病人昏迷，危在旦夕。拉开衬衫后却发现胸前刻有“拒绝心脏复苏术”的文身，那作为医生，是尊重患者意愿，还是保全生命为上？文身真的可以代表患者的最后意愿吗？文身的背后是对整个医疗体制的悲情控诉，还是患者的一时任性？患者的生命和意愿，究竟孰轻孰重？
一个文身引发的生死争议
作者：ED YONG
译者：徐嘉茵&王津雨
校对：邹世昌
编辑：赵萌萌
"We've always joked about this, but holy crap, this man actually did it."
“我们还总拿这个开玩笑，但我的天哪，这个人还真这么做了。”
本文选自The Atlantic | 取经号原创翻译
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Earlier this May, Gregory Holt had just finished doing the
morning rounds
at Miami's Jackson Memorial Hospital, when he got a call about a new patient in the emergency room. He went down with seven colleagues to find an unconscious 70-year-old man with breathing problems and signs of
septic shock
. He was alone and had no identification. His blood was full of alcohol, and its pressure was dropping. And when the doctors peeled back his shirt, they found a tattoo, running along his collarbones.
在今年五月初，迈阿密杰克逊纪念医院中，格列高利·霍尔特刚结束
晨间查房
，就接到呼叫，急诊室新接收了一位患者。霍尔特和七个同事一起下楼，找到了这位昏迷的七十岁老人。他呼吸困难、出现了
败血性休克
迹象；而且独自一人，没有可证明身份的信息。另外，他的血液酒精浓度很高，血压正在下降。但医生们掀开他的衬衫时，却发现锁骨那儿有个文身。
It said: DO NOT RESUSCITATE.
上面写着：拒绝心肺复苏术（后文简称DNR）
The NOT was underlined. There was a signature under the final word.
“拒绝”还被划了下划线，心肺复苏术一词下面还有患者的签名。
Holt was shocked. "We've always joked about this, but holy crap, this man actually did it," he says. "You look at it, laugh a little, and then go: Oh no, I actually have to deal with this."
霍尔特感到震惊。“我们总拿这个开玩笑，但我的天哪，这个人还真这么做了，”他说，“看着这个文身，轻轻地笑一下，然后转身离开：不行，我必须处理这种情况。”
By default, doctors would treat patients in this man's condition as if they were "full code"—that is, they'd want everything possible done to prolong their life. "When faced with uncertainty, you pick the choice that's not irreversible," Holt explains. "So let's do everything we can and when the dust settles, we can determine what the patient wanted if it wasn't clear from the beginning. The tattoo
threw a monkey wrench into
the decision.”
在默认情况下，医生会全力抢救类似的患者——也就是说，他们会尽一切可能去延长患者的生命。“面对不确定性的时候做选择，需要留有余地，”霍尔特解释道，“所以，我们先尽己所能抢救吧，如果在一开始患者意愿并不明确，等尘埃落定之后，我们可以再据此作出决定。这个文身
打乱
了我们的决定计划。”
In Florida, patients can ask not to be resuscitated by filling in an official form and printing it on yellow paper. (Yes, it has to be yellow.) Only then is it legally valid. Clearly, a tattoo doesn't count. And yet, the patient had clearly gone through unusual effort to make his wishes known. The team members debated what to do, and while opinions differed, "we were all unanimous in our confusion," says Holt.
在佛罗里达州，患者可以通过填写正式表格并用黄纸打印出来，从而要求不接受心肺复苏术。（是的，纸张必须是黄色的。）只有这样才合法有效。显然文身并不算数。然而，上述案例中的患者很明显已通过文身这种不寻常的举措来让别人知晓他的意愿。医疗团队成员为应该采取什么措施而争论不休，不过，尽管意见不一，“但我们都感到很困惑”，霍尔特说道。
unanimous
/juː'nænɪməs/ adj. When a group of people are unanimous, they all agree about something or all vote for the same thing. 一致同意的
They decided to temporarily ignore the tattoo, at least until they could get advice. In the meantime, they gave the man basic treatments—
antibiotics
, an
IV drip
, an oxygen mask to help him to breathe, and
adrenaline
for his plummeting blood pressure. But they avoided putting a tube down his throat and hooking him up to a ventilator. "It would have hurt to see a man with a DNR tattoo having a
tracheal tube
hanging out of him," Holt says.
