Monday, 4 December 2017

DNR

If you're in the States, you can rest assured that I am most assuredly NOT writing about the Department of Natural Resources.  Nor am I writing about Denbury Resources, Inc (whose unfortunate symbol on the New York Stock Exchange is DNR).  No, anyone remotely familiar with the medical field (or who ever watched House MD or Holby City or Grey's Anatomy or ER or St Elsewhere or M*A*S*H or Scrubs or Marcus Welby, MD [godDAMMIT there are a lot of medical dramas!]) knows that "DNR" stands for "Do Not Resuscitate".  It represents the primary right of the patient - to refuse medical treatment, even in the face of impending death.  Most usually it is employed by the elderly, severely infirm, or terminally ill to alert their medical care providers that they do not want any heroic measures in the event of sudden or imminent death.

There are various elements to a DNR, including orders not to intubate, not to do chest compressions, not to employ vasopressors (medication to artificially elevate blood pressure), not to give food and/or fluids, not to use dialysis, or to use comfort measures only.  The exact nature of the DNR order, including any and all therapies that may or may not be used, is explicitly elucidated in a signed document that is supposed to be readily available for medical practitioners to see.  That way there can be no ambiguity if an unconscious yet terminal patient is brought to the hospital.  The papers are supposed to be easy to find, though sometimes they can be difficult to track down.

Sometimes, however, the DNR is, well, let's just say sometimes it is slightly more prominent:


According to a case report from the New England Journal of Medicine, this 70-year old gentleman was brought by paramedics to a hospital in Miami, Florida unconscious and intoxicated.  He had a history of chronic obstructive pulmonary disease, atrial fibrillation, and diabetes, and he arrived without any identification or family members.  When doctors disrobed him to do their examination, they found "DO NOT RESUSCITATE" tattooed quite clearly (with "NOT" even underlined) on his chest with his signature underneath.

Open and shut case, done and done, cut-and-dried, impossible to misinterpret, right?  RIGHT?

If that were an easy question to answer, I wouldn't be writing this right about now, would I.

A few hours later his blood pressure dropped precipitously due to severe sepsis, and he developed a severe metabolic acidosis (his serum pH was 6.81 - I have never seen anyone with a pH less than 6.9 survive).  The intensive care doctors who attended to him had a decision to make: A) honour the tattoo as a legally binding DNR or B) treat him as they would any other anonymous patient.

They chose B.

According to lead author Gregory Holt, MD, the doctors chose to invoke "the principle of not choosing an irreversible path when faced with uncertainty", so they categorically ignored the tattoo, starting him on antibiotics, putting him on BiPAP, and starting vasopressors.  In other words, everything short of intubating him.

My first reaction to this story was "WHAT?  WHAT THE FUCK WERE THEY THINKING?  HIS CHEST SAYS DEE EN ARE!"  My next thought was that if they had done chest compressions, they would have been committing assault on this gentleman.  My next thought was . . . calm the fuck down and get some more information, dumbass.

*deep breath*

It turns out cases like this, while extraordinarily rare, are not entirely isolated.  In fact there is a published case report in the literature of a man with a similar "DNR" tattoo (though it is admittedly not quite as explicit) which did not reflect his actual wishes.  That patient had lost a bet while drunk many years before, the loser being required to get a tattoo of "DNR" on his chest.  

"Heh, sounds like one of your patients, Doc."

Indeed it does.  Regardless, Dr. Holt and his team obtained a consultation from their ethics team, who determined that the tattoo most likely did reflect the patient's wishes.  They advised the doctors to honour it as an ordinary paper DNR.  Out of respect for the patient's (hopefully) wishes, an actual DNR order was written.  Fortunately shortly thereafter the gentleman's real out-of-hospital DNR was obtained, and he passed the following morning without incident.

