Unconscious Patient With 'Do Not Resuscitate' Tattoo Causes Ethical Conundrum At Hospital

When an unresponsive patient arrived at a Florida hospital ER, the medical staff was taken aback upon discovering the words "DO NOT RESUSCITATE" tattooed onto the man's chest - with the word "NOT" underlined and with his signature beneath it. Confused and alarmed, the medical staff chose to ignore the apparent DNR request - but not without alerting the hospital's ethics team, who had a different take on the matter.

Image: NEJM/University of Miami

As described in a New England Journal of Medicine case report, the unnamed 70-year-old man was brought to the ER by paramedics in an unconscious state, and with an elevated blood alcohol level. The patient had a history of chronic obstructive pulmonary disease (a type of lung disease), diabetes, and an irregular heart rate. His condition began to deteriorate several hours after being admitted, and dramatic medical interventions were needed to keep the patient alive.

But with the "DO NOT RESUSCITATE" tattoo glaring back at them, the ICU team was suddenly confronted with a serious dilemma. The patient arrived at the hospital without ID, the medical staff was unable to contact next of kin, and efforts to revive or communicate with the patient were futile. The medical staff had no way of knowing if the tattoo was representative of the man's true end-of-life wishes, so they decided to play it safe and ignore it.

"We initially decided not to honour the tattoo, invoking the principle of not choosing an irreversible path when faced with uncertainty," wrote the authors of the case study. "This decision left us conflicted owing to the patient's extraordinary effort to make his presumed advance directive known; therefore, an ethics consultation was requested."

But there was more to it than just the medical ethics. Gregory Holt, the lead author of the new case study, said the biggest question in his mind was the legal aspect of whether or not it was acceptable. "Florida has stringent rules on this," he told Gizmodo.

While the DNR tattoo may seem extreme, the request to not be resuscitated during end-of-life care is most certainly not. Roughly 80 per cent of US Medicare patients say "they wish to avoid hospitalisation and intensive care during the terminal phase of illness". Revealingly, a 2014 survey showed that the vast majority of physicians would prefer to skip high-intensity interventions for themselves. Of the 1081 doctors polled, over 88 per cent opted for do-not-resuscitate status. Indeed, measures to keep a patient alive are often invasive, painful and costly. DNRs, which hospital staff refer to as "no-codes", are an explicit request to forego high-intensity interventions such as CPR, electric shock and intubation tubes. More implicitly, it's a request to not be hooked up to a machine.

Typically, DNRs are formal, notarised documents that a patient gives to their doctor and family members. Tattoos are a highly unorthodox - but arguably direct - means of conveying one's end-of-life wishes. That said, this patient's tattoo presented some undeniable complications for the hospital staff. Is a tattoo a legal document? Was it a regretful thing the patient did while he was drunk or high? Did he get the tattoo, but later change his opinion? On this last point, a prior case does exist in which a patient's DNR tattoo did not reflect their wishes (as the authors wrote in this 2012 report: "...he did not think anyone would take his tattoo seriously...").

In this most recent NEJM case, the ICU team did its best to keep the patient alive as the ethics team mulled over the situation, administering antibiotics, vasopressors (to reduce low blood pressure), intravenous fluid resuscitation, and other measures.

"After reviewing the patient's case, the ethics consultants advised us to honour the patient's DNR tattoo," Holt told Gizmodo. "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 [that is, adherence to medical tradition and norms], and that the law is sometimes not nimble enough to support patient-centred care and respect for patients' best interests."

Accordingly, the ICU team wrote up a DNR, and the patient died later that evening without having undergone any emergency DNR measures. Before he died, however, the hospital's social work department discovered the patient's Florida Department of Health "out-of-hospital" DNR order, which was consistent with the tattoo.

But as the authors of the new report point out, the whole incident "produced more confusion than clarity", saying that, despite how hard it can be for patients to make their end-of-life wishes known, "this case report neither supports nor opposes the use of tattoos to express end-of-life wishes when the person is incapacitated."

Kerry Bowman, a bioethicist at the University of Toronto, agrees that this incident was challenging.

"Advanced directives of any kind do not override most recent expressed capable wish," Bowman told Gizmodo. "In other words, [the patient] may have changed his mind and there may be no way of knowing. Tattoo regret is not rare. [The ICU team's] defence is erring on the side of life."

At the same time, however, Bowman is sympathetic to the patient, saying the tattoo may be an expression of how often patients' wishes are somehow overlooked and the system takes over. "My position would be if someone went to the great length of having DNR tattooed with a signature, it indicates a strong and clear wish," he told Gizmodo.

