Living Will Tattoo

Daisy Joyce · Dec 5, 2017

That really happened?

I always thought that was an urban legend!

elkpark · Dec 6, 2017

I half-joked for years about having "DNR" tattooed on my chest, but had a conversation with a healthcare lawyer years ago (just happened to be having the conversation; I hadn't sought someone out to ask about this) in which this topic came up and she assured me that that would not be considered legally binding and no one would take a chance on honoring it. I have to say I'm pleasantly surprised that his tattoo was honored (perhaps the secret is to do as he did, spell out "do not resuscitate" rather than simply having "DNR," and including the signature). Good for him!

Sour Lemon · Dec 6, 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?

My thought is "slow code".

KatieMI, BSN, MSN, RN · Dec 6, 2017

This happens because people do not trust doctors. And, honestly, they have their reasons. In today's legal climate, I am surprised that docs finally honored the will of the patient.

Hospital lawyers can say whatever but, should something happen, they won't sweat much over it. The MD/DO who signed the chart will get it all. I'd seen patients with clearly stated wishes of "DNR" coded and resustitated because the living will was signed whole half a year ago and "who knows, the guy might change his opinion, so we better be on a safe side" or because "you know what sort of family it is - I do not want problems with them, let them know that everything was done". Or just because it was Trauma Code Lever 1 and senior resident really wanted to run the show (and later he was not reprimanded for doing that).

Re. end of life conversations, they just gotta have happen, and to be in clear, unequivocal English or whatever first language patient/family prefers. Again, it is my personal experience, but I have a strong impression that an average hospital visitor or nursing home resident's DPA has no idea whatsoever what is implied under those "code papers", and still much less about what pretty frequently happens after a successful code (meaning horrendous and very difficult to control pain from broken ribs, hypoxemic encephalopathy and multiorgan failure). That needs to be changed, and if there are going to be specially trained and purposefully delegated for this and similar tasks RNs to conduct these talks (instead of the staff nurse who is running through X+1 admission of her shift with no chance to pee for the last 10 hours), then so be it.

MunoRN, RN · Dec 6, 2017

I've had multiple patients with DNR tattoos, some are less clear than this one (one was just a caduceus in a circle with a line through it), one went to an ethics committee that determined it would be legit if it was a full POLST form tattoo, another agreed any clear declaration of a wish to be DNR would count.

If there's clear reason to believe the patient would not want to be resuscitated then they should be DNR, a tattoo is pretty clear.

Trauma Columnist · Dec 6, 2017

The hubs and I were talking the other day about this. In the first place, no one is going to honor this as its not a legal document. I practice in IL and unless a pt has an active/valid POLST form.

POLST Illinois | Practitioner Orders For Life-Sustaining Treatment

So...while pts may have a DNR tattoo, at least in IL, I wouldn't honor it.

mmc51264, BSN, MSN, RN · Dec 6, 2017

both my kids are Type 1 diabetics. They are too young now, but a lot of T1s get that tattooed on themselves.

NunNurseCat · Dec 6, 2017

Good on him for going the extra step and having a tattoo, but I can see how such a tattoo also creates some questions about the finer legalities.

I know in my state (FL, where this occured) our AD's require two witnesses in addition to the patient's signature. In this case his signature was reproduced, and there were no legal witnesses.

Also in Florida a formal DNR order requires a physician's signature AND the form has to be printed on yellow paper (I just double-checked to be sure that's still true and it is).

Finally let's say this patient had revoked their DNR, but not updated the tattoo...then what?

I like asking questions, but simple truth is I respect this man and am glad he ultimately had his wishes honored.

Guest374845 · Dec 6, 2017

The case study published by that patient's physicians is far better than the layman editorializations in the media. Other questions raised in the ethics consult were things like, "what was his states of mind at the time he got the tattoo... drunk, depressed, joking?", and "what if the tattoo does not reflect his current wishes?". Safer to work that code and let it get sorted out in the ICU.

MunoRN, RN · Dec 6, 2017

traumaRUs said:

The hubs and I were talking the other day about this. In the first place, no one is going to honor this as its not a legal document. I practice in IL and unless a pt has an active/valid POLST form.
POLST Illinois | Practitioner Orders For Life-Sustaining Treatment

So...while pts may have a DNR tattoo, at least in IL, I wouldn't honor it.

A "legal document" is not required in any state for a patient to make their DNR wishes known, including Illinois, they only need to make this known through any means. It's disturbing that even if you had reason to believe a patient would not want to resuscitated that you would still impose resuscitative measures on them because you feel they didn't meet some legal threshold that doesn't actually exist.

**NICU Guy, BSN, RN** · Dec 6, 2017

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.