Bizarre, Society, Torts

Miami Doctors Allow Man To Die Because Of “Do Not Resuscitate” Tattoo On Chest

nejmc1713344_f1-800x601Doctors at the Jackson Memorial Hospital faced a novel issue when a 70-year-old man was brought into the emergency room after being found intoxicated and unconscious on the street.  (The man lived at a nursing home and had a history of pulmonary disease).  The doctors were working to assist the man when someone noticed a large chest tattoo reading “DO NOT RESUSCITATE.”  It even had a tattoo signature.  After consulting an “ethics expert,” the hospital treated the tattoo as a viable DNR form and allowed the man to die. In my view, the expert was wrong on the law if his decision was based solely on the tattoo.

Florida agencies have a specific form and states:

Do Not Resuscitate Order—Form 1896 (Multilingual)
Important! In order to be legally valid this form MUST be printed on yellow paper prior to being completed. EMS and medical personnel are only required to honor the form if it is printed on yellow paper.

The form has a place for a physician’s signature and required showings of informed consent.  Florida does not recognize a metal DNR bracelet or necklace.  A patient may carry a “patient identification device”, a smaller version of DH Form 1896 for their wallet or even a chain.

The problem is that “Do Not Resuscitate” teeshirts and tattoos are common jokes.  There was no way that the staff could determine if this was a joke or waiver.

A similar case was discussed in a 2012 article in the Journal of General Internal Medicine, involving a 59-year-old patient.  He had “D.N.R.” tattoo across his chest but he said the tattoo was a joke and the result of losing a bet in poker. 

In this case, there are reports that the the hospital may have been able to secure an DNR order from the patient that was signed previously.  That would obviously impact the decision greatly and support a DNR decision. It would be the waiver not the tattoo that should be determinative.

The question is whether to err on the side of life and the answer in my view is clearly yes.  The staff should not have made an assumption that this tattoo was meant as a substitute of a DH Form 1896 or constructive waive of resuscitation.

The controversy was discussed in the New England Journal of Medicine,

What do you think?

72 thoughts on “Miami Doctors Allow Man To Die Because Of “Do Not Resuscitate” Tattoo On Chest”

  1. My answer is that when 400 of the highest trained medical people in society give the same opinion to a simple question – you have a fact you can hang your logic hat on: CPR is not an option, not for thousands of us who (regretfully) do it for a living.

    I wrote a chapter on the just this – the public’s continued juvenile TV notions of CPR. in my book. But no need to take my word for it. Here’s another gentleman who has treated as many patients as I have:

    https://www.rte.ie/radio/mooneygoeswild/pdf/How%20Doctors%20Die.pdf

    Or, you could just ask your own physician. You might not like the answer.

    1. Don’t overblow your expertise.

      I presented a scenario that directly contradicts the statement I am critical of. You chose not to deal with that statement because you can’t and you return to a “so-called study” that you did which sounds more like a promotion for a book than a true study.

      Go ahead and ask those 400 physicians if they would choose death over life in the circumstances I provide two comments below. You might find all 400 changing their votes. There is a big difference between futile care and the type of care I mentioned below.

      1. My “expertise” is public and easily found, for those interested. My alma mater is UCSD School of Medicine in La Jolla. My partners and I have – over 35 years – treated well over 20,000 patients in the field, including just over 1,000 cardiac arrest patients. I know exactly of what I speak.

        I’ll sit tight and await your ACLS patient care experience.

        1. In this case, you don’t have to provide your credentials regarding your knowledge of medicine. I accept that, but that is not what we are dealing with in this case. In this case, we are dealing with statistics and studies. I doubt many statisticians would find my questioning of the 400 to zero to be wrong. Instead, I believe many would likely have made similar statements and virtually all would agree with my statement having validity. It doesn’t take a rocket scientist to come up with the same statement that your study seemed unusual or selective.

          But, let us return to your medical expertise and present a real question presented twice and still not answered.

          “Let me quote what you said:

          “When the time comes for your medical crisis, Doctor, do you want CPR performed on YOU?
          Out of 400 MDs nationwide, do you know how many responded “Yes?” Zero.”

          I’ll pick an age greater than the 40 years you mention. A doctor comes into the hospital. His crisis is a heart attack followed by an arrhythmia. He suddenly stops breathing and it is noted that he has an arrhythmia that will kill him without treatment. Standard CPR is called for and he is cardioverted back to a normal rhythm.

          Do you think that the entire 400 doctors would decline CPR under those circumstances? Cardiac arrhythmias are not uncommon and decades ago were a major cause of death in those that had a heart attack.”

