"소생시키지마시요" Tattoo한 환자앞에서 의사들은 무용지불이 되고, 윤리위는 개인의사 존중하라하고, 결국 환자는...

길가던 사람이 갑자기 쓰러져 혼수상태에 빠졌다.  옆사람들의 도움으로 병원이 이송되여, 담당 의사가 치료할려고 가슴팍을 열었는데, 그곳에는 "소생시키지 마시요"라는 문구가 Tattoo되여 있었다.  의사들은 결정을 못하고, 시간은 촉박해 오고...

이럴경우 사람들의 의견은 거의 반반씩으로 갈리는것 같다.  법의 판단을 기다려 그결정에 따라 의사들이 응급처지 하기에는 시간이 오래걸려, 별로 실효성이 없어 보여서 이또한 깊은 딜레마에 빠지게 한다.  

윤리위원회(Ethics Consultants)에서는 다음과 같이 조치하도록 조언해주고있다.

환자의 상태를 조사한후, 윤리위원들은 Tattoo에 표시된데로 환자의 뜻을 존중해주는게 우리의 할일이다.  또 윤리위원들은 타투에서 나타난 뜻이 진정원하는것으로 존중해줄 충분한 이유가 된다라고. 법집행은 때때로 사활을 헤매는 순간에 대한 초대의 관심사를 신속히 대응하지 못하는점이 있다는것도 주의해야할 사항일수도 있다고 본다.

의사들은 꺼져가는 생명을 회생시키고, 환자를 건강하게 치료해주기위해 수년간 어려운 공부를 해서, 의료기관에서 항상 대기하고 있는 전문인들이다. 

민주주의 사회에서 개인의 자유와 인격을 존중해주는것을 Freedom의 기본으로 알고 살아가는 사회이기에,  생명을 잃어버릴수 있는 순간에도, 당사자의 의견을 존중해 주는것이 도리인것으로 일반화 되여 있기에.... 생명을 연장시키는것 보다 더 우선순위라고 한다니....   세상은 참으로 복잡하다.  오직 신(God)만이 아실텐데.... 아쉽게도 신의 목소리를 들을수 없는게 우리 인간의 딜레마다. 

미국의 Miami에서 일어난 의료사건에 대한 기사 내용이다.

Doctors in Miami faced an unusual ethical dilemma when an unconscious, deteriorating patient was brought into the emergency room with the words “Do Not Resuscitate” across his chest.

The 70-year-old man was taken earlier this year to Jackson Memorial Hospital, where doctors made their startling discovery: a chest tattoo that seemed to convey the patient's end-of-life wishes. The word “Not” was underlined, and the tattoo included a signature.

It left the medical team grappling with myriad ethical and legal questions.

Was it an accurate representation of what the patient wanted? Was it legally sound? Should they honor it?

The case was detailed Thursday in the New England Journal of Medicine, in a report that laid out the medical team's struggle for answers.

“This patient’s tattooed DNR request produced more confusion than clarity, given concerns about its legality and likely unfounded beliefs that tattoos might represent permanent reminders of regretted decisions made while the person was intoxicated,” the paper's authors wrote.

Gregory Holt, a critical-care physician and lead author of the paper, said in an interview that “I think a lot of people in medicine have joked around about getting such a tattoo — and then when you finally see one, there's sort of this surprise and shock on your face. Then the shock hits you again because you actually have to think about it.”

[‘Damaged for the rest of my life’: Woman says surgeons mistakenly removed her breasts and uterus] 

Holt said the patient, who had a history of pulmonary disease, lived at a nursing home but was found intoxicated and unconscious on the street and brought to Jackson Memorial.

He arrived with no identification, no family or friends, and no way to tell doctors whether he wanted to live or die.

Holt said the man had an infection that led to septic shock, which causes organ failure and extremely low blood pressure.

When his blood pressure started to drop, emergency room doctors called Holt, who specializes in pulmonary disease — and they first agreed not to honor the tattoo, “invoking the principle of not choosing an irreversible path when faced with uncertainty,” according to the case study.

They gave the man intravenous fluids, antibiotics and blood-pressure medication to buy themselves more time to make the life-or-death decision.

The medical team used a breathing mask on the man, Holt said, but struggled the most with the decision to hook him up to a machine that would breathe for him.

“We had a man I couldn't talk to,” Holt told The Washington Post, “and I really wanted to talk to him to see whether that tattoo truly reflected what he wanted for his end of life wishes.”

[Doctors thought a woman had cancer — but it was just a reaction to an old tattoo] 

Doctors treating the elderly patient knew of “a cautionary tale” published in 2012 in the Journal of General Internal Medicine. That paper told of a 59-year-old patient who had a “D.N.R.” tattoo across his chest but said he wanted lifesaving measures to be taken, in the event that he needed them.

When the patient was asked why he had the tattoo, he told doctors he had “lost a bet playing poker,” according to the report.

When outside of hospitals, Florida requires do-not-resuscitate orders to be printed on yellow paper and signed by a physician and the patient, or a surrogate. But inside the hospitals, doctors can talk to a patient, or the patient's family and friends to determine what the end-of-life wishes are.

Since the patient was unconscious and doctors at Jackson Memorial had never seen a DNR tattoo, they called an ethics consultant to discuss the legal and ethical issues.

Holt said the consultant determined doctors could presume the tattoo was an accurate reflection of the patient's wishes.

According to the case study:

After reviewing the patient’s case, the ethics consultants advised us to honor the patient’s do not resuscitate (DNR) tattoo. 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.

In any case, social workers were later able to track down the man's proper DNR paperwork, leaving doctors relieved, Holt said.

The man, who was never publicly identified, died the next morning.

Arthur Caplan, a professor of bioethics and head of the division of medical ethics at the New York University School of Medicine, said there are no legal penalties for ignoring a tattoo that instructs medical personnel not to resuscitate.

On the other hand, he said, letting a patient die without the legal documents to back it up could pose a problem.

“The safer course is to do something,” he said. But, he added, he did not consider the doctors' decision risky because doctors routinely have to make difficult decisions in an instant.

Still, Caplan said a DNR tattoo is not a substitute for an advance health-care directive, or living will.

“A tattoo, I think, is best seen as a way to alert medical staff to your wishes or trigger an inquiry to family and friends and partners: ‘Is that what he meant?’” he said, adding that patients should keep the actual document in a pocket or wallet. “It’s useful to back up a living will or an advanced directive.”

Caplan said patients should also make sure their families and friends are aware of their wishes. If a family member or friend calls 911, he said, the emergency medical technicians are going to resuscitate the patient.

“If you trigger the emergency response system, I’m going to say it’s pretty darn likely you’re going to get resuscitated — I don’t care where your tattoo is,” Caplan said.

Holt, the doctor at Jackson Memorial, said his patient's tattoo seemed like a serious request, and doctors honored it.

“It also seemed that he didn't trust that his end-of-life wishes would be conveyed appropriately,” he said of the patient. “So, to me, it means we need a better system.

“We need a better system for people to be able to convey their wishes — if these are their wishes — so that we don't do things to them that they don't want, like in the throes of an emergency when a man like this comes into the emergency room unconscious.”

An earlier version of this story incorrectly suggested that Florida requires all do-not-resuscitate orders to be printed on yellow paper, both inside and outside of hospitals. The post has since been updated.

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https://www.washingtonpost.com/news/to-your-health/wp/2017/12/01/a-man-collapsed-with-do-not-resuscitate-tattooed-on-his-chest-doctors-didnt-know-what-to-do/?hpid=hp_no-name_hp-card-national%3Ahomepage%2Fcard&utm_term=.7f84b9e8f740