Melissa Garrido, an Associate Professor at the Icahn School of Medicine at Mount Sinai in NYC, shares this sentiment, saying that even when a DNR order has been entered into a medical record, it is not always readily accessible in a health crisis. "A standardised tattoo may be a readily accessible method for communicating a strongly held care preference," she told Gizmodo.

[New England Journal of Medicine]

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    Of course tattoos and scarification are important parts of some cultures but in the west they are primarily decorative. If I was part of the medical team involved I wouldn't have honoured it - the guy can kill himself later if he so desires.

      In the US were he could leave his family with a hundred thousand dollar medical bill?

        *where (autocorrect ftw!) - I’d edit the post, but it’ll go into moderation forever and never be released ¯\_(ツ)_/¯

      It's not quite as cut and dry as this.

      The crux is to strike a balance between respecting patient autonomy while not unfairly depriving them of healthcare.

      Except the difficulty in this case, as mentioned in the article, is whether a tattoo constitutes a legal document. Certainly in most states here, a DNR order either needs to be a statement of medical decision (i.e. written and signed by a medical practitioner) or patient wishes (notarised by a JP or other recognised person).

      There is no precedent that a tattoo is legally binding. Indeed, following one could lead to accusations of negligence. The safest path would be to corroborate the patient's wishes with them or their recognised proxy decision maker.

      While doing this, under a "good faith" clause it's reasonable to continue life sustaining treatment. Medical staff wouldn't be doing this with the intention of prejudging the authority of the tattoo but more to buy time to ascertain its authority. Certainly it would be more justifiable to cease therapy once the DNR was unequivocally established, than stop prematurely and discover too late that it wasn't valid. Death is somewhat irreversible!

      There's also the conundrum of the definition of "resuscitation". To many people it means cardiac arrest management. But to some clinicians it means rescue and support organ systems to prevent (potential) cardiac arrest. So, again, without context it's impossible to know for certain what the patient's intent was.

      Either way, it sounds like they did the right thing in this case. Not jumping conclusions was the smart, defensible way to go.

      Last edited 02/12/17 12:26 pm

    Seems pretty open and shut and good to know hospital staff know what they’re doing.

    Tattoos are not legal documents therefore there’s no ethical issue in not honouring them. If they had not resuscitated however, this potentially could raise legal issues, as they had no legal authority to make that decision without next of kin or legal documentation...

      Did you not read? They did not resuscitate... They honoured the tattoo and wrote up a formal one in the ICU... However, before he died they did also find his out of hospital DNR form so there were absolutely no doubts anyway

        They initially did commence resuscitation because doubt existed - as is appropriate in this case.

          Only until such a time as the ethics team made a call though and prior to any documentation being located.

          They lucked out really. Had there been no formal documentation the the tattoo found to be decorative then I'm sure there'd be a huge uproar.

        Yes I can read. Can you?

        They treated him while waiting for a decision to be made. Like I said pretty open and shut. And as someone else said, the ethics team lucked out.

        It just happened that there was documentation this time. Yet the tattoo itself presents a problem and highlights the need for a more robust form of documentation that a consumer could wear to avoid potential legal issues which could arise... ie not resuscitating and then finding out later there’s no docs and being liable for a person’s death.

        Actually, they DID resuscitate. They later withdrew support, but they did resuscitate. Resuscitation is what you do in the initial period to stabilize the patient. This phase of his care was complete, and they then withdrew support in ICU after the ethics team were able to make a decision.

      Man didbyou even read the article??? Should maybe read it all before opening your mouth and making a fool of yourself

    If he had changed his mind, it would've been easy to score out the "not".

      Exactly. Regrets in this situation are pretty easily fixed, any tattoo shop would be able to cross that out in a matter of minutes, probably for sweet FA cash. I'd argue it would be easier to get this changed in the case of regret, than a notarized official document.

    If he actually had the "NOT" underlined and then had his signature tattooed directly under it then I take that to be a pretty obvious sign of his wishes.

      So, using your logic, you could tattoo a cheque on your skin and it would be valid? could tattoo a mortgage agreement?

        One is a statement of opinion and state of mind other is a financial transaction with very clearly laid out rules and regulations they not similar at all by any stretch.

          Wrong. A DNR most definitely does have very clearly laid out rules and regulations around what can and can't be done, as well as when and where they are to be done. There are a dozen or more items on a DNR authority form. It's not JUST CPR and Defibrillation. Some people only have a DNR for a terminal illness which only applies to that specific situation, not to accidents or emergencies, and is required to be witnessed by, in Australia, a JP or similar, and logged with a lawyer and the health system.

