It’s been quite a while since an end-of-life issue has caused such a buzz in the medical world or in the public conversation.  Everybody from the New York Times to NPR and other news outlets have shown the image of the chest tattoo on a very ill patient presenting to an ER in Florida with alcohol on his breath, unconscious, with severe COPD and multiple other medical problems.

Photograph of the Patient’s Tattoo Entered into the Medical Record to Document His Perceived End-of-Life Wishes. This patient’s presumed signature has been masked. New England Journal of Medicine, November 2017. 

As a recovering ER doc, I recognized this confusing scenario – though not the tattoo itself.  I actually thought the ER did a great job – patients can often be stabilized enough to buy time to sort out their wishes.   The teams took the time for an ethics consult and for gathering some medical information, looking for family or other corroborating evidence of his values and wishes.  And everything confirmed that this tattoo probably represented a real choice.  He was ultimately allowed to die without heroic and invasive attempts to keep him alive.

Ink your preferences…preferably on paper

While written directives – even of the more conventional types – have become more common in the last couple of decades, they present problems during acute downturns when the patient or family is unable to give input.  Written directives are static, and don’t reflect the intent or values that underlie the documents.

Most of the articles on this particular gentleman with the DNR tattoo reference “A Cautionary Tale” published Journal of General Internal Medicine, October 2012.  In that case, an ill but conversant patient was able to correct his own tattoo, relating that he had lost a drinking bet.  Thus the long-ago tattoo was something that he didn’t really mean.

Communication

But how many times have we talked with patients who said “Oh, I didn’t mean THAT with my directive”?  People change their minds, the directives are often done as part of a pile of legal paperwork, and inadequate time is taken to discuss the implications – often without medical guidance.  It really is hard to conceive of procedure-based instructions for our future that are absolute.  We just don’t know the circumstances we will find ourselves in down the road.

So get yourself a MDPOA, and talk to your agent and to your loved ones about what is important to you if  were to get too sick to direct your care.  Remind them that you may well change your priorities over time.  Keep the conversation going, and stay away from those (dirty) needles!

References cited:
http://www.nejm.org/doi/full/10.1056/NEJMc1713344#article_citing_articles
https://link.springer.com/article/10.1007%2Fs11606-012-2059-8