    2. Patricparamedic,
      …
      -In your profession, you are probably obligated to attempt CPR even if there is realistically no hope of resusitation.
      In a hospital setting, there’s a better chance that there’d be something on record like DNR instructions.
      Arriving at the scene, my guess is that in most cases paramedics don’t have any way of knowing the patients’ wishes in most cases.
      My understanding is that in cases of total cardiac arrest a patient may have a 10-20% chance of survival under ideal conditions.
      Those conditions would include immediate response in a hospital setting, or paramedics with defibrillators at the scene within seconds of the patient suddenly losing consciousness and going into total cardiac arrest.
      Based on your experience, is that estimate of a 10-20% survival rate, under ideal conditions, too high?
      (I’m not factoring in the condition of those 10-20% who might “survive”, but with brain damage, etc).

      1. Hi, Tom –

        As you may know, there are 9 recognized signs of Obvious Death. If a patient exhibits any one of these signs (i.e. rigor mortis or crushed skull or lividity) then no, Paramedics do not initiate care. We pick up the phone and advise our base ER that the patient is beyond help. Then we document our findings and call the coroner.

        In the case we are discussing here with tattoo-man, he apparently exhibited no obvious signs of death – thus the dilemma. A person with no heartbeat is not – as you know – irretrievably gone – neither is a flatline EKG a sign of brain death. One difference between EMTs and medics, is that medics make these determinations on a weekly basis. EMTs don’t, normally. Neither do they compare notes over the phone with an MICN nurse or the ER doc, which we do.

        “Based on your experience, is that estimate of a 10-20% (CPR) survival rate, under ideal conditions, too high?”

        Yes, it is too high – for patients we respond to in the field. The “ideal” scenario is a patient lying in a hospital bed with a crash cart nearby and ACLS staff. Nationwide, the field survival rate is closer to 1%-2% – and those who claim it’s much higher are playing with the numbers. Keep in mind there is more then one way to define “success.” Medicine loves such nifty pollywoggles as “CPR field save.” It pumps up statistics – which another reader here was so fond of – to inflate the numbers, which generates money.

        One of the most bizarre scenarios in medicine is for a Paramedic team to receive “CPR save” accolades on the same day as the patient’s funeral. The poor fellow had no pulse when we found him, we used our cool tools to retrieve his heartbeat before he got to the ER. He dies at midnight in the ICU. In the wickedly wild Twilight Zone world of medicine – that’s considered a “Paramedic save,”

        But as I’ve mentioned before – and as most any experienced medics can verify – almost no adult over the age of 50 will ever rebound from full cardiac arrest in the field, respond to ACLS therapy, and live to walk out of the ICU someday.

        That happens only on television.

        1. Thanks, Patric. Is the “heretic” label self-imposed, or did the medical establishment take official action because of your views on CPR?😃
          I suppose that when the expectations of the success of CPR /resuscitation have been raised to unrealistic levels, there is an expectation for responders to “do something”.
          Based on my limited observations and experience as a layman, I came to question the odds of “successful” CPR years ago.
          In one case, involving an elderly relative who suddenly lost consciousness (was subsequently found to have both A-fib and V-fib), I was pretty sure she was gone with no detectable signs of breathing or hearbeat.
          I lifted her out of the chair, turned her on her side, and she vomited .
          That shock seemed to revive her, and she was fully conscious when the paramedics got there a few minutes later.
          But there was no “CPR” performed on my part, and it’s also possible that she still had some level of cardiac activity or breathing that I couldn’t initially detect.
          Hope the snow in Seattle that I saw n the news is gone now.
          Seattle is one of the more “interesting” cities to drive in when there’s snow.

          came to question the odds of “successful” CPR years ago.

          1. Ignore the last paragraph…I thought I’d deleted it after the “scroll” function froze, and I retyped it when I started over.

            1. Thanks for the info…..I look forward to reading your book, as well as visiting the website.

  2. Allan said this in response to my statement:

    Out of 400 MDs nationwide, do you know how many responded “Yes?
    Zero.

    “You must have had an unusual or selective survey.”

    Not at all. My questions were asked to physicians nationwide at random.

    The typical MD – just like the typical RN and Paramedic – knows full well that CPR is brutal, unwise, preposterously advertised and almost always a dismal failure at “saving” anybody over the age of 40.

    Here’s a concept you would be wise to hang your hat on: The CPR cheerleaders are not those who live and work in the world of EMS.

    1. “Out of 400 MDs nationwide, do you know how many responded “Yes? Zero.”

      I’ll repeat what I said. “You must have had an unusual or selective survey.” Additionally, I’ll add that the question might not have been asked appropriately or under appropriate conditions. I’m not pushing for CPR or even stating that it succeeds as well as the population thinks it does. TV can make things seem a lot better than they are.