他们决定，至少在得到建议之前，先暂时无视这个文身。同时，他们对患者进行了基础治疗——注射
抗生素
、进行
静脉滴注
、佩戴氧气罩辅助呼吸、注射
肾上腺素
以阻止血压继续急速下降。但他们没有插喉管连接呼吸机。“看着一个有着DNR文身的人身上插着
气管导管
，实在太伤感情了。”霍尔特说道。
All of this bought them enough time to get a hold of Ken Goodman, the codirector of the University of Miami's ethics programs. "My view was that someone does not go to the trouble of getting such a tattoo without forethought and mindfulness," Goodman says. "As
unorthodox
as it is, you do get a dramatic view of what this patient would want."
这些治疗给他们争取到了足够的时间，去联系迈阿密大学的伦理学项目主任肯·古德曼。“我的观点是，一个人要是没有经过深思熟虑，是不会不嫌麻烦弄这么个文身的，”古德曼说，“这件事情如此
另类
，你们确实需要认真审视这位患者的意愿。”
unorthodox
/ʌn'ɔːθədɒks/ adj. If you describe someone's behaviour, beliefs, or customs as unorthodox, you mean that they are different from what is generally accepted. 非正统的; 另类的
But tattoos are permanent and desires are fleeting, so the team pondered whether the words actually represented the man's desires. And there's good reason to be cautious. Back in 2012, Lori Cooper at the California Pacific Medical Center was caring for a (conscious) patient who was going to have a leg amputated, when she noticed a "DNR" tattoo on his chest. The man revealed that he got the tattoo after losing a poker bet many years ago, and actually, he would very much like to be resuscitated if the need arose. "It was suggested that he consider tattoo removal to circumvent future confusion about his
code status
," Cooper wrote. "He stated he did not think anyone would take his tattoo seriously and declined tattoo removal."
然而，文身恒久远，意愿本无常，所以医疗团队仔细思量了DNR是否切实代表着该患者的意愿，而且他们有充分理由保持谨慎。2012年，加州太平洋医疗中心的洛丽·库珀在照顾一位（意识清醒的）即将接受截肢的患者时，注意到患者胸口有一个DNR文身。该男子透露，这个文身是他在多年前输掉一场扑克赌博后刺的，而其实如果需要的话，他还是特别想要心肺复苏术的。库珀记录道：“有人建议过该男子考虑去掉文身，以避免别人对他
是否愿意被抢救
产生困惑。但他表示之前以为不会有人把文身当真，所以拒绝将其洗掉。”
Code status:
Code status refers to the level of medical interventions a patient wishes to have started if their heart or breathing stops. 病人愿意接受抢救的程度
Holt's unconscious patient couldn't weigh in, but social workers used his fingerprints to track down his identity. He had come from a
nursing facility
, and to everyone's immense relief, they had an official DNR form for him, printed on the requisite yellow paper. The man's condition deteriorated, and he passed away in the night.
霍尔特的那位昏迷患者无法发表意见，但社工用了他的指纹来追踪其身份。该患者来自一家
护理机构
，而且这家机构为他保留着一份按要求印在黄色纸张上的正式DNR表格，这让每个人都如释重负。后来患者病情恶化，在夜里去世了。
The team did the right thing, says Nancy Berlinger from the Hastings Center. They provided basic care to buy time, called for an ethics consult, and got social workers involved. "Even if the records weren't there, it was right to honor the patient's preferences," she says. "Paper gets lost, and some people do not trust paper. This man may have been trying to safeguard against that, and [the tattoo] might have been the most reliable way to make his voice heard. It was right to take it seriously."
哈斯丁中心的南希·伯灵格指出，医疗团队的做法是正确的。他们提供了基本的医疗护理以延长患者生命，寻求了伦理方面的咨询，并让社工参与其中。“即使没拿到官方记录，患者的意愿也应该得到尊重。”伯灵格说道，“纸质文件会丢失，而且有人并不相信纸质文件。这位患者可能一直在努力防范上述情况，所以（DNR文身）可能已是能表明其意愿的最可靠办法。医生们认真对待了文身，这是对的。”
But Lauris Kaldjian, an ethicist at the University of Iowa, says he wouldn't have honored the tattoo without finding the official form. A DNR order isn't an end in itself, he says. It's a reflection of a patient's goals—how they want their life to end. Patients are meant to discuss those goals with a physician so they can hear all the options available to them, and make an informed decision; the physician must then sign the order. "That's not meant to be a
paternalistic
move," Kaldjian says. "It's meant to give evidence that a rational discussion was had, and I don't think tattoo parlors are a place to have to have a code-status discussion."