After contemplating this case for some time, I've come to the realisation that it isn't nearly so clear cut as I had originally thought.  If I got a dying trauma patient who had a prominent and unmistakable DNR tattoo, would I really be able to say "Wait, stop, don't do anything.  Look, it says DEE EN ARE right there on his chest!"?  Would that really be the right thing to do without verifying it first?  The part of me that explicitly respects patients' wishes says an very emphatic "Yes", but the entire rest of me (which is admittedly rather small) says "Not so fast".  

I believe that treating a patient who does not want to be treated is malpractice.  However, I also believe I would be obligated to verify the DNR prior to withdrawing or withholding care while consulting my own ethics team.  I also also believe doing anything short of this would be malpractice.

What do you believe?

42 comments:

  1. Id rather go for not trusting the tatoo. In this case it did have his full signature however so thats a big red flag its legit vs a simple 3 letter DNR on a person isnt so cut and dry.

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    1. 3 letter DNR tattoo is obviously referring to the Department of Natural Resources

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    2. Well lets say hes a fan of someband with the initials or his girlfriends initials its not exactly clear cut

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  2. Then you get my uncle.
    He has a DNR in place, well advance care planning that specifies DNR in certain situations ie if his heart stops or he is found unresponsive.
    now nice and simple you would think given he is on neckline dialysis since he is awaiting a heart bypas and valve replacements, is uncontrolled diabetic since no one wants to put him on metformin given it might contraindicate with everything else going on plus he refuses point blank to follow his fluid and diet restrictions.
    He can't have an AV since if they do decide to do his heart op it will immediately collapse plus he has put on 4 stone (56lbs) since july and now weighs 21 stone due to not following his restrictions and stuffing his face with multipack and family size packs of potato chips and guzzling fluids.

    We had a discussion regarding his wishes and he specified he did not want to die of CHF as the guy in the bed next to him did.
    OK i said i'm good with that.
    He then said he wanted to be revived if his heart stopped.
    I said that doesn't make sense you don't want to die of CHF (and everything else) and be revived but you want to be revived if you have a heart attack so you can then die of CHF.
    I said if you have a heart attack etc and your heart is still beating we will do all we can to keep you going.
    If your heart stops then we won't.
    He then said he wanted to be revived.
    I said we can do that and cancel your DNR, but he said i don't want to be revived if it is due to CHF.

    He doesn't want to be revived but he he does.
    I've explained it to him, the doctors have, the nurses have, the nurses in my family have.
    He wants reviving if it isn't due to CHF but not that it is despite him being told he has severe CHF and if his heart stops it will in all probability be due to that.
    They have even had to reduce their take on his dialysis because he gets to breathless etc (due to previous)
    He thinks this means he is getting better when it means he is getting worse and there will come a time they will have to say nothing can be done.
    Today he has been diagnosed with an infection in his neck line so swabs, photos and antibiotics and hope it clears up.

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    1. good luck. it sounds like you need it.

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    2. He's afraid to die, and in denial of just about everything, which makes it very hard to talk to him. Would he be open to a shrink-like person to talk to him?

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    3. Thanks Ken and Mary. He simply doesn't want to discuss it with anyone. If they try, he simply tunes them out. He doesn't want to hear it.He hates hospitals to the extent he will say he is fine even when he clearly isn't and will minimise or omit info if he thinks he can get out of hospital quicker even when he had the massive kidney abscess that kept him in for 5 weeks, he had been discharged from the hospital after he had accidentally pulled his nephrostomy tube out and they managed to reinsert a new one. It was clear he was unfit for discharge but he lied and said he was such was his need to get out of hospital.
      I don't know if he is in denial as to how sick he is as when he had a neck line before when he had a AKI it came out after 4 weeks, maybe he thinks it is the same now. The heart op should have been done sometime between July and Sept. Since then he has piled on the weight and no one seems in any rush to do it. I don't know if he is scared or if he doesn't care and will agree to any procedure the docs say. Time will tell

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    4. It sounds as if you may just have to watch him kill himself, slowly but surely. It's a miserable situation.