      If the medical attendants knew the individual and what his signature looked like. However, not really legal without dates and witnesses... so yeah... needs a couple more signatures still to be legal lol

    There's no way, as a paramedic, I'd honour the tattoo. There's no way to verify that it is the current existing wishes of the patient, and where doubt exists about the presence of a DNR, protocol is to resuscitate.

    There's also varying degrees of resuscitation - it isn't just CPR and shocks. Some people will want various interventions which may prolong life but want to stop short of active advanced life support in cardiac arrest. Some may only want it to apply in particular circumstances - if there is a reasonable chance of recovery, as opposed to a low chance, they may want attempts to be made.

    Theres too much ambiguity in a tattoo for wishes to really be determined, and the decision not to resuscitate is final - you can't take it back once they're dead.

    Those who say they would ignore the instruction display an amazing level of hubris.
    My body, my choice.
    And suicide is not an alternative to demanding to be allowed to die in the natural course of events.

      I don't think anyone's suggesting a patient's DNR instruction should ever be ignored. Just that in this circumstance, it wasn't entirely clear that that was the instruction.

    a prior case does exist in which a patient's DNR tattoo did not reflect their wishes (as the authors wrote in this 2012 report: "...he did not think anyone would take his tattoo seriously...")

    If you are that stupid...

    While I can see it's grey area legally... There might be no way to verify if his thoughts haven't changed since the tatt, but same with signed DNR paperwork from 1,2,5,10 years ago. Also, if a medical professional won't take a tattoo as gospel, put there willingly by that person, do they also ignore drug allergy and other medical alert tats? Hmm

      There is a big difference between letting someone die because a tattoo told you to, and switching to a different antibiotic because a tattoo stated the patient was allergic.

      The consequences of the tattoo being wrong are very different.

    I would love to get a tattoo like that. I have spoken to Medicare to try to make my feelings known, but they won't document it and keep it on file.

      Um, why were you speaking to Medicare about it? They are a publically owned universal health care organisation. Their task is to FUND medical care, they have nothing to do with medical decision making.

      You're better off discussing it with your GP, and potentially your local hospital. You can have an advanced care directive put into place.

        I spoke to them as everything is computerised these days and so potentially more people would have access. An advanced care directive is fine, but generally the piece of paper floats in someone's filing cabinet

          This is true, but as somebody in the industry, I can assure you that they would have no ability whatsoever to influence a doctors decision making, nor inform them of anything. A medicare office is the last place I'd look for a patient's medical history because they have nothing to do with it.

          Not every hospital has computerised medical records (GP services are far more advanced in this area), but most have at least partially computerized systems.

          Advanced care directives made while in hospital will generally result in a flag on the emergency department's patient management system for a given patient, so will likely result in doctor's being aware of your wishes in an emergency situation. It wouldn't have helped in the situation described in the story however, because they were not able to establish his identity.

    I disagree with nearly all of you. I'm an intensivist and I would have honoured it. The arguments about whether this really represents his wishes or whether he might have changed his mind could apply equally to a very legal-looking advance care directive document. Are we going to honour someone's explicit prior wishes or not?

      But as you know the standard for filling out an AHD is higher than walking into a tattoo parlour and asking to get it inked across the chest.

      If someone presents me with an AHD that looks legal and in order, I'll enforce it. A tattoo is completely different, and I'd hate to follow it then find out there's nothing that backs it up. Until a precedent is set suggesting it would be reasonable to withhold resuscitation, I won't be following a tattoo splashed across my patient's chest.

      I'm a physician and I agree with you. If I saw that tattoo there is no way I would resuscitate them. They've clearly gone through a significant effort to document their wishes. Saying that they may have changed their mind since is a cop out as it's much more likely they haven't.

      Now I understand that legally this is a controversial and unclear area. The patient or family could probably sue either way (at least in the US). Think about if you had terminal cancer, got this tattoo, but were resuscitated anyway. Now you've got a more protracted, painful death to look forward to. Grounds for legal action. Yes the more legally valid way is to do an advanced health directive. But unless the paramedic picks up the paperwork while they're reviving the person no one would know - hence why people get these tattoos.

    Sounds like documented DNR's need a register, and a registration number.
    That way, the tattoo could quote a registration number for validation.

    Since tattooed serial numbers have seriously negative connotations, you could also try a barcode (Agent 47 style).

    Is there a reason people in situations like this can't get MedicAlert bracelets/dog tags with DNR instructions?

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