A DNR Tattoo? Really? Great Teaching Image for Geriatrics or Palliative Care

by: Alex Smith

Perhaps you have said, or heard someone declare, “I want DNR tattooed across my chest!”

Well, someone actually had it done. See this image in JGIM of the tattoo and the unusual story behind it. In this case, the DNR tattoo was the result of a lost bet in a drinking game – bad idea jeans – the patient actually wanted to be full code!

In an accompanying editorial, Bernie Lo and I describe the problem with actually tattooing DNR across your chest. As we say, the idea is intuitively appealing, but flawed as policy.

This could be used a teaching image about respecting individuals’ rights to avoid resuscitation. The idea is to provoke a thoughtful discussion. Questions for trainees could include:

  • What is behind the idea of the DNR tattoo? Why would someone say that, or do it?
  • Imagine you are seeing a new patient who arrests in front of you. Preparing to do CPR you see a DNR tattoo on the chest. How do you respond? Why? Should DNR tattoos be respected?
  • What can we do to protect the interests of people who really do not want to be resuscitated?
  • Should we as a society put greater ironclad protections in place for people to irrevocably fix their code status at DNR? What are the risks? What if someone codes from anaphylaxis? Chokes on some food in front of you?
  • What do you think about allowing leeway or flexibility in decision making? In all cases? Giving the surrogate leeway? The clinician? Do the advance directive forms or POLSTs you use allow for leeway? Should they?
  • What do you think about Ulysses contracts? (Then Ulysses said, “Eurylochus, come quickly! Tie me to the mast, for I shall hear the Sirens song and live!”). Caringadvocates offers such documents (run by frequent GeriPal commenter Stan Turman). Example: do not give me food or water when I have advanced dementia, no matter what I say or do.

Feel free to share your teaching experiences in the comments. I think the geriatrics and palliative care communities really appreciated the discussion about how to use this video from a previous post as a teaching tool.

Complete Article HERE!

Go Down, Death

Go Down, Death by James Weldon Johnson

Weep not, weep not,
She is not dead;
She’s resting in the bosom of Jesus.
Heart-broken husband–weep no more;
Grief-stricken son–weep no more;
Left-lonesome daughter –weep no more;
She only just gone home.

Day before yesterday morning,
God was looking down from his great, high heaven,
Looking down on all his children,
And his eye fell of Sister Caroline,
Tossing on her bed of pain.
And God’s big heart was touched with pity,
With the everlasting pity.

And God sat back on his throne,
And he commanded that tall, bright angel standing at his right hand:
Call me Death!
And that tall, bright angel cried in a voice
That broke like a clap of thunder:
Call Death!–Call Death!
And the echo sounded down the streets of heaven
Till it reached away back to that shadowy place,
Where Death waits with his pale, white horses.

And Death heard the summons,
And he leaped on his fastest horse,
Pale as a sheet in the moonlight.
Up the golden street Death galloped,
And the hooves of his horses struck fire from the gold,
But they didn’t make no sound.
Up Death rode to the Great White Throne,
And waited for God’s command.

And God said: Go down, Death, go down,
Go down to Savannah, Georgia,
Down in Yamacraw,
And find Sister Caroline.
She’s borne the burden and heat of the day,
She’s labored long in my vineyard,
And she’s tired–
She’s weary–
Do down, Death, and bring her to me.

And Death didn’t say a word,
But he loosed the reins on his pale, white horse,
And he clamped the spurs to his bloodless sides,
And out and down he rode,
Through heaven’s pearly gates,
Past suns and moons and stars;
on Death rode,
Leaving the lightning’s flash behind;
Straight down he came.

While we were watching round her bed,
She turned her eyes and looked away,
She saw what we couldn’t see;
She saw Old Death.She saw Old Death
Coming like a falling star.
But Death didn’t frighten Sister Caroline;
He looked to her like a welcome friend.
And she whispered to us: I’m going home,
And she smiled and closed her eyes.

And Death took her up like a baby,
And she lay in his icy arms,
But she didn’t feel no chill.
And death began to ride again–
Up beyond the evening star,
Into the glittering light of glory,
On to the Great White Throne.
And there he laid Sister Caroline
On the loving breast of Jesus.

And Jesus took his own hand and wiped away her tears,
And he smoothed the furrows from her face,
And the angels sang a little song,
And Jesus rocked her in his arms,
And kept a-saying: Take your rest,
Take your rest.

Weep not–weep not,
She is not dead;
She’s resting in the bosom of Jesus.

A 56-Year-Old Physician Who Underwent a PSA Test

Six years ago, after celebrating my 50th birthday, I chose to begin an annual ritual of having my prostate-specific antigen (PSA) level checked. I have been a practicing academic oncologist with a clinical practice that is devoted exclusively to prostate cancer for 25 years. I also have a PhD in health policy. My dissertation found that older men who are diagnosed as having prostate cancer are less likely to have complete staging evaluations and are also less likely to undergo a prostatectomy or radiation therapy as treatment.

At that time, my PSA level was 1.5 ng/mL (to convert to micrograms per liter, multiply by 1.0), raising some concern. One year later, I had my PSA level checked again; it was 2.5 ng/mL. I met with a urologist, a faculty colleague with whom I had collaborated on research, and requested a biopsy, which was performed 6 weeks later. I was anxious: did I have cancer? If so, what was my Gleason grade? How much tumor? I had treated hundreds of patients with prostate cancer and had seen thousands of prostate biopsy specimens, but now this was my biopsy. Two days later, I called the pathologist, another faculty colleague, anxious to hear the results. The slides had just finished processing. Would I want to look at the slides myself? I ran downstairs, sat at the microscope table with my friend, and together we were the first to see the cancer. Gleason 3 + 3 in 1 of 12 biopsy specimens, 5% of the gland, and no evidence of lymphatic, seminal vesicle, or extraprostatic involvement.

