And now for a question to move away from fires. Today’s correspondent is
… at a point of my life where, due to illness, I could die anytime, anywhere. I do not want to get resuscitated and plan to put a DNR order in place. My question is, how would anyone know about this order if they find me laying somewhere? how would the ambulance know? would they not start resuscitation before trying to find out who I am and if I may have such an order in place?
That is indeed a complicated question as a search of the terms “DNR”, “withholding” or “communicating” on this blog site will show. Any one of those searches will bring up multiple posts from people concerned about how to communicate their wishes and from first aiders and paramedics concerned about how they will know what they are to do.
I think the starting point on this question (which is not the question about what makes a valid refusal, but how to communicate it) is the Canadian case of Malette v Shulman (1990) 67 DLR (4th) 321. Ms Malette was a Jehovah’s witness who carried a card saying she did not want a blood transfusion under any circumstances. The court said the treating doctor should have honoured that even though it meant she would have died. Robins JA said:
I do not agree… that the Jehovah’s Witness card can be no more than a meaningless piece of paper. I share the trial judge’s view that, in the circumstances of this case, the instructions in the Jehovah’s Witness card imposed a valid restriction on the emergency treatment that could be provided to Mrs. Malette and precluded blood transfusions.
Robins JA found that she had:
… chosen in the only way possible to notify doctors and other providers of health care, should she be unconscious or otherwise unable to convey her wishes, that she does not consent to blood transfusion…
So the answer is to find a way to communicate that wish. I think a tattoo across the chest that says “Do not perform Cardio-Pulmonary Resuscitation” would be clear and should be honoured but I know that many who read this blog disagree and would be unwilling to honour that direction. See
- More on DNR tattoos (January 30, 2018);
- Withholding resuscitation in first aid (November 21, 2017);
- ‘Medical tattoos offer important health information’ (March 3, 2012).
- ‘Do-not-resuscitate tattoos: What’s a doctor to do?’, Radio National, Monday 29 January 2018).
Like Ms Malette’s card it would be a way, even if not the only way, ‘to notify doctors and other providers of health care, should she be unconscious or otherwise unable to convey her wishes, that she does not consent to’ CPR.
Another way is a medic-alert bracelet, but again some are reluctant to accept that – see Ignoring a medic-alert bracelet (July 19, 2015)).
When a family member of mine was terminally ill we found that there was a process to record the DNR order with NSW Ambulance so that if an ambulance was called to their home, the coordination centre could advise, and the paramedics understood, that they were terminally ill and could treat accordingly (see Withholding treatment from a patient in palliative care (November 19, 2019)). That process may not work if the sudden cardiac arrest happens outside the home because the order was linked to an address. There would be no way to link the order to a call to a person collapsed away from their home. It would not be possible or reasonable to require paramedics to check back with coord, when they find a patient’s name, to see if there is any recorded DNR order linked to that name nor could they be sure that the patient they are treating is the same person for whom the DNR order has been recorded.
Ultimately there is no easy or guaranteed way to ensure that ‘anyone [would] know about this order if they find me laying somewhere’. That’s true whether the ‘anyone’ is a good Samaritan or a paramedic. And yes one would expect that the paramedics (and others) would start resuscitation and if you are away from home have no way of trying to find out ‘who I am and if I may have such an order in place’.
Conclusion
The best that can be done is to find a way ‘to notify doctors and other providers of health care, should [you] be unconscious or otherwise unable to convey [your] wishes…’ As I say I think an unambiguous tattoo should be enough, but I doubt it is. The other would be, depending on the state or territory in which you live, to work with your treating doctor (see Asking for a DNR order (August 24, 2019)) to get an order formally documented in accordance with the terms of the legislation (if any) in your state or territory, and carry a copy in your pocket – perhaps along with a medic alert bracelet and a tattoo directing people to it.
If you collapse in the street you can still expect that a good Samaritan bystander is going to start CPR because it is simply too much to expect them to deal with those issues, but paramedics and then doctors at hospital may be willing to terminate treatment even if others have started it.
Australian Emergency Law 
Isn’t part of the issue (in honoring a DNR order that is tattooed on a person) whether or not that person was competent when the order was made? Were they drunk, drug affected etc? This may have been what they wanted when the tattoo was made, but is it what they want now? There is no easy way to determine this. As you’ve indicated, the major part of the issue is associated with the communication of a person’s wishes to the family of that person in the event that something happens. In Victoria, the purpose of the Medical Treatment Planning and Decisions Act is to do precisely this.
I’ve addressed all those issues in the posts on tattoos linked from this post and I’d urge you to read them. These were also the arguments made by the doctor in Malette’s case. The court there said that ultimate responsibility lay with her if she carried a card in her wallet. Equally a person could get line tattooed through a tattoo on their chest if they want to. The fact you ask these questions is why I say “I think a tattoo across the chest that says “Do not perform Cardio-Pulmonary Resuscitation” would be clear and should be honoured but I know that many who read this blog disagree and would be unwilling to honour that direction.”
Indeed the Medical Treatment Planning and Decisions Act is there to facilitate communication that is why I said probably the best response is to get an order in accordance with legislation and carry it with you.
Thank you for your answer, it provided clarity about the situation. I live in Queensland. Having read your suggestions, I will see my GP and arrange such an instruction form and I will discuss advance care directive. In addition, I will inform my family and friends once this order is in place. I believe just telling them is not good enough. Do you know where one could obtain such a card, which may be more likely to be accepted than one I make myself?
When you speak to your doctor he or she will be able to give advice on the documents prescribed by the legislation and whether there is an official card (and I don’t think there is).
Many thanks again. When one has become more fragile these issues can become overwhelming and clarity through your answers certainly have helped.