Bioethics

Why can’t a tattoo be a legal advanced directive?

By Chris Rangel MD ⋅ May 17, 2006 ⋅  Email this post ⋅  Print this post ⋅ Post a comment

It’s a common joke among health care workers. After seeing the living hell that patients endure following cardiopulmonary resuscitation (before ultimately dieing) many in the health care field like to claim that not only are they “DNR” (Do Not Resuscitate) but they’ll get it tattooed on their chest just to make sure that it doesn’t happen.

It turns out that more than one patient has actually done gone and did this! The latest DNR tattoo convert is Mary Wohlford, 80, of Iowa, who wants to make sure that there is no ambiguity about her wishes (link via the pro-life fanatics at Fark.com). However, such an unorthodox way of communicating your end of life wishes is being scoffed at by the legal dept.

“Bob Cowie . . is chairman of the Iowa Bar Association’s probate and trust law section. He suggests people sign a living will or authorize a medical power of attorney.”

Why can’t a DNR tattoo be a legal document? First off, an advanced directive must have three elements; 1. It must represent the true and un-coerced wishes of the patient, 2. It must be un-ambiguous, and 3. It must be morally and legally appropriate. A tattoo, being a quintessential example of personal expression and consent is more than qualified to be a legal document (the signature being the body on which it is placed). It seems “a priori” that a tattoo is less likely to be a result of coercion or trickery than a simple signature on a document.

Whether the tattoo spells out “Do Not Resuscitate” or just “DNR” these terms have very specific and un-ambiguous meaning to health care personnel. The “DNR patient” does not get CPR (chest compressions or rescue breathing), is not defibrillated (shocked), is not intubated and placed on a ventilator, and does not get special medication via an IV to simulate the heart and elevate the blood pressure. Most paper advanced directives are far more ambiguous than this and often it states only that the patient does not want to be kept alive via “artificial means”. Huh?

The third requirement is more problematic but it doesn’t matter if there is a paper document or a tattoo involved. A DNR (particularly an out-of-hospital DNR) is most appropriate when the patient has a condition(s) that significantly decreases the likelihood that a successful resuscitation would lead to meaningful long-term survival. For example, patients older than 70, those with very poor kidney function, advanced HIV disease, and general severe debilitation have < 4% chance of surviving successful resuscitation to be discharged alive from the hospital. Patients with metastatic cancer and those with severe acute illness like sepsis, pneumonia, or stroke have about a 0% chance of survival! In these cases it is more than appropriate for a patient to tattoo their DNR requests on their chest.

However, patients suffering cardiac arrest from certain arrhythmias have actually much better survival odds (25-40% or more) without any serious lasting disability if their attack is witnessed and help (like an out of hospital defibrillation device) is immediately available. If you are relatively young and in relative good health (even if you have pre-existing heart disease) then a DNR tattoo doesn’t make much sense.

But is a DNR tattoo, even in the appropriate patient, really a good idea? Advanced directives and end of life wishes commonly maintain a certain amount of ambiguity up to the point where they need to be followed. This is because no one can anticipate the exact clinical situation that may arise and whether it is appropriate to evoke a DNR order.

In my medical school ethics course we were given an example of the problem of blanket DNR orders. This was back in the mid 1990s when HIV and AIDs had very poor outcomes and few treatment options. The vignette was of a HIV positive patient with advanced AIDs who entered the hospital for a relatively minor infection. He requested a DNR status, which included no intubation or mechanical ventilation, but after getting his first dose of antibiotics he developed an acute anaphylactic reaction with airway swelling. He needed emergent intubation to allow him to breathe but that would go against his DNR request. What to do?

The utilitarian solution would be to treat him because the condition had nothing to do with his HIV status and is very survivable with appropriate treatment. Yet, this is an example of how blanket DNR requests like a tattoo can be problematic even in seemingly appropriate populations.

However, due to the often ambiguous nature of advanced directives and the unpredictability of clinical situations, most state laws regarding advanced medical decision making allow DNR orders to be revoked at any time and allow next of kin to make decisions for an incapacitated loved one without anything more than their belief of what the family member would want in the particular situation. No documents are required to make these decisions and family may even contradict what is stated in an advanced directive signed by the patient!

This can be a problem if the patient does not trust their “loved ones” to make the right decision. It is not uncommon for family to have other interests in mind other than what is best for the patient. From economic concerns (collecting the patient’s retirement checks) to emotional self interest (”I don’t want my Grandma to die!”), to simple ignorance (”The doctors can save her!”) family members make bad decisions all the time and the patient needlessly suffers. In these cases, the 80-year-old patient with the DNR tattoo more then likely knows what the hell they are doing. My advice in this case would be to read and follow.