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    5. tania, is there any chance you are seeing the onset of dementia? It can cause all sorts of erratic and inconsistent thought and behavior. Watch particularly for "sundowning" where things get worse in the evening. I knew someone whose first real sign of dementia occurred in a hospital, and it was weird. They said things that were calm and coherent, but completely out of context.

      What you have said suggests to me that perhaps your uncle lives on his own. For someone like that a hospital or any other place where he is thrown in with a bunch of other people not of his choosing can be an extreme stressor, especially when accompanied by people poking and prodding him and making him talk to them all day long. If he's lived on his own for a long time, he's probably made all important decisions for himself for a long time, and anyone else intruding without leave is just one more annoyance. For such a person, the hospital is likely never going to be a place for calm and rational discussion.

      An advance directive (terminology varies) is something I encourage everyone to get aging parents or other relatives to execute when rational thought still prevails. It is no guarantee that it will make it easy for the person designated to make decisions, but it is of some help. If you are designated as the decision maker, be sure to keep a copy at hand so that it can be faxed or emailed.

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    6. Hi Doug, Uncle lives with me. I moved him in when he was originally discharged from hospital after 7 months wandering through the medical A-Z getting stuff i had to google and so rare we had every consultant in the country visiting him with large pointy needles.
      He has been tested for dementia and shows no sign of that but he does have short term memory loss.
      He didn't have the greatest upbringing and as a result was shy and antisocial which meant when he was admitted to hospital i had to tell the staff and ensure he was kept in a side room for several months once he came out of his several visits to icu till we got him socialized.
      He is better socially than he was which has taken 3 years of hard work, patience, occasional nagging that it is fine to wear a furry hat with a red star on as people won't pay him or it any attention (eventually he removed said star)
      Despite his protestations i insisted he wear a bright coat and have lights on his 4 wheeled walker on the grounds he may not see them or the traffic (peripheral vision left eye, a floating membrane in his right eye, 10% cataracts and diabetic retinopathy combined with a refusal to wear his distance glasses) they at least will be able to see him. Unfortunately he has gotten too big for his red coat and they only had his size in grey and he has managed to somehow break the lights.

      I have a copy of his advance directive as his next of kin and the numerous medical departments dealing with him have copies as well.

      You are correct as he lived on his own all his life once he moved out, he got into all sorts of pickles as he was out of work a lot and in the UK if you don't stand up for yourself you end up losing out and he wouldn't ask for help. heck he rarely opened the door to us if we went to visit/check him.
      One Christmas my bro and i knew he was in but he refused to open the door so we told him through the window let us in or we will start singing!. That did the trick and we could drop our prezzies off and do a secret quick check on if he was coping.
      When he collapsed and the neighbor upstairs helped by calling 999 (911) whilst bro and i administered first aid etc, the neighbor and i have become firm friends.

      He hates hospitals with a vengeance and always has to the extent that when he has eventually used one it has been pretty serious and needing admission, when, if he had gone to the doctor first thing , antibiotics etc would have solved it.
      I only found out about one admission because he slipped up and told the nurse whilst i was there.

      Left to his own devices he would have died 15 times since his original discharge. I have to pay close attention to his appearance, his body language and asking the right questions otherwise he will say nothing till it is too late or he will lie and minimize to the staff and me. The staff are now aware of his little predilections and will call me if they aren't sure if he is being honest (usually he isn't) and can then take appropriate action/treatment.
      As he is under so many different departments, most of whom don't talk to each other, if they want to know what is going on, they call me as i know more than they do (The UK NHS)it has saved a lot of unnecessary appointments, allowed for necessary tests which should have been done but weren't and for tests which if done would have killed him due to drugs used causing contraindications (urology and nephrology depts didn't talk to each other)

      I still can't get him to join the family for Christmas dinner (bro and his family) he does his own thing christmas day.

      Merry christmas one and all and may 2018 be a bloody good one xx

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    7. poor health and iatrophobia (fear of doctors - I looked it up) are not a good combination.

