A 79 year old euthanasia campaigner in New Zealand has attracted local and international publicity after having the words ‘Do Not Resuscitate’ tattooed across her chest. Although this seems unlikely to be widely emulated her action highlights the problem that at the time when it might be most important to make one’s views known, patients are often unconscious or incompetent.
Actually, this idea is not a completely original one. Others have had similar or more complicated directives tattooed prominently on them. Among my medical colleagues, we would sometimes joke about having instructions to ambulance paramedics tattooed upon our bodies – telling them that under no circumstances were they to transport us to ______ emergency department. Since none of us ever carried through this threat, we did not have to deal with the practical issue with what to do if we moved cities, or if _____ emergency department’s reputation improved.
But, there are other reasons to doubt the appropriateness of permanent, external inscriptions of one’s advance medical preferences. Although the tattoo in question makes the wishes of the patient fairly clear in general terms, in practice it might not be respected because it may not be legally binding. Nor may the instructions be clear enough to help in an emergency. If someone has a ‘DNR’ tattoo, should a friend or paramedic attempt a Heimlich manoeuvre when they are choking on their sandwich? My own preferences would probably be something more like those of Australian doctor Michael Mackay – happy for DC cardioversion in the event of witnessed collapse and ventricular fibrillation, but not keen for prolonged resuscitation in the event of an asystolic arrest. But his 214 word “advance healthcare directive” would be painful and awkward to have tattooed…
Should I have my cardiac arrest while going about my duties in the
emergency department — immediate defibrillation please! And maybe a
whiff of oxygen. (If I don’t survive, I will be quite surprised.) Should I arrest in the hospital dining room, forgo the mouth-
to-mouth (I am squeamish about these things).
Advance written directives may be able to provide detailed instructions, requests that are relevant to the circumstance and which are legally binding on the resuscitator. However they are not always able to be found at the moment when they are needed. That is one reason for a desire to have something available with the patient that could provide immediate and relevant information.
A simple solution would be a bracelet or necklace, like those that provide emergency information about allergies or illnesses. More sophisticated technological solutions have been conceived, and would not be difficult to implement, with implanted microchips able to store large amounts of information. Such solutions would be a far more flexible and appropriate way of recording end of life preferences than tattooing. However the biggest obstacle to widespread use of such an intervention is that few people think seriously about, or talk about with their doctors or families, what they would like to happen in the event of a critical illness or cardiac arrest.
There is another problem: Staleness. How long ago was the directive written? Has it been read since and commented on? If the idea is to get the current intention of the lingering person, it is probably impossible because there is probably no such thing. I think the idea is to get the intention the person would of had in the last lucid moment, had the person thought about it then. The more recent the expression by the person involved, the greater its evidentiary value. So, it would not be a bad idea to develop a habit of reviewing these things. It would not be a bad idea for a hospital office to review these things and their circumstances when the patient is admitted, even though it would be unpleasant for the patient to think about such a thing on entering a hospital.
What’s the big deal? Law suits and threatened criminal prosecutions if the directive is carried out. They would be pressed by relatives and ideologically driven prosecutors.
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