While the majority of my work is assisting with the living process, these past few week has been occupied with planning for the dying process.
I am currently working with two wonderful ladies who have both been assigned palliative care physicians. One who is lucky enough to be home and the other is currently in the hospital. One had been recovering from a catastrophic stroke and was sent home and the other went into the hospital with stomach pain and required emergency surgery. At age 94, surgery is never elective; and while the surgery in itself was successful, her organs did not respond well and her kidneys have started to shut down.
The determination process deciding how we live until we die has now occurred with both families. The conversation was led by the palliative physicians and it was a discussion about goals and choice.
The consideration is between life determining intervention (i.e. CPR) and comfort care. The issue of signing a Do Not Resuscitate order was discussed and decided in both of these situations.
Do you remember the newspaper article last year that read: ‘A Florida man collapsed with a ‘Do Not Resuscitate’ tattoo. Doctors didn’t know what to do’.
The full article in the New England Journal of Medicine described doctors in Miami who found themselves caught in what they describe as an usual ethical dilemma. Reportedly, an unconscious man was brought to the ER with a chest tattoo that read ‘DO NOT RESUSCITATE’; his signature was underneath. He did not have any identification or family with him. The doctors initially decided not to honor his wishes ‘invoking the principle of not choosing an irreversible path when faced with uncertainty.’ The ethics team advised them to honour his tattoo as “they suggested that it was most reasonable to infer that the tattoo expressed an authentic preference, that what might be seen as caution could also be seen as standing on ceremony, and that the law is sometimes not nimble enough to support patient-centered care and respect for patients’ best interests.” The DNR order was signed. Subsequently the hospital was able to locate a copy of his Florida Department of Health, DNR order which was in keeping with the tattoo. The gentleman passed away that evening.
The NEJM article concludes “this case report neither supports nor opposes the use of tattoos to express end-of-life wishes when the person is incapacitated.”
A professor of bioethics, Dr. Arthur Caplan opined that the DNR tattoo is not substitute for an advance health-care directive. He recommends keeping the actual document in your pocket or wallet.
Most of us don’t want to think about this dying process and if we had, we do not carry this document around with us. In Ontario we do not have a central registry. I am not sure why it cannot be part of our OHIP record. Quebec is the only province that does have a central registry. I have previously blogged about the Alberta ‘Green Sleeve’ program and gains they had made in having doctors spend time with their patients reviewing and discussing issues/concerns.
It seems pretty clear to me having instructions tattooed on one’s chest should be a clear message. However, until practice, policy and the law are consistent, we can and should start with having the conversation with our loved ones.