Issue 8 / 11 March 2013

THE Minister for Mental Health and Ageing Mark Butler last year told of witnessing a man rip off his shirt to expose a “Do Not Resuscitate” tattoo emblazoned across his chest.

He said a woman in Darwin had boasted of the same tattoo, similarly placed, who claimed that on her back was tattooed “PTO”.

It seems the increasing penetration of tattoos into mainstream society has thrown up an unexpected option patients may want to discuss with their doctors — medical tattoos.

Medically motivated body art seems to come in two flavours — alerts and advance directives.

Those who have them laud tattooed alerts as a never-to-be-lost alternative to the traditional medical alert bracelet.

While they won’t be for everyone, I suppose they are at least an option if a patient’s condition is likely to have them fall unconscious and their care could be aided by treating doctors knowing about it early.

In the Diabetes Queensland newsletter it was argued that a medical tattoo was at least worth thinking about. It seems a logical solution for a young person with diabetes prone to hypoglycaemic attacks.

However, anyone seriously considering such a tatt would need to give careful thought to its placement and design. While a medical bracelet is likely to be noticed, a faded, stylised allergy warning, even if placed on the wrist, could easily go unheeded in the hubbub of resuscitation.

On balance, I’d stick with the locket and chain.

Tattooed advance directives probably aren’t a good idea either.

While there is no doubt that finding “DO NOT DEFRIBRILLATE” printed between the nipples in 40 point copperplate would give any early responder cause for hesitation, script like that cannot and should not be seen as an actual advance directive.

Many states stipulate forms on which advance directives must be made and common law demands that while an advance directive must be respected, it also must be “clear and unambiguous”.

This was the ruling in a NSW Supreme Court case involving an unconscious man who had an advance care directive. “If an advance care directive is made by a capable adult, and is clear and unambiguous, and extends to the situation at hand, it must be respected”, the judgment said.

An inked DNR may be clear and unambiguous but there will usually be reasonable doubt about its relevance depending on the situation a patient might find themselves in.

Unless your patient is prepared to give up most of their epidermis to a lengthy indelible document detailing their future desires, I’d suggest a better move would be a bracelet directing medical personnel to a written document.

There are still many drawbacks to using body art as a medical instruction.

Dr Christopher Ryan is the director of consultation-liaison psychiatry at Sydney’s Westmead Hospital and an honorary associate of the University of Sydney’s Centre for Values, Ethics and Law in Medicine, where he is the program director of the mental health and psychiatry stream.

Posted 11 March 2013

3 thoughts on “Christopher Ryan: Trouble with tatts

  1. Michael Eburn says:

    Christopher Ryan says:
    Many states stipulate forms on which advance directives must be made and common law demands that while an advance directive must be respected, it also must be “clear and unambiguous”.
    That is not correct. Many states provide forms upon which advance directives may be made, but do not require that the form be used and further, specifically state that a person’s pre-existing, common law rights remain in force (see Powers of Attorney Act 1998 (Qld) s 39; Guardianship and Administration Act 1995 (Tas) s 48A; Medical Treatment Act 1994 (Vic) s 4; Guardianship and Administration Act 1990 (WA) s 110ZB; Medical Treatment (Health Directions) Act 2006 (ACT) s 6; Natural Death Act 1988 (NT) s 5; The Consent to Medical Treatment and Palliative Care Act 1995 (SA) does not have an express saving provision but neither does it say that a directive under s 7. Further the South Australian Act only applies to decisions that may be relevant if the patient is “in the terminal phase of a terminal illness, or in a persistent vegetative state” and a person may want to refuse treatment in other circumstances, in which case the Act is not relevant).
    New South Wales does not have relevant legislation but the right of a patient to refuse treatment was affirmed by the NSW Supreme Court that said:
    “… the analysis should start by respecting the proposition that a competent individual’s right to self-determination prevails over the State’s interest in the preservation of life even though the individual’s exercise of that right may result in his or her death… It is necessary to bear in mind that not all those who execute advance care directives are legally trained. … the court must feel a sense of actual persuasion that the individual acted freely and voluntarily, and intended his or her decision to apply to the situation at hand.” (Hunter and New England Area Health Service v A [2009] NSWSC 761, [37].
    If it comes to CPR it is not a court but a doctor or paramedic that will need to make the decision, but having “”DO NOT DEFRIBRILLATE” printed between the nipples in 40 point copperplate” would not leave much room to doubt that the person acted freely and voluntary and intended that direction to apply in the circumstances where defibrillation may be required.
    When summarising the applicable principles McDougall J said
    “A person may make an “advance care directive”: a statement that the person does not wish to receive medical treatment, or medical treatment of specified kinds. If an advance care directive is made by a capable adult, and is clear and unambiguous, and extends to the situation at hand, it must be respected. It would be a battery to administer medical treatment to the person of a kind prohibited by the advance care directive.” Hunter and New England Area Health Service v A [2009] NSWSC 761, [40].
    If carrying a card was sufficient in Malette v Shulman (1990) 67 DLR (4th) 321 it is hard to see how “Do not defibrillate’ tattooed on the chest could be anything other than ‘clear and unambiguous’ and extending to the situation at hand if in fact the patient requires defibrillation. If, somehow, they intend their direction to be limited in some say, but still have the tattoo applied, the risk that the tattoo will be acted on rests with the patient.

  2. Jim Friend says:

    The rumour was, a couple of generations ago, that a well regarded Sydney neurologist had tattooed on his scalp: “If I am found unconscious in the street, do not let (X– Y–) operate on me.” X– Y– (not his real initials) was a neurosurgeon who was less well regarded.

  3. james gillop says:

    As a doctor in the Royal Navy it was normal practice for royal marines to tattoo their blood group on the right shoulder. Sailors choices of tattoos tended to be more exotic.
    One generation later I find myself doing minesite medicals. Recently I found the nurse to have written ‘no tattoos or piercings’ in the patients notes, so rare has this phenomenon become!

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