Ethical dilemmas in the acute setting: a framework for clinicians

A 22 year old woman presented to a district general hospital with an overdose of tramadol and paroxetine. She was morbidly obese with a body mass index of 51. She had been admitted to the hospital’s accident and emergency department several times previously for deliberate self harm and had required surgery to remove foreign bodies from her abdominal wall. After treatment for the overdose, the patient was discharged with community psychiatric follow-up. Roughly 30 minutes after discharge, while still in the hospital grounds, she poured lighter fluid over her head and neck and set herself alight. Spotted by nearby paramedics, she was readmitted with 15% mixed depth burns to the head and neck. As the clinical signs suggested a serious airway injury, she was intubated, admitted to the intensive care unit for an overnight stay, and transferred to a regional burns centre the following day.

On admission to the burns unit, she had the burnt skin removed and a surgical tracheostomy. It was during the scrubbing and excision of the burnt skin that the theatre team spotted a tattoo under the dressings (figure⇓). In a prominent place on her chest, the tattoo read “DNR, do not resuscitate.” No advance directive was found in the patient’s notes. This unexpected discovery triggered a debate among the team in the operating room. After discussing the possible options, the team proceeded to initiate further resuscitative treatment on the grounds of “best interests.” The rest of the patient’s stay in intensive care was uneventful and she was eventually discharged to a psychiatric care facility.