · Dec 7, 2017

In less than a week, I have personally had two different patients who were signed up with hospice care and in both cases, their facility sent them to the hospital via ambulance. One came from an AFC, one from a nursing home. Both patients had been current with hospice care at their facilities for at least a month before they were sent in to us.

Both ended up dying in the hospital with strangers taking care of them instead of in their familiar home setting with their familiar caretakers and hospice nurses around them.

Sadly, this is not all that unusual an occurrence, at least at my facility.

Pepper The Cat, BSN, RN · Dec 7, 2017

I've always said I am going to get DNR on my chest, "No G-tube" across my stomach and "No Enemas " across my tooshie!

Richard Wolfe, RN · Dec 7, 2017

They withheld care from an unidentified, intoxicated, unconscious human-being based on a tattoo. That sounds completely unethical in every sense of the word. How do we know that he was not intoxicated when he had the tattoo and now regretted it? I read that they found a "DNR" form after he was admitted, but how do we know that he was not intoxicated when he completed the form? Would it be legally binding in the state of Florida if that were the case?

What about if the "Do NOT Resuscitate" had been written in Sharpie? Would that be legally binding?

The man obviously tattooed neither the "Do Not Resuscitate" nor the signature onto his own chest. How legal is that? How ethical is it for a provider to abide by the tattoo?

Here.I.Stand, BSN, RN · Dec 7, 2017

Well.... How do we know the pt didn't sign a POLST under duress? How do we know it wasn't forged or altered in some way? How do we know the pt didn't change his mind ten seconds before arresting -- even with a proper POLST?

Generally tattoo artists limit their inking to what a client requests. Considering the Ockham's razor principle, that tattoo's presence is more simply explained by "this man commissioned this tattoo," vs "the tattoo artist drugged the man and acted without consent, having been paid off by a murderous wife who wants to collect his life insurance and move to Fiji with her young Latin lover."

One acting in a feduciary capacity is supposed to make the decisions that to the best of their knowledge is what the PATIENT would want.

I can see "DNR" might be problematic, since it could mean "Daffodils 'N Roses" or "Dine Nightly on Ribs" or could be a loved one's initials strategically placed near the heart. But "do not resuscitate" with a signature? In the absence of other information, that sounds pretty clear.

K9lover, ASN, RN · Dec 7, 2017

jeastridge said:

In this morning's NY TIMES, I read an astounding article about a person who took his advance directives so seriously that he had them tattooed on his chest: His Tattoo Said â€˜Do Not Resuscitate.' Doctors Wanted Another Opinion. - The New York Times
Why should a step like this be necessary? Why is it that with our EMRs, our focus on paperwork, and our multitudinous permission slips on admission--why is it that something radical like this has happened? Did this man fear that his wishes would not be honored? Was he afraid that someone wouldn't be able to find the paperwork?

As the article points out, he came in unaccompanied and unconscious--a challenging situation for the care team no matter what. After consulting an ethicist, they honored his stated wishes and he died.

What are your thoughts on this?

How can we improve our end of life conversations?

Do you have some ideas about what we could do better?

How can our current EMRs help or hinder?

I do not have any tattoos but I would most certainly have this one if it were legally binding. The basic problem is that we don't recognize or accept death as a part of life for the most part in this society. We keep people alive indefinitely on forced feedings, vent etc...never mind that the vast majority would never want this for themselves, they inflict it on family especially if they were young when they suffered an anoxic brain injury. I never cease to be amazed at what we inflict upon those who cannot make decisions, I knew an elderly, retired doctor who had an MI @ age 90 in front of the post office (this is a very small town. His wife told the paramedics he did not want chest compressions but they disregarded her, she was very upset by the whole thing. Someone pointed out to me an ER doc and I pointed out the wife to him, the ER doc had the paramedics stop. My dad had that card on him at all times which is what anyone needs to do, I think everyone should complete a DPOA upon turning 18, I had my son do so and the notary still balked a bit saying he was 'too young.' He was old enough to suit up and go to war but not old enough to make a decision on if he wanted to be in a vegetative state? I think not. The EMAR does not help when people are out and about, I carry that card everywhere and instructions under 'emergency' on my phone state if found down with no spontaneous resps I do not want BLS, ACLS et al.

db2xs · Dec 7, 2017

A DNR tattoo is not legally binding. What one could do instead is get a DNR medical bracelet with your name on it, which only an MD can prescribe. DNR Guidelines for Medical ID Wearers

I plan to get one soon.