      Let me quote what you said:

      “When the time comes for your medical crisis, Doctor, do you want CPR performed on YOU?
      Out of 400 MDs nationwide, do you know how many responded “Yes?” Zero.”

      I’ll pick an age greater than the 40 years you mention. A doctor comes into the hospital. His crisis is a heart attack followed by an arrhythmia. He suddenly stops breathing and it is noted that he has an arrhythmia that will kill him without treatment. Standard CPR is called for and he is cardioverted back to a normal rhythm.

      Do you think that the entire 400 doctors would decline CPR under those circumstances? Cardiac arrhythmias are not uncommon and decades ago were a major cause of death in those that had a heart attack.

  3. You should really read the whole story next time: http://www.wctv.tv/content/news/Do-Not-Resuscitate-tattoo-leaves-doctors-debating-whether-to-save-mans-life-462057183.html

    “At the same time, the hospital’s social work department had managed to obtain a copy of the patient’s Florida Department of Health “out-of-hospital” DNR order, and the medical team confirmed that it was consistent with the message of his tattoo.”

    So in other words, a non-story

  5. Maybe we should each be required to get a tatoo of ‘DNR’ on our body in a specific location so that there is never an error made. I know of more than one case where an elderly person was brought to an emergency room, and because the DNR papers were not on file at that hospital or not immediately presented by a family member, the person was resuscitated and placed on life support only to find out later that there was a DNR order prepared by the person who was resuscitated and placed on life support and a feeding tube. I don’t ever want that to happen to me. If a man has Do Not Resuscitate tatooed on his chest, honor that wish.

    1. David, perhaps the Florida law isn’t wrong rather your understanding of Florida law isn’t complete. In any event, the cause of action in a case like this wouldn’t come from the state of Florida. It would come in the form of a suit by a family member or other interested party.

        1. David, I think it is the interpretation of Florida Law here on the blog that is wrong. Florida supplies such a yellow paper which I guess is to make it more visible, but any color paper and different wording is permitted as well.

          Thus if you believe the way the law is being carried out in Florida requires a yellow DNR then you are wrong.

  7. What are the chances of you being able to produce a legal DNR in the emergency room when you are unconscious? Even if it is in your wallet will the hospital representative find it before the extraordinary measures to save you are performed? In Texas you need 2 DNR’s. One for in hospital and another if you are not in the hospital. I am glad the medical personnel followed this mans wishes. I speak from the prospective of a widower who when confronted with the death of his terminally ill wife, who had a DNR, performed CPR to the best of my ability. Family does not always follow the patients wishes in a crisis.

  8. Although the medical personnel were not “required” under Florida law to honour the DNR,I would suggest they were entitled to do so,even in the absence of finding the formal directive.The patient could not have made his intentions any clearer

  9. “After consulting an “ethics expert,”
    ~+~
    That is where this error originated. The matter is of statutory interpretation and should have been handled by the legal department (if available). Given the emergency nature, this is not entirely feasible.

      1. David Benson – I am with you on this one, The statute is clear about having to follow the yellow paper DNRs, but leaves an escape clause for all the others. You can or you cannot. In this case, it was in a prominent place on the body and signed. Even if it counted in another state, it should have been honored here.

  10. On this particular case, I happen to agree 100% with JT. How often does this happen? Let me put it to you this way. The odds are almost as bad as winning the lottery and then getting struck by lightening the next day on the way to the lottery office to submit the winning ticket. So you KNOW JT has to be right in this case.

    A DNR request has to have legal force. I’ve known several elderly people who have needed to move to nursing homes. One of the standard things that a visiting nursing home doctor typically addresses is determining if the patient wants DNR or not. There’s a simple form for this if the patient wants DNR and it can always be revoked at the patient’s request if the patient changes his/her mind. DNR is the exception, not the normal assumption for medical personnel, so it has to be not only explicitly stated, but it must be documented in its proper legal form. It’s a simple and quick process and does not require the services of an attorney.

    Also, while we’re on this topic, let me give you a little hint to better prepare yourself for dealing with elderly or sick relative or friend, as this is likely to happen to you at some point in your lives. Try to persuade the person to address these life and death issues that many people want to avoid, like DNRs, wills, powers of attorney, etc. (And yes, for many of these things, you will want to engage a competent attorney who specializes in this area of law.) The time to address these matters is BEFORE the situation becomes dire and BEFORE the person develops the ability to even address the issues, such as dementia. I know that none of us like to think of this, but life here is going to go on after we’re all gone. Prepare for the inevitable, and while you’re at it, don’t leave a legal mess for your heirs to sort through.