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    8. Are you his legal guardian, Tania? Does he need to have his competency reviewed? I don't want to sound cold, but in general I think that if everyone else is working harder to make someone live than the person himself is, it might be a good idea to step back and consider the meaning of all your efforts. Has he been assessed to see if antidepressants or anxiolytics would be indicated?

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    9. Hi Mary i am not currently his legal guardian but i am his official carer. I have given up on monitoring his fluids and diet since it was pointless measuring out his fluids to drink for the day only for him to buy drinks or just make drinks from the tap. The day that sealed it was when he was allowed 600mls to drink (output plus 500mls) plus 400 mls allowed for his foods and he drank 1.4L and still had 100mls of his allowance left in his bottle. When i pointed this out to him he just tuned me out.
      he eats multipacks of potato chips in his bedroom and was outed by one of my cats who pulled his duvet back and revealed 2x4 packs of snickers bars. it is pointless me following the rules if he doesn't. I rang up the dialysis unit and spoke to his named nurse to update them, they said they would get the dietician to visit. I pointed out we had already done all that got the lists etc and he refuses to follow them so it was pointless if he will continue to ignore them. He has type 2 diabetes which when he was doing as he was told was diet controlled. now he needs metformim since his blood sugar before dialysis is now getting to be 10 - 11 when it should be a max of 7 but no one seems in any rush to prescribe it. his weight today was 134.4kg (296.30128lbs) up from 122kg sept 1st. he is almost at the weight he was back when he first collapsed june 2013. it was fun since he was such a big boy, myself and my bro are both raspberry rippled, the neighbor upstairs who help was also raspberry rippled and the 2 lady paramedics who came were 5'2 ish and none of us could touch uncles left side due to his whole left arm having cellulitis and massively swollen and oozy, inguinal sepsis (i didn't check that bro did when uncle's pants fell down) and uncle was delirious and grabbing for his cellphone and charger. it took all 5 of us to get him on the gurney. It was funny as heck looking at it now. Luckily in our family, medicine passes for entertainment and boy are we entertaining.

      For someone who hates hospitals he sure tries to get there as often as possible. Come to think of it he is about due for something to go bosoms up and readmission, odds are on heart attack or fluid overload (again)

      Big hugs every one xx

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  3. I guess I would ignore it if if there was a high likelihood of full or nearly full recovery following resuscitation. If the patient was clearly terminal, I would observe the tatoo. In other words, I would do unto the patient what I would prefer to have done unto me.

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  4. Legally, until the presence of a DNR tatoo is lawfully binding- I would choose to preserve my (future (5 months- whoohoo!)) nursing license and perform all that I could do to resuscitate him. After working medical credentials, and in Healthcare for over 15 years...people do some strange S$%^. And im not going to be sued by a pt's family, or the pt because they got the tatoo on: A- a dare, B- a drunk bender with their buddies (on a dare). Its not worth it to my practice or the hospital. Yup- the family can still sue, but the cheances of sinning a lawsuit in the absence of a true DNR seems slim.

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  5. I'd try and save him. A tatoo, while intriguing, just isn't clear enough. Although I do worry that my own wishes will not be apparent if I'm in that situation. Ugh

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  6. Unless I see that "golden ticket" as we call them (an official DNR on yellow paper) I wouldn't withhold treatment. Too much liability, not to mention the guilt if you actually end up not helping a pt who actually wanted it.

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  7. Damned if you do, damned if you don't.

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  8. Only in America is a DNR tatto with a signature considered not clear enough to document a person's wish not to be resuscitated.

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    1. consider that MY orders are to actually SEE THE OFFICIAL DOCUMENT rather than take the word of anybody but the patient.

      OTOH, do not resuscitate is pretty specific to what happens AFTER cardiac arrest. before that, you do all reasonable measures.

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  9. As a middle-aged person with no significant other (and no longer looking), and a sister who has expressly said she wouldn't carry out my wishes to be removed from life support in the event of an irreversible medical setback, I do wonder how to make my wishes plain enough to the medical staff who might find me on a gurney before them. I've thought about putting a laminated card in my wallet with a link to a full document spelling out what I want done (or not), but would anyone actually accept such a thing?