Skittles767, RN · Dec 9, 2017

I read about this story and actually learned that after some effort they were eventually able to find the man's signed DNR. I agree though a bracelet would save alot of time money and pain for everyone.

Libby1987 · Dec 9, 2017

How about a bracelet and a tattoo? At least the tattoo won't be missed and the bracelet to corroborate?

jag nurse, RN · Dec 9, 2017

I do not have any tattoos but I would most certainly have this one if it were legally binding. The basic problem is that we don't recognize or accept death as a part of life for the most part in this society. We keep people alive indefinitely on forced feedings, vent etc...never mind that the vast majority would never want this for themselves, they inflict it on family especially if they were young when they suffered an anoxic brain injury. I never cease to be amazed at what we inflict upon those who cannot make decisions, I knew an elderly, retired doctor who had an MI @ age 90 in front of the post office (this is a very small town. His wife told the paramedics he did not want chest compressions but they disregarded her, she was very upset by the whole thing. Someone pointed out to me an ER doc and I pointed out the wife to him, the ER doc had the paramedics stop. My dad had that card on him at all times which is what anyone needs to do, I think everyone should complete a DPOA upon turning 18, I had my son do so and the notary still balked a bit saying he was 'too young.' He was old enough to suit up and go to war but not old enough to make a decision on if he wanted to be in a vegetative state? I think not. The EMAR does not help when people are out and about, I carry that card everywhere and instructions under 'emergency' on my phone state if found down with no spontaneous resps I do not want BLS, ACLS et al.

Good for you! Like someone said, we no longer consider death a part of our existence. I believe it's greatly due to everyone afraid of being sued. Do the paramedics/EMTs even check for cards or paperwork, on the person. I've never seen that instruction in any of my BLS training. I think until the pt gets to the hospital, they WILL get CPR performed. I worked with a nurse, who had a "Do not resuscitate" tatooed, on her chest. I wondered if that would hold up legally. I also worry about getting compressions, if I were to ever go down. I know what the after effects are, and I don't want them. There should be some way that we can be assured, of our own desires.

Dragonnurse1, ASN, RN · Dec 9, 2017

In my state I have seen any number of patients DNR's ignored at family request. One must have a living will with medical proxy on file with each hospital in my city in order to cover their wishes unless the medical proxy arrives with the patient. My first patient in critical care clinicals was a DNR, she had her living will made out but her family did not agree with her wishes. When I left the ER all the doctors that admitted patients to the local nursing homes were beginning to "force" families to face the future before their loved ones were admitted by going over advanced directives and in a large number of cases signing DNR's prior to the patient being moved to the NH. I had one patient come from a NH with a DNR but family was with and the family overrode the DNR. I was also asked by my Mother to speak to a very close friend of hers regarding following her husbands living will advanced directives that she did not want to follow and her husband was a physician.

I am faced with the same type of situation as some of my patients. I have 4 children and only 1 is capable of carrying out my wishes when the time comes for me. Most likely he will not be in this city when that occurs and the ones that are will demand my wishes be overridden. I am trying to find a way to prevent that from happening. I currently have to wear medic alert dog tags, I carry documents but in an emergency personal items are often lost so what do I do?

Nation-wide we need to address this problem. I feel that there should be one standard regarding advanced directives not 50 standards. This is one situation where universal adoption of legality would benefit patient, family, emergency responders and hospital personnel. Just my opinion.

RRTNurse · Dec 9, 2017

Check the NEJM where they sought the Ethics Committee for a ruling on a similar case.

People have these tattoo's for a reason. Paperwork does not always work, and healthcare proxy's and POA's sometimes have no idea what the person wanted and opt for the full-court press. Paramedics can't assume and once CPR is started cannot legally stop.

Conservators on the other hand are only after money and so opt to keep the person alive as long as they can so they can get paid.