A recent New England Journal of Medicine article presented a case in which a “Do Not Resuscitate” (DNR) tattoo (see Figure 1) created an ethical dilemma for the emergency and critical care physicians caring for the patient, who were guided by a questionable recommendation from their ethics consultants.1 The unknown patient presented to the emergency department unconscious and in critical condition. “Do Not Resuscitate” was tattooed across his anterior chest wall, accompanied by his presumed signature.
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ACEP Now: Vol 37 – No 04 – April 2018Without the guidance of next of kin or advanced directive paperwork, the health care team initially decided not to honor the DNR tattoo. However, they later reversed their decision and honored the tattoo after an ethics consultation. The ethics consultants concluded that the tattoo could be presumed to represent the patient’s authentic preferences and that the “law is sometimes not nimble enough to support patient-centered care and respect for patients’ best interest.” The conclusion of the ethics consultants should not set a precedent for future similar cases, as the DNR tattoo was neither legally nor ethically sufficient to guide medical care.
Before delving into the specific insufficiencies of the tattoo, it is useful to review advance care planning (ACP). There are two main forms of ACP documents: advance directives (AD) and physician orders for life sustaining treatment (POLST). ADs are legal documents that can be completed at any time in life to guide future care and/or appoint a surrogate decision maker. ADs must be completed by the person (him/herself) and require either a witness or notary, depending on the state. POLST forms are physician orders for end-of-life (EOL) care designed to be transferred among health care institutions. They are for patients who are seriously ill or frail who are near the EOL and can be completed with the assistance of a surrogate. Table 1 summarizes the differences between ADs and POLST.
(click for larger image) Table 1: Comparison of ADs and POLST
The “Do Not Resuscitate” tattoo in the article is neither legally nor ethically sufficient to guide medical care for the following reasons:
- Tattoos are not legal ADs nor POLST, which are the two ACP documents transferrable among institutions in the United States. The tattoo cannot be considered a wearable AD, as it does not include a witness or notary to complete the legal documentation.
- Informed decision-making cannot be presumed. Studies have reported that patients have a poor understanding of EOL care terminology, and only about half of emergency department patients surveyed had a correct understanding of the term “Do Not Resuscitate.”2 There is no evidence that the tattoo indicates a clear understanding of a DNR status.
- The tattoo contains insufficient information to guide medical treatment. Does the patient mean no chest compressions, no intubation, no vasopressors? ADs and POLSTs clarify preferences so that providers can better interpret patient wishes, although confusion may still arise as to whether specific interventions are desired.
- EOL care preferences are dynamic. Depending on factors such as age, health status, prognosis, and advancement of medical technology, a person’s EOL preferences may change.3 In contrast to a tattoo, ADs and POLST forms may be easily amended to reflect a patient’s current wishes.
- Tattoo regret is common. More than 50 percent of individuals later regret their tattoos.4 The most frequent motivation for tattoo removal is poor decision making, often the result of intoxication, leading to subsequent regret. A case report of a DNR tattoo that did not represent a patient’s current wishes has previously been reported.5
An important ethical principle for emergency physicians to consider is that withholding and withdrawing life-sustaining treatment are considered ethically equivalent. Therefore, when faced with ambiguity regarding a patient’s wishes, emergency physicians should proceed with life-saving interventions. When further information is obtained, the patient’s care can be appropriately de-escalated in accordance with their preferences.
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9 Responses to “Do-Not-Resuscitate Tattoos: Are They Valid?”
April 16, 2018
Ferdinando L. Mirarchi, DOEmergency and physicians of all specialties need to be aware that this article is in contrast to what occurs in law. The law provides providers with immunity if they allow the Patient to die when they have a LW or POLST. If you save a patients life first and you happen to be wrong then you are at risk for Wrongful Prolongation of Life Litigation. TRIAD VIII and the use of Patient to Clinician Video is the Most Accurate Way to get a patient’s wishes correct and protect both patients and medical providers. The use of smart phones now allow patient to clinician video (MIDEO) to be retrieved in seconds. MIDEO will be featured at the ACEP solutions Conf May 23rd in DC.
It’s time to to be state of the art and not accept status quo and be advocates of our patients.
April 19, 2019
Joseph B.Vocabulary lesson: “Pedantic” — caring too much about unimportant rules or details and not enough about understanding or appreciating a subject.
The amount of over-thinking and over-analyzing on display here is a disgrace. You’ve “lost sight of the forest for the trees” … it’s time to take a big step back and use a little common sense. To the average person, “do not resuscitate” means “allow death to occur.”
Perhaps you want to go down the rabbit hole of “Informed decision-making cannot be presumed” from a tattoo; how do you know an advance directive was full understood or that the person wasn’t suffering from depression when the signed paper documents…? This mentality of moving-the-goalpost anytime you disagree with a patient is unacceptable.
In the ***VAST*** majority of cases, I believe that a D.N.R. tattoo is a clear representation of the person’s desire to allow death and it should be fully respected.
July 14, 2019
Patricia KWhat Joseph B said. If somebody wants to let death occur should something happen to the point they have it PERMANENTLY BRANDED ONTO THEIR BODY…. perhaps you ought to consider that’s what they actually want and respect that.
July 28, 2019
TerrieI do believe if you have a tattoo that says do not resuscitate or D.N.R. that it should be legal because you’re stating your wishes. I don’t want somebody to keep me on machines for years. I had to make the horrible decision to take my youngest son off machines after 7 Days of waiting to find out if he had brain waves or not. So if I have a tattoo on my body that says do not resuscitate or a D.N.R. a doctor should except my wishes… I don’t think anybody has the right to decide for me I will decide for myself with the tattoo
October 10, 2019
GiaTerrie,
I am sorry to hear about your son. I also have lost a daughter and miss her so much. I always say, don’t bring me back if I am already gone, I don’t want to die twice and I get to be with my daughter.
November 14, 2019
DanI’ve been concerting getting a DNR tattoo.
Given this information do you think I should still get it?
October 29, 2020
flamewolf393Get it notarized! A guy got the DNR tattoo, then had a notary put their stamp on his chest, and then their tattoo artist went over the notary stamp to make it permanent. Your tattoo is now a legally binding document.
May 2, 2021
JamesWhy wouldn’t you simply fill out an advance directive in your state with your regional hospitals?
A tattoo artist’s rendering of a notary stamp imprint is just that – a copy that does not constitute a notary stamp. Your body will not become a legal document to say nothing of the absence of a notary stamp.
May 19, 2021
Timothy FreemanBrand the notary stamp.