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jueves, 10 de enero de 2019

DO NOT RESUSCITATE TATTOO that is legal? ¿Tatuaje no resucitar es legal?

DO NOT RESUSCITATE  TATTOO that is legal? ¿Tatuaje no resucitar es legal? 

P: ¿La adiccion a las drogas es una opcion o una enfermedad?
R: Son ambas, inicia como una opcion y se convierte en una enfermedad de dependencia debido al sistema de recompensa del cerebro y la liberacion de dopamina.
P: ¿Si un adicto con un tatuaje de "DNR" (do not resuscitate) y la sobredosis es intencional, honramos el tatuaje?
R: No, un tatuaje no es un documento legal, el documento legal de DNR, debe estar firmado por un doctor.
P: ¿Incapacidad mental?
R: En EUA, en la mayoria de los estados tenemos documento legal que nos permite llevar un paciente al hospital en contra de su voluntad cuando hacen comentarios o atentados encontra de su vida o otros. (En Massachusetts es el M.G.L part I, titulo XVII, capitulo 123, section 12)  
by Christian Goring, NREMT-P


Man's "Do Not Resuscitate" tattoo leaves doctors debating whether to save his life
BY ASHLEY WELCH
UPDATED ON: DECEMBER 4, 2017 / 3:50 PM / CBS NEWS

Doctors at a Florida hospital faced an ethical dilemma when an unconscious man arrived in the emergency room with a tattoo that read "Do Not Resuscitate" emblazoned on his chest.


The patient, who was 70 years old, had an elevated blood alcohol level and had a history of chronic obstructive pulmonary disease (COPD), diabetes and atrial fibrillation. A few hours later, his blood pressure dropped to an abnormally low level.

The man had arrived with no identification and no family or friends.

His tattoo, which included a signature and had the word "Not" underlined, left doctors unsure of what to do next.

Was the tattoo a clear representation of the patient's wishes? Should they honor it and avoid any heroic efforts to save his life? Were they required to, legally?

Doctors detailed the case and the decisions they made in a report published in the New England Journal of Medicine.

At first, they decided not to honor the tattoo, "invoking the principle of not choosing an irreversible path when faced with uncertainty," they wrote.

However, this decision left the medical team conflicted, and they brought in an ethics committee to consult on it further.


After reviewing the case, the committee advised the doctors to honor the DNR tattoo.

"They suggested that it was most reasonable to infer that the tattoo expressed an authentic preference," the doctors wrote.

What doctors, patients want at end of life
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.

The man's condition deteriorated and he died without any further medical intervention.

The doctors write that they were "relieved" to find the patient's official written DNR request in the state files, as the "tattoo produced more confusion than clarity." They cited one other case, found in a review of the scientific literature, involving a person with a DNR tattoo — but that patient's tattoo no longer reflected his current wishes.

They also mentioned being concerned about the potential unknown circumstances in which a person might get such a tattoo. What if the patient had done it while under the influence of drugs or alcohol?

Medical ethicist Dr. Arthur Caplan, Ph.D., said that legally, DNR tattoos are not binding.


"There's no law that says you have to respect or recognize a tattoo," Caplan told CBS News. "But morally, it carries a lot of weight."

Caplan, the founding head of the Division of Medical Ethics at NYU School of Medicine, was not involved in the patient's case.

He said the first step for doctors treating such a patient would be to contact next of kin or seek a written DNR order.

"If that's not available and there are no family or friends around to verify the patients' wishes, would I not resuscitate him just on the basis of the tattoo? Probably not, because I wouldn't know if I could trust it," he said. "I wouldn't know whether it was 10 years old or five minutes old. I wouldn't know if maybe he had changed his mind. There's too much uncertainty."

Caplan advises that if people want to have a DNR tattoo or bracelet to call attention to their end-of-life medical wishes, they should also carry a copy of a living will or advanced directive in their wallet.

"At the end of the day, tattoos are not substitutes," he said. "They're also not substitutes for having conversations with your family and friends or with your doctor about your wishes."

First published on December 4, 2017




Do-Not-Resuscitate Tattoos: Are They Valid?
By Laura Vearrier, MD, MA | on April 10, 2018

A recent New England Journal of Medicine article presented a case in which a “Do Not Resuscitate” (DNR) tattoo (see Figure 1) created an ethical dilemma for the emergency and critical care physicians caring for the patient, who were guided by a questionable recommendation from their ethics consultants.1 The unknown patient presented to the emergency department unconscious and in critical condition. “Do Not Resuscitate” was tattooed across his anterior chest wall, accompanied by his presumed signature.

