DNR Tattoos

"The tattoo was such a dramatic display of rejection. I think this was someone who really didn't want to be resuscitated."
"The ethical standard is, you should do to an unconscious patient what they would want if they were conscious. But the problem with all advanced directives --even a document signed with a witness -- is that someone can change their mind at any time."
Dr. Kenneth Goodman, director, Institute for Bioethics and Health Policy, University of Miami

"Unless the Supreme Court says a tattoo is a legally binding document, then it's nothing more than an expression of emotion."
"A tattoo doesn't obligate a physician to not provide care if they don't have more information, and I wouldn't advise my colleagues to be worried that they'll have to justify their actions."
"When I read a document, I don't just say 'this is what I will or won't do' because DNRs are not black and white. People will write things like 'I'll be on dialysis but only for a week', so they think they've thought things through, but it's really more confusing for the physician."
"Things like better communication in hospitals need to be addressed, but I don't think [getting DNR tattoos] is the way to fix it."
Dr. Bojan Paunovic, executive member, Canadian Critical Care Society

"I would argue that in the absence of a clear indication that the tattoo represents a patient's current position, then the doctor would be well within their rights to proceed [in caring for the patient]."
Osborne Barnwell, lawyer, medical malpractices

One man's "Do not resuscitate' tattoo left doctors with no idea on how to react. New England Journal of Medicine

Dr. Paunovic points out that it has been his experience that many people have a change of attitude faced with a serious medical situation. Where they might have been convinced that they had no intention of permitting doctors in an emergency medical situation that looked grim in its outcome to use all possible technological and professional expertise to prolong a life not at that point worth preserving, when the actual moment arrives, they give it second thought, deciding that life is, after all, preferable to death; even a severely impaired life.

In 2012, an article describing a situation where a man who'd gone to the trouble of having a 'do not resuscitate' tattoo placed on his chest, irrespective of its prominence and the attitude it presented, really did want to be resuscitated. The reason for that article to have seen publication was to alert physicians that the tattoo had resulted from a lost poker bet. It did not in actual fact express the wishes of the man who wore it. Presumably the article did not need to delve into the inadvisability for anyone to recklessly display such an existential threat.

Yet this is the kind of thing that increasingly emergency room physicians are faced with, one that tests the ethical, moral framework of their profession What to do when such a tattoo is prominently placed on the body of a patient in extreme medical distress? Honour the tattoo as a significant authorized request to hold of on any extraordinary measures to save a life, or proceed, using every measure available to modern medical science to save the life of the individual expressing those sentiments?

This was an actual case that appeared in the New England Journal of Medicine recently, where doctors initially attempted to save the life of a man who had a tattoo on his chest. Addressing their uncertainty, in a desperate last minute appeal, the medical team queried an ethics counsellor and in the event made the decision to take the tattoo as an official endorsement of the man's wish to stop resuscitation efforts. Supporting documentation in the hospital's files were found, confirming the man's wishes. He died soon afterward.    

An increasing number of such mute, but highly legible attestations to intent are being seen in hospital emergency rooms. And Dr. Paunovic, an ICU physician, states that his attention would briefly fixate on the request, but it would take supporting documentation to convince him that the patient really did want resuscitation efforts to be withheld. Awareness of context, as far as Dr. Paunovic is concerned, is critical with any type of DNR order, inclusive of a signed document.

Joe Raedley / GettyImages

People do strange things. Could be that someone in a state of temporary depression decides to have a tattoo for DNR. They may change their minds, but tattoos are pretty close to permanent; their removal isn't conveniently and swiftly accomplished. The eradication process is time-consuming, expensive and painful as a procedure to undo what has been done when a change of mind occurs.