  11. They could save him and then give him a gun to kill himself if he was of that mindset.

  13. Bam Bam said this:

    “The tattoo is meaningless.”

    No, actually, it isn’t meaningless at all – not in the world of EMS, for numerous good reasons:

    1. Although Mr. Turley is correct that “DNR” is sometimes scribed as a joke, – its existence on the very place on the body where chest compressions would be performed, is taken at face value, by those of us who do this stuff for a living in my area. we never assume “jokes.”

    2. This man was confined to a long term care facility with 3rd-stage lung disease. He knew he wasn’t ever going home. The “P” in CPR stands for pulmonary. Pulmonary means lungs. Both the staff and the gentleman like knew full well that dying lungs don’t get better. Patients in a SNF don’t expect miracles.

    3. Those of us in the world of rescue know several things that the lay-public should be taught from about 8th grade – but aren’t. And that’s a pity. The most important is that CPR almost never “saves” the unhealthy patient. CPR was never created for the elderly with serious organ failure. Quite the contrary. Its purpose is to buy a survivable patient – one with a healthy heart and lungs and brain, such as drowning – time to get to advanced care needed to fully recover.

    4. This gentleman confined to a bed in a SNF had bed-baths by staff members. Don’t ever for a minute think the staff was unaware that he wanted no “heroic” procedures.

    Lastly, for those interested, in research for one of my books I questioned 400 physicians on several matters, one of which was this:

    “When the time comes for your medical crisis, Doctor, do you want CPR performed on YOU?”

    Out of 400 MDs nationwide, do you know how many responded “Yes?”

    Zero.

    In fact, more than a few have their own chest tattoos.

    1. The paramedic makes interesting points including the location of the tattoo. But I agree with Mr Turley, in the face of uncertainty, one legally and morally err on the side of life.

    2. Well said! As a registered nurse I couldn’t agree with you more!
      Also the tattooed signature removes any reasonable doubt in my estimation. This dude was as serious as a heart attack about his DNR status and I would honor it.
      His condition was terminal.
      Documents get lost. Tattoos are forever unless removed with laser.

    3. “Out of 400 MDs nationwide, do you know how many responded “Yes?”

      Zero.”

      You must have had an unusual or selective survey.

      1. My brother is an MD, and he said almost every doctor he knows has a DNR order because they have seen the horrors involved with brain dead patients being kept alive.

        1. I understand, your brother the doctor said…

          He’s a doctor, not a statistician. At best those are the doctors he knows. Do you really think every time he meets a doctor he asks if the doctor has a DNR?

    4. Thank god they honored the patients’ wishes. Not everyone can carry around a yellow DNR on their person 24 hours a day. I would say it is safe to say that they chose twhat the man wanted.

    5. There is a reason, or, in actuality, a multitude of reasons, as to why documents, such as wills and healthcare directives come with a variety of rules and requirements. Rules and requirements which were not taken, out of thin air, and mandated as necessary in order to validate said documents. The outcome or outcomes are far too important and far too grave to not require strict adherence with regard to rules when it comes to distributing a lifetime of assets or the care requested in case of a health emergency. No one–and, I do mean, no one–wants someone, who claims to be, in the “business”–to begin interpreting the legality or legitimacy of documents, much less, tattoos. That isn’t your job. Your job is to save lives, if at all possible. You are in no position, as a paramedic, to decipher the intent or legality of words engraved into a patient’s body. You have no expertise or knowledge regarding this, and, as such, should just proceed in the normal manner of attempting to preserve the life. This guy was drunk, passed out on the street. Those responding had no idea as to his mental capacity or his sanity. The tattoo may very well have been a joke. A farce. An act committed in some impaired state. Then, what? You let the unconscious man die because you were capable of reading a tattoo? Until and unless you, as a responder, have any legal notice, which advises you otherwise, you are supposed to behave as a medical professional and save the life. And, the alleged survey of doctors, who all claim to not want to be resuscitated in case of an emergency? All 400 of them? Laughable. Must be a part of the crowd, who claim to be atheists, who insist that tgere is no God, yet who fervently pray in foxholes.

  14. There is also the notion of revocability with this DNR Order. According to the Florida D.O.H. website:

    The form can be revoked at any time either orally or in writing, by physical destruction, by failure to present it, or by orally expressing a contrary intent by the patient or the patient’s health care surrogate.

    A tattoo is largely understood to be permanent. Given the cost and difficulty in removing or obliterating a tattoo The patient could be placed into a situation where they had such a tattoo but later their medical wishes changed. While the ordinary yellow copied DNR Order may simply be destroyed, the reliance on a tattoo DNR contravenes this.

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