Living Will Tattoo

Nurses General Nursing

Updated:   Published

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 ‘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?

EDITED TO ADD

After reading this story, I was prompted to write an article about the necessity of talking to our patients about their end of life decisions. To read the article, go to Can We Talk? End of Life Discussions.

I have thought about a DNR tatoo but a lawyer stated unless you are with someone who knows your wishes the tatoo would not make a difference.

Specializes in Critical Care.

It seems the criteria required to honor an Out-Of-Hospital (OOH) DNR and what criteria a Physician is expected to use when determining code status are getting confused. The story was about how a tattoo that conveys a patients wishes should be utilized in a process of a physician or other LIP determining code status. While a valid OOH is a particularly reliable way for a physician to determine a patient's wishes it's certainly not required, anything that helps convey the patients wishes are what the physician must take into account.

And while it's technically possible that the tattoo was placed without the patient's knowledge, it's extremely unlikely outside of fictional storylines, and the same small potential for practical-joke-based DNR wishes occurs with really any format. What it comes down to is determining whether it's more likely that the patient want's to be a DNR rather than not.

DNR status is sometimes seen as something where you can just resuscitate them and then figure it out later without negatively altering the patient's course, which isn't correct. If we can agree that "harm" occurs when someone is subjected to weeks, months, years worth of otherwise unnecessary misery and suffering then resuscitating someone who didn't want to be resuscitated clearly has the potential for significant harm. Once we've resuscitated someone there is no 'undo' button with resuscitation.

where did you get your information. you can go get a medical bracelet off of the internet or at Walgreens or any other drugstore

Specializes in Critical Care.
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.

A family or even a POA can't actually legally substitute their wishes for the patient with the patient's expressed wishes. The POA/family is only allowed to make sure the patient's wishes are being followed. Unfortunately it's not unheard of for those known wishes to get overridden by practitioners who just don't want to deal with the hassle of dealing with a family/POA who is intent on ignoring the patient's wishes.

well, you are wrong, if the family says no do all you can to save my family member, we have to do it.

Specializes in OR, Nursing Professional Development.
well, you are wrong, if the family says no do all you can to save my family member, we have to do it.

Nope. Seen it done. Family even went as far as having the patient declared incompetent to make their own decisions. Patient in preop articulated exactly what would happen without the surgery his family consented to that he refused. My staff objected and it was sent to an ethics committee. Ethics committee overruled the family and the patient was allowed to refuse surgery. Not an emergent case, but exactly the case where we did not follow the family's wishes, including after the patient became septic, comatose, and truly unable to make his own decisions.

Specializes in Critical Care.
well, you are wrong, if the family says no do all you can to save my family member, we have to do it.

That's not correct. We are required to abide by the patient's wishes even if they conflict with what the family would prefer. The role of the family/ POAs, etc is to convey what the patient's wishes would be. They do sometimes inject their own preferences for the patient, which is why it's our responsibility to clarify and differentiate between the two.

If a patient had been declining treatment and then becomes unable to make their wishes known, the POA cannot override the patient's established wishes, they can only help convey the patient's wishes that weren't already clearly established.

well, you are wrong unless someone in the family is there that has POA we have to follow the family wishes

Specializes in OR, Nursing Professional Development.
well, you are wrong unless someone in the family is there that has POA we have to follow the family wishes

No. If the patient has established wishes that is what we go by. If your facility has a practice of not abiding by the patient's established wishes, your facility is in the wrong. Please name it so that I can avoid it- I definitely would not want to be treated there.

Specializes in Critical Care.
well, you are wrong unless someone in the family is there that has POA we have to follow the family wishes

It's never actually legal to "follow the family wishes" if they contradict the wishes of a competent patient, that would actually be clearly unethical a potential felony.

That doesn't mean it doesn't happen, it's certainly not unusual for a provider to just go along with a family's directives even though they may not be in accordance with the patient's wishes just because it's easier and it saves them time and grief, but that's why the patient has a nurse; to ensure that these ethical and legal breaches don't occur.

If you're a nurse and aren't aware that a competent patient's established wishes can't be overridden by a POA's personal wishes for the patient then you should not be allowed to practice as a nurse until you have a basic competency for these issues.

Specializes in LongTerm Care, ICU, PCU, ER.

In most cases, a living will tattoo is not considered legally binding. Neither are tattoos with blood type or allergies. If the patient is unresponsive, how do we know that the information in a tattoo is correct? It is much safer to carry a copy of your living will and medical history; including allergies, blood type, and a list of medications (with dose and frequency) in your wallet. I carry mine with me and update my history about every 6 months.

It's never actually legal to "follow the family wishes" if they contradict the wishes of a competent patient, that would actually be clearly unethical a potential felony.

That doesn't mean it doesn't happen, it's certainly not unusual for a provider to just go along with a family's directives even though they may not be in accordance with the patient's wishes just because it's easier and it saves them time and grief, but that's why the patient has a nurse; to ensure that these ethical and legal breaches don't occur.

If you're a nurse and aren't aware that a competent patient's established wishes can't be overridden by a POA's personal wishes for the patient then you should not be allowed to practice as a nurse until you have a basic competency for these issues.

As you stated it does happen even though it shouldn't. We did have resident that had his wishes drawn up by a lawyer. I saw the completed paperwork in his chart..no feeding tube, trach, etc. His POA did not follow his wishes which were clear as day. He ended up with everything he didn't want. It was sad. He could not communicate anymore but it was apparent he was in pain. He went to the hospital a year later, was coded 5 times and FINALLY a MD convinced the POA that this was cruel. As a nurse most of us are well aware that patient's wishes shouldn't be overridden by a POAs wish. But even as you search out the answers online, there are different opinions to whether or not a competent order for a DNR can be cancelled. Its not that clear cut. And as a nurse we can advocate, but we all know the power is not with us.

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