Last summer, when physicians at Jackson Memorial Hospital in Miami cared for an unidentified, unconscious 70-year-old man, they were unaware that an urban legend was about to be proven true.
At first, the man's alcohol level was elevated, his blood glucose was fine, and clinicians presumed he'd sleep it off in the ED. But as morning came, the man wasn't waking up, and Gregory E. Holt, MD, PhD, was called down from the ICU to evaluate him. The man had tachycardia and hypotension, and when Dr. Holt ordered an arterial blood gas test, the pH result was 6.81.
“It was an acute respiratory acidosis, so clearly the man is not ventilating well and we need to do something,” said Dr. Holt, a pulmonary and critical care physician. “That's about the same time when we noticed this ‘Do not resuscitate’ (DNR) tattoo...right where you'd have to put your hands to do chest compressions.”
Dr. Holt, an assistant professor at the University of Miami Health System, recounted the confounding case in a letter published on Nov. 30, 2017, in The New England Journal of Medicine. He recently spoke with ACP Hospitalist about the experience.
Q: What was your first reaction when you saw the DNR tattoo?
A: You think of these things as urban legends, or at the end of a code, someone will say, “I'm going to have ‘DNR’ tattooed on my chest so this never happens to me.” So we finally see one . . . and you don't really know what to do. We don't know is this a real tattoo, is this not his real wishes, and is it even legal? We want to think only about the patient's health, but to do so, you have to say, “Is this tattoo a realistic manifestation of his true wishes for life-sustaining therapy?”
Q: What were your next steps?
A: Initially, we make the decision to do some temporizing measures. We put him on bilevel positive airway pressure because I felt like without it, he would cease breathing. We give him fluids, antibiotics, and we put him on vasopressors because without it, we figured he would go into cardiac arrest from PEA [pulseless electrical activity]. By doing these things, I felt like we could temporize everything while we tried to figure out the legality, the veracity, and who he was. Everything we did—we gave him sugar and oxygen, tried to wake him up—to get him more conscious failed. After treating the patient and thinking about it, that's when it dawned on us that we really needed ethics [to consult]. It was within the first two hours of us seeing the man that ethics got involved.
Q: What did the ethics consultant determine?
A: Ken Goodman, PhD, is our ethicist. He is amazing. He did a great job, I thought—really looked at the case, looked at the patient, looked at the tattoo. The thing about this man's tattoo is he spelled out the words, he underlined the word “not,” and he even put what we presumed was his signature, but there was no way to actually determine that exactly. So [he] thought, given all the things that the patient did to get that tattoo, most likely this was consistent with his wishes. It probably took him one to two hours after getting called for him to think it through, and then we said, “All right, we'll make him DNR then.” We provided for comfort, of course, and he ultimately passed away, probably about a full 24 hours from when he presented to the emergency room.
Later that night, the social worker was finally able to identify the man. They called his place of residence to try to get some more records. When they went into his domicile, they found his Physician Order for Life-Sustaining Therapy form, and it was consistent with his tattoo. That just made us all feel very reassured that ethics was spot-on brilliant in their evaluation and analysis of this patient's case.
Q: What kinds of reactions have you gotten to how you handled this case?
A: Some people suggest that the DNR tattoo should not have been honored. What Florida [law] suggests is you need to have it on yellow paper. If it's not on yellow paper, you are not legally mandated to honor it. A lot of people, actually, say the opposite: that we shouldn't have even had a discussion—we should've looked at the DNR tattoo and said, “This is a manifestation of the man's wishes; honor it.” A couple of people have called me cold and distant and too professional without caring for patients because of what I did.
In his case, [the tattoo] prevented him from being intubated. So on a case of n=1, it clearly worked. Was it easy? No. Did it cause us a lot of confusion? Absolutely. There's one other case, I think it was in 2012, of a man with “DNR” on his chest, and it turned out he just lost a bet while drunk. When he was asked, he said two things: First, no, he did not want to be DNR, and two, he didn't think anybody would take it seriously that he actually had a DNR tattoo. I think that kind of gets to the root of DNR tattoos in terms of conveying somebody's wishes for life-sustaining therapy: Although it sounds like a good idea, it doesn't always translate into an appropriate response from providers who actually see the patient.
Q: What advice would you give hospitalists based on this experience?
A: Know that you have an ethics department and just be able to use them. That's the biggest thing that I've taken from this. Even if they had come down and made that decision that we should honor [the tattoo] and then later we find out that it wasn't [the man's wish], I would still feel better that we had somebody who's an expert in ethics come to a conclusion that was based on the facts and the evidence of a case to the best of our ability. I hope, after all these discussions that have come out of this, that it starts a national conversation about a better system to get in place to get people's end-of-life wishes known.