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    1. assuming you have a regular doctor, you can file everything that way. he will still have to fight with your sister, but you could also direct that your sister not be notified until after the fact.
      in Oregon, it is mandatory for health insurance to cover fees for getting that all established with your doctor and estate planning people. or as Sarah Palin calls it, "death panel"

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    2. After spending a full week with my nieces when they were deciding to take my sister off life support I decided that I didn't want to burden my children with that decision. I gave medical power of attorney to a close friend who has worked in geriatric care for her entire nursing career. My kids know that she has a copy of my DNR and will be making decisions for them. My kids are actually relieved about it.

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  10. I actually thought about doing a tattoo, but got a DNR medallion on a chain around my neck instead. That way no one can say I might have changed my mind. (I hope). I do have all the advance whatnots signed, but if you fall over in the street the paperwork registered with a doctor does no good at all. I guess all you can do is your best to stay out of the ER or ICU. Also, the paperwork that went along with getting the medallion can be posted on the fridge at home for emergency responders. Nothing is sure, though, but I really want to spare my son the decision to stop treatment for me. I know from experience it is a hard decision to make even when you are sure it is the right thing for the loved one.

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  11. Absolutely honor it.
    If someone is stupid enough to get such a tattoo on a bet, then tough. I can remove a tattoo in seconds with a belt sander or a wire wheel on an angle grinder. Bit messy, and a tad uncomfortable, but once again stupidity has its rewards.

    Wallets, pendants, bracelets, et cetera, can become detached from a person. The tattoo makes the person's wishes clear. It may not be on Form W7K394-8, Revision C, but to reject it for that reason is absurd. If I went off to some dumb bugger wearing black gloves, so as to hide the fact that they are grubby (pet peeve - were it up to me, no cop, mechanic, tattoo artist, or pretty much any of the others to who they are marketed would be allowed to use black "exam" type gloves), to get such a tattoo, and some paramedic, nurse or doctor disregarded it and I survived, I'd be demonstrating just how quickly total hepatectomy can be done. Without gloves.

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    1. in my department, black gloves are used for non-patient-contact applications, which means black gloves can be disposed of in regular trash.

      oh, and if the medics feel you are a threat to them, there WIll be a cop. in black gloves. the good news, your odds of not receiving lifesaving care in a timely manner will be greater.

      as for your "I can remove a tattoo in seconds"
      it still does not remove the obligation to be sure a DNR is legit.

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    2. Try to catch the point as it whizzes by you. Someone who gets a DNR tattoo can have it removed if they want. If they don't have it removed, and especially if it is signed, then it should be honored. You don't get to substitute your wishes for those of someone else because it isn't on a form approved by you or your "department."

      Perhaps your department needs to bring in someone capable of thought. Because biohazardous crap is obscured by being inconspicuous on black gloves does not mean it is appropriate to dump said gloves in general trash. If you use the gloves to dig mud out of wheel wells or wash the exterior of the vehicle, then OK.

      Cops do love their black gloves. They fit right in with the blackshirt thug costumes and hyper-aggressive attitudes so many of them wear these days.

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    3. try to catch the point as it whizzes by YOU.
      the law is specific as to what constitutes a valid DNR order. the patient saying "I have a DNR" is acceptable. the mutipage form with the patient's signature and the signatures of witnesses is acceptable. the patient having had a DNR yesterday is NOT acceptable. if the patient says "I changed my mind about the DNR," then NO format of DNR is acceptable.
      if there is any doubt about the validity of the DNR, then it is NOT acceptable.

      and apparently it also went over your head that we only use black gloves for stuff that allows us to dispose of the gloves in the regular trash.

      and the aggressive one, here, seems to be you. maybe that's why you don't get along well with cops.

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    4. Wow. You’re sort of a dick. Ken is right. It doesn’t matter if they have “Do not fucking recusitate me, medical people” in big neon letters. It’s not legally binding.