Without the guidance of next of kin or advanced directive paperwork, the health care team initially decided not to honor the DNR tattoo. However, they later reversed their decision and honored the tattoo after an ethics consultation. The ethics consultants concluded that the tattoo could be presumed to represent the patient’s authentic preferences and that the “law is sometimes not nimble enough to support patient-centered care and respect for patients’ best interest.” The conclusion of the ethics consultants should not set a precedent for future similar cases, as the DNR tattoo was neither legally nor ethically sufficient to guide medical care.

Before delving into the specific insufficiencies of the tattoo, it is useful to review advance care planning (ACP). There are two main forms of ACP documents: advance directives (AD) and physician orders for life sustaining treatment (POLST). ADs are legal documents that can be completed at any time in life to guide future care and/or appoint a surrogate decision maker. ADs must be completed by the person (him/herself) and require either a witness or notary, depending on the state. POLST forms are physician orders for end-of-life (EOL) care designed to be transferred among health care institutions. They are for patients who are seriously ill or frail who are near the EOL and can be completed with the assistance of a surrogate. Table 1 summarizes the differences between ADs and POLST.

The “Do Not Resuscitate” tattoo in the article is neither legally nor ethically sufficient to guide medical care for the following reasons:

Tattoos are not legal ADs nor POLST, which are the two ACP documents transferrable among institutions in the United States. The tattoo cannot be considered a wearable AD, as it does not include a witness or notary to complete the legal documentation.
Informed decision-making cannot be presumed. Studies have reported that patients have a poor understanding of EOL care terminology, and only about half of emergency department patients surveyed had a correct understanding of the term “Do Not Resuscitate.”2 There is no evidence that the tattoo indicates a clear understanding of a DNR status.
The tattoo contains insufficient information to guide medical treatment. Does the patient mean no chest compressions, no intubation, no vasopressors? ADs and POLSTs clarify preferences so that providers can better interpret patient wishes, although confusion may still arise as to whether specific interventions are desired.
EOL care preferences are dynamic. Depending on factors such as age, health status, prognosis, and advancement of medical technology, a person’s EOL preferences may change.3 In contrast to a tattoo, ADs and POLST forms may be easily amended to reflect a patient’s current wishes.
Tattoo regret is common. More than 50 percent of individuals later regret their tattoos.4 The most frequent motivation for tattoo removal is poor decision making, often the result of intoxication, leading to subsequent regret. A case report of a DNR tattoo that did not represent a patient’s current wishes has previously been reported.5
An important ethical principle for emergency physicians to consider is that withholding and withdrawing life-sustaining treatment are considered ethically equivalent. Therefore, when faced with ambiguity regarding a patient’s wishes, emergency physicians should proceed with life-saving interventions. When further information is obtained, the patient’s care can be appropriately de-escalated in accordance with their preferences.

default to proceeding with life-sustaining measures does not mean that tattoos or other non-standard means of communicating preferences should be ignored. The tattoo, an alternative form of communication, should be used as piece of information in the decision-making process. A major limitation of AD and POLST documents is that in most states they must physically accompany the patient and are often not available when providers are making key decisions.

Some states, such as Oregon and California, have electronic databases that providers can access, but the lack of this type of accessible database may cause patients to be concerned that their wishes may not be known. In our era of smartphones, patients should be encouraged to enter “ICE” (In Case of Emergency) data into their phones, which can include medical information and emergency contacts. Emergency providers should also be encouraged to routinely search for available ICE data on the phones of incapacitated patients.


Dr. VearrierDr. Vearrier is clinical assistant professor in the department of emergency medicine at Drexel University College of Medicine in Philadelphia.  

References
Holt GE, Sarmento B, Kett D, et al. An unconscious patient with a DNR tattoo. N Eng J Med. 2017;377:2192-2193.
Marco C, Savory EA, Treuhaft K. End-of-life terminology: the ED patients’ perspective. AJOB Prim Res. 2010;1:22-37.
Vearrier L. Failure of the current advance care planning paradigm: Advocating for a communications-based approach. HEC Forum. 2016:28(4):339-354.
Burris K, Kim K. Tattoo removal. Clin Dermatol. 2007;25:388-392.
Cooper L, Aronowitz P. DNR tattoos: a cautionary tale. J Gen Intern Med. 2012;27(10):1383.



Here are some hard questions:
Is drug addiction a choice or a disease? If an addict has DNR tattooed on him and the OD was presumed intentional, what are our ethical responsibilities for resuscitation? Could the same be applied to any suicide? Or do we assume mental incapacity to non-addicts who attempt to take their lives?

Have a safe week everyone.

Respectfully,
DanSun

DO NOT RESUSCITATE TATTOO that is legal? ¿Tatuaje no resucitar es legal?

Muerte Subita y Cardioproteccion "Zona Cardioprotegida" Desfibrilador Externo-Automatico

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