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.

Without 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:

1. 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.
2. 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.
3. 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.
4. 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.
5. 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.

A default to proceeding with life-sustaining measures does not mean that tattoos or other non-standard means of communicating preferences should be ignored. The tattoo, an alternative form of communication, should be used as piece of information in the decision-making process. A major limitation of AD and POLST documents is that in most states they must physically accompany the patient and are often not available when providers are making key decisions.

Some states, such as Oregon and California, have electronic databases that providers can access, but the lack of this type of accessible database may cause patients to be concerned that their wishes may not be known. In our era of smartphones, patients should be encouraged to enter “ICE” (In Case of Emergency) data into their phones, which can include medical information and emergency contacts. Emergency providers should also be encouraged to routinely search for available ICE data on the phones of incapacitated patients.

Dr. Vearrier is clinical assistant professor in the department of emergency medicine at Drexel University College of Medicine in Philadelphia.

References

1. Holt GE, Sarmento B, Kett D, et al. An unconscious patient with a DNR tattoo. N Eng J Med. 2017;377:2192-2193.
2. Marco C, Savory EA, Treuhaft K. End-of-life terminology: the ED patients’ perspective. AJOB Prim Res. 2010;1:22-37.
3. Vearrier L. Failure of the current advance care planning paradigm: Advocating for a communications-based approach. HEC Forum. 2016:28(4):339-354.
4. Burris K, Kim K. Tattoo removal. Clin Dermatol. 2007;25:388-392.
5. Cooper L, Aronowitz P. DNR tattoos: a cautionary tale. J Gen Intern Med. 2012;27(10):1383.