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Table of Contents
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
13c* Do Not Resuscitate
Scenario 1
An unconscious patient is admitted into the hospital in cardiac arrest. Across the patient’s chest is tattooed: Do Not Resuscitate. There is no living will or durable power of attorney on record, and no surrogates are available. What does the medical practitioner do?
Scenario 2:
An unconscious patient is admitted into the hospital in cardiac arrest because of attempted suicide. Written with a Sharpie all over the patient’s body is Do Not Resuscitate! There is no living will or durable power of attorney on record, and no surrogates are available. What does the medical practitioner do?
A. Comply with the patient’s wishes and do not provide CPR.
B. Get a court order.
C. Get an ethics consultation.
D. Provide CPR.
TAC: Think - Assess - Conclude
I. Think: What is the question?
[C13:3] Does a tattoo or Sharpie written on a patient’s body represent a legitimate form of informed consent?
II. Assess: Specify & Balance the four principles of bioethics
Patient: 1) Autonomy - Inform Consent
[C13:4] In the first scenario, one would think that getting a tattoo would not be done without some careful and thoughtful consideration. However, there has probably been a case or two where this has not been the case. There is also no knowledge of when the person got the tattoo and whether or not the patient still holds to that supposed conviction. Nor is there any knowledge as to whether or not the patient had decision-making capacity when getting that tattoo.
[C13:5] In the second scenario, DNR has been written with a Sharpie all over a patient’s body. Certainly, it is clear that the writing on the body is very recent and, therefore, might be what the patient wants. However, there is no knowledge of whether or not someone wrote it on the patient as a joke, or maybe even because of malice. There is also no knowledge of whether or not the patient had decisional capacity if and when the patient wrote DNR on their body with the Sharpie.
[C13:6] Regardless, this is an emergency with the patient in cardiac arrest, so autonomous informed consent is by definition not possible under these conditions.
Practitioner: 2) Beneficence & 3) Nonmaleficence
[C13:7] The professional obligations of beneficence (do good) and nonmaleficence (do no harm) require that practitioners in emergencies conduct treatments as directed by medical best practices. In both scenarios, that would be the performing of CPR.
Public Policy: 4) Justice
[C13:8] The state has an interest in the protection and well-being of its citizens. Under emergencies where autonomy is impossible, the state encourages its citizens to help each other in need. This is evidenced by Good Samaritan laws which provide legal protection for aiding others with reasonable assistance.
[C13:9] Both scenarios indicate that medical standards of care would be to provide CPR.
[C13:10]
III. Conclude: Nationally or Professionally True Answer
[C13:11] Provide CPR to both patients.
Answer Options: [C13:12]
(Choice A) Comply with the patient’s wishes and do not provide CPR.
A is wrong because both the tattoos and the Sharpie written on the body is not a legal document, nor is it morally valid informed consent. There is also no way to determine if the patient had decisional capacity in either scenario or if the patient was the one who wrote with a Sharpie on themselves.
(Choice B) Get a court order.
B is wrong because this is an emergency, and there is no time to get a court order.
(Choice C) Get an ethics consultation.
C is wrong because this is a medical emergency and there is no time to get an ethics consultation. It is also important to understand that ethics consultations can only provide a recommendation for what ought to be done, and they do not have the authority to provide a decision. Ethics consultations are relevant for building consensus, for example, when multiple family members acting as surrogates disagree with each other on what the patient would have wanted.
(Choice D) Provide CPR.
D is correct as based on beneficence, nonmaleficence, and justice.
***
Assessment
TATTOO
SHARPIE
Principles
NO
CPR
NO
CPR
CPR
CPR
NA
NA
NA
NA
Autonomy
X
X
X
Beneficence
X
X
X
Nonmaleficence
Justice
