Q&A on DNR Orders

Advance Directives and What They Have to Do With Tattoos

As an emergency responder on scene for a 911 call, imagine opening the patient’s shirt to find a large tattoo which reads “Do Not Resuscitate” and a picture of a heart with a circle and slash through it. Clearly, at some point in this patient’s life, they were adamant enough about their desire to not go through CPR and other cardiac arrest life-saving measures to make a permanent commitment to it. Or did they lose a bet? Or did they get the tattoo back when they were 30 and have changed their mind in the 20 years since, but just haven’t gotten around to getting the tattoo altered? Is it a judgment call on an EMT’s part? Or is it a legally binding matter?

When asked, AED Superstore’s resident rural Wisconsin EMTs said they would absolutely ignore the tattoo and carry on as if it wasn’t there. You see, in Wisconsin a “Do Not Resuscitate” Order (DNR) is used to secure a DNR bracelet which EMS may or may not notice. Sudden cardiac arrest means quick action is required and EMTs have the same “do no harm” commitment doctors have. It is important for them to follow their department’s protocols and while there is a bracelet requirement, there is not currently laws in place in Wisconsin for tattoos as legally binding end-of-life wishes. Plus, if there was a known DNR order, it is unlikely an ambulance would have been called in the first place, so they will proceed as protocol dictates.

What, Exactly, Is a DNR?

A DNR order is a simple document, signed by you and your doctor, which states you do not wish to receive cardiopulmonary resuscitation (CPR) or defibrillation should you go into sudden cardiac arrest. Some states have a Do Not Intubate (DNI) section included on the form. Other states require a separate form. Intubation is the insertion of a tube down the throat to assist in breathing and is standard procedure during a cardiac rescue by EMS personnel.

Who Should Get a DNR?

In all states, any mentally competent adult can request a DNR form from their doctor. Since they need to be signed by a doctor, the patient is usually someone for whom CPR/AED use and intubation could cause more harm than good. If someone is physically frail, CPR can lead to intense physical trauma, including bruising, internal organ damage, broken ribs (beyond what is normal in CPR), and a long painful recovery time, if they recover at all. Some patients have an illness which, if they did receive CPR and a shock from an AED, the results may only last a short time and may cause the patient pain.

The doctor should make sure the patient understands the implications of having a DNR order in place. A DNR only covers resuscitation/intubation and has no indications on other end-of-life wishes. Those require different forms.

What Other Forms Are There?

Many people confuse DNR orders with advance directives. Sometimes called living wills, an advance directive allows anyone, of any age and health status, to appoint a health agent (or proxy) who will act on their behalf in the event the person cannot give their consent to care due to being unconscious or otherwise incapacitated. They are more comprehensive than a DNR order, which covers only resuscitation and intubation. They give your appointed health agent a guideline to use when deciding on your care.

Again, the forms vary by state but typically include sections on:

• Feeding tubes
• Life-sustaining procedures during a vegetative state (do you wish them to “pull the plug”?)
• Any other wishes you may have regarding your end-of-life care

Copies are filed with your doctor, your health agent, and anyone else you wish to have a copy. Here is a list of advance directives by state

How Can I Let EMS Know about My DNR?

Some states allow the paper form to be presented to emergency medical personnel. Other states have different requirements. For example, in Wisconsin, the doctor’s form is used to order a DNR bracelet, either a plastic one (like a hospital bracelet) or a metal one you have to order from a third party. In Florida you get a card you can carry in your wallet or place on a keychain, and California has a medallion you can wear (or choose not to wear). It seems there are as many methods of letting medical workers know of a patient’s DNR wishes as there are states. Learn more about your state’s DNR requirements.

What About a DNR Tattoo?

In early 2017, an unconscious gentleman with a high blood alcohol level was brought to a hospital in Florida with a “Do Not Resuscitate” tattoo on his chest. It gave emergency room workers pause, and they set about trying to find out if he had a directive on file. They also went to their ethics department for their input. Faced with a decision, the hospital’s ethics department decided to honor his tattooed wishes and resuscitative efforts were ceased. The man passed away. By using the man’s fingerprints, his Florida Department of Health “out-of-hospital” DNR order was eventually discovered, which backed up his tattooed request.

Author Casey Quinlan went as far as to get a QR code tattoo on his sternum which, when scanned, not only links to his advance directive form, but also his health history, medication record, allergies, emergency contact, primary care MD info, and insurance info. To be sure there was no mistake about what it was, the words “Scan Before Treatment” are tattooed around the outside of the QR square, and the password is at the bottom. Fairly brilliant as long as EMS knows what a QR code is and how to use it. It also requires an exceptionally skilled tattoo artist to get the proportions exactly right so it is read correctly.

Unfortunately, in almost every state, tattoos like these will probably cause more confusion among treatment staff than a clear directive.

What’s a Better Option Than a Tattoo?

Luckily, there are ways to prepare yourself so that your wishes are followed even if you’re not conscious and able to communicate them yourself.

Research: If you are committed to not receiving CPR or intubation, check out your state’s DNR laws. Ask your doctor for the form and talk with him or her about what it covers and what it doesn’t.

Indicate: Make sure you have the jewelry you might need (medallion, bracelet, anklet, etc.), or the card, or the form printed on your state’s designated colored paper.

Inform: It is recommended you tell your family members, friends, and those you can trust with the information about your DNR and explain why you have it so there is no confusion should an occasion arise where it would come into play.

The same is true of advance directives, and the more encompassing details they include about extraordinary life-saving methods. Some even include a section on organ donation so you can be specific about how you would like your remains used should you be in a vegetative state.

What About Bystander CPR?

Should bystanders who witness a sudden cardiac arrest be looking for a medical alert bracelet or necklace before performing CPR or sending someone to get an AED? The short answer is “no”. Good Samaritan laws protect bystanders from repercussions if they attempt a rescue on someone with a DNR order.

As mentioned earlier, sudden cardiac arrest requires quick action to save a life. By taking time to search a patient for DNR information, precious seconds are being wasted. If you open the patient’s shirt to begin CPR and see a DNR tattoo, it’s safe to go ahead and start CPR and AED use anyway.

Maybe in the future we will all have a way to let physicians and emergency workers know our wishes, regardless of where we are. Perhaps it will be a microchip in our arm, a card everyone carries, a scannable tattoo, or something nobody has even thought of as yet.

Let us know your thoughts in the comments. Would you get a DNR tattoo? What about a microchip?