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  12. "I believe that treating a patient who does not want to be treated is malpractice."

    How do you distinguish such a patient from a regular ornery patient, though? It seems that a lot of people may be reluctant to get treatment (e.g., people who have cancer but refuse treatment for religious/moral reasons). In an emergency situation though, isn't the role of the doctor to first do everything in his or her power to save them? In this case, the patient's wishes seem pretty clear to me, but that probably isn't common.

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    1. For my trauma patients, yes. But if a conscious, alert, and coherent patient refuses treatment after being fully informed of the ramifications of said refusal, I am absolutely obligated to oblige, even if I know that decision may result in death. I cannot and will not force anyone to undergo any treatment he/she does not want.

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  13. DNR tattoo on chest (especially with signature tattooed. they are really making that unambiguous) should be treated as a regular DNR. Any persons getting a DNR tattoo in the future should be notified that the tattoo constitues a legal DNR.

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  14. This is a difficult one evidently - if there is any ambiguity about the meaning of the tattoo then obviously you would have to treat them until you could verify their wishes. "DNR" as an abbreviation on its own could mean any number of things, but spelled out and signed like that does seem entirely unambiguous and I feel it should be respected.

    The tattoo might be out-of-date but I think we have to allow for a certain amount of personal responsibility here; If you change your mind then you get the DNR tattoo obscured or written over, crossed out or something. Any evidence that it had been tampered with would clearly void the instruction but without that, its intention is clear.

    I would even say that if the tattoo is new enough that you might not have had a chance to reconsider it or have it crossed-through (i.e. it's still healing) then there is enough doubt to ignore it. However, if you get a "DNR" tat' as a bet and leave it there for years without getting a line tattooed through it to show it's void then that's your fault just as much as if you jump from a plane without making sure your parachute is correctly fastened. We need to accept some responsibility ourselves and expect others to do the same.

    Ugi

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    1. emergency services providers are mandated to protect eople from the consequences of their bad decisions.

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  15. The problem here is if the person is non-responsive, it's nearly impossible to know the true intent behind the tattoo. It could have been a stupid dare from years ago. He could have changed his mind since getting it and hasn't gotten back to the tattoo shop to get it crossed out. It could simply be some statement of stupid bad-assery with no intentions of following through. People get stupid stuff tattooed all the time like "DOA" "Return to Sender".

    I highly doubt you could even make the case that that is a legal signature as he likely didn't physically tattoo his signature on himself, but rather was done by his artist.

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    1. That brings up an interesting point. Would such a thing be considered forgery? Inquiring minds want to know!

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    2. Wouldn't a prosecutor have to prove intent to confuse the tattoo client's skin with a legitimate sheet of paper with other words on it and stuff? I mean, they could forge your signature from the "consent to tattoo" sheet if they wanted -- they have copy machines -- but I think it would be pretty hard to argue that a tattooist meant for the signature to be considered as legal and valid, even if some very bitter man gets a tattoo of a signed alimony check. IANAL; TINLA.

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  16. Related, but different. I wish hospitals were more respective of family and the AD and DNR documents. My grandmother was dying of cancer that we didn't know she had at the time, and CHF, and diabetes. She was in renal failure at the ER. My mom refused to let them do dialysis (my grandmother hated any invasive lines or tubes at that point) and had the paperwork that supported this, and the doctors told her over and over that she was killing her mother. It was exceedingly stressful. Mom wasn't killing her, cancer and multi organ failure were. Be kind to the families who already made the tough decisions, got the legal documents, and are now trying to make their loved one as comfortable as possible.

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  17. Probably off the topic but I’d love Doc B’s opinion on this: http://areyoucrooked.com/

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    1. Yes, off topic. And I strongly suspect you and everyone else here can easily guess my opinion of that bullshit.

      Oops, I let it slip totally by accident.

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    2. Apologies to our dear Leader and teller of stories! I had a good laugh imagining Doc B shaking his head wondering what straws they will grasp at next!

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