When an unconscious patient shows up at the hospital with a “Do Not Resuscitate” tattoo, the medical staff needs to determine what to do next. Do they follow the patient’s tattooed request, or do they proceed with life-saving measures?
The answer remains a hotly debated issue in the medical community. While nonstandard advanced healthcare directives may seem obvious to the patient, they leave more questions than answers for medical staff. As care providers who have the most direct patient contact, nurses face a complicated array of decisions when it comes to end-of-life orders.
“Patient advocacy is often at the top of a nurse’s list when providing patient care, as it should be. Following a patient’s wishes is certainly one of the most important forms of patient advocacy. While many medical providers would be quick to say that this type of tattoo should be followed, we need to dig deeper to determine what is truly in the patient’s best interest,” attorney John A. Musacchio said on the Washington State Nurses Association website.
As clinical and administrative leaders, registered nurses (RNs) who have earned doctor of nursing practice (DNP) degrees are responsible for ensuring that staff nurses understand DNR orders and how to go forward. Part of being an effective nurse manager is understanding, and possibly drafting, a facility’s DNR tattoo policy for all nurses to follow.
The DNR Explained
When a DNR order is placed in a medical record, healthcare personnel know that CPR should not be attempted. Ideally, patients have the orders on file in the hospital or medical center to make their wishes known in advance of an emergency.
The DNR does not mean that the patient will not be treated, which is a common misconception. Instead, it simply means CPR should not be attempted. Medical personnel can administer life-saving measures such as dialysis and feeding tubes. They may try other treatments that can prolong life and keep the patient free of pain.
In an effort to clarify patient wishes, several states have adopted new directives including medical orders for scope of treatment, or MOST, and physician orders for life-sustaining treatment, or POLST. However, the DNR remains the most popular choice for patients to let medical personnel know their wishes. One way that patients have been expressing their DNR wishes is by having the letters tattooed on their bodies.
Tattoo You
Most frequently, a DNR tattoo raises more questions and concerns than it answers. Take, for example, the case of a 70-year-old man who was rushed to a South Florida emergency room when he fell unconscious. While administering medical treatment, the healthcare professionals saw “Do Not Resuscitate” and his signature tattooed on his chest. Recognizing that the tattoo was not legal documentation, the medical staff disregarded the DNR.
Musacchio, in his Washington State Nurses Association statement, said the staff did the right thing because the intent of the tattoo was not clear. The hospital later obtained a copy of the patient’s formally executed DNR and followed through on the patient’s wishes.
Musacchio said the best practice for all nurses is to seek guidance from a supervisor or department leader when unsure.
“Nurses should also be familiar with their facilities’ internal policies and procedures with regard to the use of patients’ advance directives,” he said.
In fact, nurses must play a leading role in clarifying uncertainty around the patient’s plan, David G. Glenn, RN, MS, said in “Nurses Must Lead Care Team in Interpreting DNR Orders.”
“The most important role for nurses is to assess the patient’s wishes for, and understanding of, the overall plan of care,” Glenn said. “Because the nurse spends a great deal of time at the bedside, the nurse may be the person most likely to notice discrepancies between the patient’s and the physician’s understanding of the plan of care.”
DNP-Educated Nurses Making DNR Decisions
As experts in evidence-based nursing and members of senior management, DNP-educated nurses who work in hospitals and medical centers may be faced with determining the intent of a DNR order or tattoo. In deciding, DNP-educated RNs must turn to their advanced training in ethics, leadership and clinical practice.
With coursework in management, policy, ethics and evidence-based practice, RNs who have earned DNP degrees play a crucial role in organizational decision-making. At Duquesne University, the online DNP program prepares RNs to innovate care programs that impact patients and medical communities. They are also positioned to implement training programs to help staff nurses better understand DNR orders.