Now, what do I do? I had counseled hundreds of men with similar biopsy results. Most of the men my age had opted for surgery, a small number opted for radiation therapy, and a smaller number chose active surveillance. I chose to be an informed patient and got an opinion from leading medical, surgical, and radiation oncologists throughout the country. In the end, I decided to undergo a radical prostatectomy. My selected urologist was a national leader. I came away from a discussion with him believing that a prostatectomy, performed by him on a healthy person like me, would have an extremely low risk of sexual, bladder, or bowel dysfunction and 100% 20-year prostate cancer–specific survival. I chose surgery, viewing the risks as small and the benefits as great.

Fast forward 5 years: cancer free. However, as a result of the surgery, my right arm and right leg are permanently weak, with this deficit appearing immediately after surgery. The reasons for this outcome are unclear. My PSA level remains 0, but my daily 5-mile jog is no longer possible.

Where am I now on the PSA dilemma in light of the recent US Preventive Services Task Force recommendations? It is clear that prostatectomy results in a very high chance of 20-year prostate cancer–specific survival, but even when the procedure is performed by an expert urologist, it can also result in significant rates of sexual, bladder, and bowel dysfunction and other less common adverse effects, such as my weakness. Active surveillance with longitudinal PSA tests and physical examination is associated with very low rates of bowel, bladder, and sexual dysfunction and has a high probability of correctly identifying when to move from surveillance to treatment. If I could do it all over again, I would not undergo the surgery; instead, I would opt for active surveillance. Even the most informed patient (me in this case) has difficulty making a truly informed decision.

Complete Article HERE!

Mediation – Death vs Dying

— Nancy Meredith, November 1987

Death vs Dying
It’s not as if they are the same thing. Dying is still warm, still connected to life as we know it. Death is cold. Dying is letting go. Death is being gone. Death is something I don’t know anything about, except that embalmed bodies are poor representations of the people who once animated them. Neither is anything I like to think about. So I figure they are probably topics I should give some attention to, to try to write some of the feelings they engender.

If I Should Die Before I Wake
It was only recently that I realized how early I had lay me down to sleep. I began very late in life the struggle to wake up from the soft comfort of my habits and routines. It’s hard getting up out of a warm bed when you don’t know what the weather’s like outside.

Coming to Terms with Mortality
Thinking about my own death feels different from thinking about someone else’s, but both feel lonely. Both bring on a panicky “No! Not yet!” When I’m confronted with the death of someone who has touched my life, the feeling is that I should have done more, that there is unfinished business here. Guilt confused with feeling that we don’t always get dealt a fair hand.It’s easier to die symbolically than to be symbolically dead. I can imagine ways I mightdie, my reluctance to leave tempered with the need to comfort those I leave behind. There’s a bit of poignancy about it, bittersweet and loving. And I am still (somewhat) in control.But I have trouble going beyond dying to death. I am responsible for so much and so many right now. Who will do the work I’ll have left undone? Who will take care of the people I love and all the little things in my life to which I attach so much importance? Who will feed my cat? If I try this exercise long enough I sometimes experience a moment of clarity and a fresh perspective on what’s really important to do today, right now. But it’s never long before I tighten up with a renewed sense of urgency to do more, faster. When I notice reminders of my own mortality—a bleeding mole, tightness in my chest, recurring asthma—I inevitably resist. “No, not yet! I have too much to do!”

I don’t think I want to live forever. When I hear people speak of the immortality of the physical body as a viable option, I feel somewhat embarrassed, as I am by the part of the

Apostles’ Creed that avows belief in the resurrection of the body. My resistance to my own death seems to be not so much a reluctance to leave my body as an unwillingness to relinquish control. To trust that the people I love can get along without me very well.

Just Moving On
Dying must be a lot like moving from one place to another. I’ve said goodbye many times in my life. Life goes on—for me and for those I leave behind. But it feels lonely, especially at first, and the nostalgia for past lives never completely disappears.

A Taste of Humility
Raymond Kaiser observed that the bottom line about death is that sooner or later people are going to say “So what?” No matter how important you are in their lives right now, no matter how wonderful you are, they’re going to come to a place where they accept your


Mini-Deaths
absence and proceed with business as usual. Trying to experience how that feels is an exercise in humility. It defeats arrogance and renews trust in others and faith in the continuity of life.

Whenever I think of death—particularly my own—I feel lonely. On the other hand, all the dark, lonely times I create for myself are deaths of a kind. Whenever I allow myself to feel alone, detached from those around me, I am already, for a time, dead. I am saying No to life and embracing Not Life. Lately I’ve tried to bring the light of consciousness to these times, to experience them as mini-deaths, with the benefit of then being able to embrace life more fully. I emerge from the dark more sensitive to my connection with others in my life, more aware of their feelings, more caring about their needs. I am more present. Perhaps the value in practicing death is not so much to be able to die better, but to be able to live better.

Judgment
I don’t like death, and I cannot embrace it as “moving on to a better place.” I don’t like acknowledging its inevitability. I tremble before it. It constitutes, after all, a fall into the unknown. I recently signed up to be a Hospice volunteer. Maybe by helping others deal with imminent death—their own or that of someone they love—I can learn to look at death squarely and say, “So what?” but I don’t think I’ll ever like it.