Ethics Quiz: The DNR Tattoo

 Paramedics brought a 70-year-old man to the University of Miami hospital emergency room after finding him on the street, intoxicated and unconscious. Doctors tried to revive him got no response. Then they had an unusual problem: The man had a ‘Do not resuscitate’ tattoo on his chest, with a line under the ‘not.’ There was also something that looked like his signature. Tattoos are not legally-binding DNR orders, and in Florida, there are  very specific requirements for DNRs. to be legal.  Both a doctor and the patient must sign it, and they must be on paper, not on chests.

The doctors decided to respect the man’s tattoo. They did not try to revive him after the initial efforts failed

Your Ethics Alarms Ethics Quiz of the Day:

Was that the right call?

The story says they consulted ethicists. They didn’t consult me. I would have said that they had to try to resuscitate him, and I don’t think it’s a particularly close question:

1 The DNR wasn’t official or legal.

2. Tattoos are often ironic or facetious, or done and regretted later. It looked like a possible joke to me.

3. The signature was the best argument for taking the tattoo seriously. But when was the tattoo made? How did the doctors know that he hadn’t changed his mind? It’s a lot harder to change a tattoo than a signed and dated document.

4. The hospital has a conflict of interest: if the man ended up on a ventilator, it might be stuck with the bill. Letting him die was obviously the hospital’s smartest course, and those ethicists worked for the hospital.

5. In an ambiguous situation, the default decision should be in favor of life, not death.

41 thoughts on “Ethics Quiz: The DNR Tattoo

  1. It’s a prime directive violation of the Dr.’s oath (if that was the reason).

    If they couldn’t revive him and found the tattoo on his butt would the situation still be the same?

  2. Hmm…I have to admit that I lean the other way on this one.

    1) Irrelevant, since I thought we’re discussing Ethics here and not the law.

    2) Sure, it could be a joke. It could be serious. That’s actually the question being placed in front of us, isn’t it? The question itself is not, by definition, the answer.

    It seems WAY WAY WAY more plausible to me that the tattoo was serious, and that this man felt strongly enough about it that he planted this VERY PERMANENT message where any EMT would see it, knowing that he’d be unable to speak for himself in that moment. The fact that he used a tattoo as the medium for this message only goes to show that he felt strongly enough about it that he had no expectation of changing his mind, ever.

    3) The longer ago it was made, the more time and opportunity the man has had to have it removed or substantially changed–assuming he ever wanted to. Not having done it indicates that it is still his preference.

    Really, I’d think fresh ink from only the night before would be a much stronger argument that it was not intended as a legitimate message.

    4) Irrelevant to the question in front of us. If the hospital stood to profit somehow from the man’s ongoing care, it would not change the decision on whether or not the DNR-order-by-tattoo should be honored.

    5) Here, I’m 100% with you, but the whole concept of a DNR order is based on weighing individual autonomy versus a societal cultural value. I’m not a fan of DNR’s in general, but I would never presume to overrule one without a specific reason besides my own beliefs.

    This guy felt so strongly about this that he had it tattooed on his chest, complete with a signature. I find that very hard to dismiss.


    • I find this compelling.

      On the legal issue, we’d need more details. It’s likely that a legally binding DNR would be necessary to overrule next-of-kin objections or immunize the hospital against lawsuits for not saving the patient, but that hospitals are still allowed to act on patient directives conveyed by other means. Much of modern medical ethics involves respecting the patient’s wishes, if they are known.

      The tattoo, complete with signature, seems to spell out the patient’s wishes quite clearly — much more so than the “D.N.R.” tattoo mentioned elsewhere, which could be anything from a girlfriend’s initials to a band name.

      The issue of whether he could have changed his mind also favors obeying the tattoo. A DNR directive is, by definition, always evaluated when the patient is unable to discuss the goals of his medical care, so even if the DNR is signed, witnessed, and notarized (or whatever the legal hoops are) it is not possible to be perfectly certain the patient has not changed his mind. However, unlike some easily-forgotten DNR form filed with the hospital medical records office or the Florida Department of Health, the patient would have seen that tattoo every day when he looked in the mirror. That seems like a very reliable indication of his state of mind.

      • I think this is right. It’s not too often I find myself in disagreement with Jack’s analysis, but yours seems more compelling.

        As I grow old and have seen death up close and personal, the DNR wishes of a person are much more personal to me than when I was younger. If I had been a doctor ministering to him, I would’ve been inclined to respect the tattoo. It’s possible he might’ve changed his mind, but in my view that’s not much different from changing your mind and not updating your directive. Tattoos may be harder to update, but by no means impossible.

        • “First do no harm.”
          That has to be the starting point: it’s the prime directive, agreed? Now, keeping a man alive who maay not have wanted to isn’t “harm” within the definition of medical ethics; that’s why DNRs have to be legal.But letting a patient die when he can be saved and there is no legal order directing otherwise IS harm. It’s a bright line breach of medical ethics.

          The potential conflict nailed it for me.

          • …and that’s precisely what I meant when I said “weighing individual autonomy versus a societal cultural value”.

            Here we have a true ethical dilemma: the expressed wishes of an individual (autonomy) versus the “First, do no harm” medical ethics, which is a cultural value that we’d created and widely accepted.

            So I disagree here: I think that resuscitating a man who may not have wanted it IS doing a form of harm to his individual liberty and autonomy. I think this because I personally value autonomy higher.

            Even if we stipulate that he had NO legal DNR order on file, but that the tattoo did indeed reflect his true wishes, I think I’d still come down on the side of honoring the DNR-by-tattoo.


            • As far as I can find, the vast majority of medical ethicists and the profession do not accept that killing someone who might be saved is ever not harm., and saving someone from death cannot be harm. There are dissenters, of course.

    • Very bad call, people do stupid shit and regret it later. A tattoo artist is not a lawyer or medical professional and incapable of advising someone on a DNR or performing proper due-diligence in the case.

      I would hate to be condemned to death for some idiotic thing I wrote 20 years ago.

  3. I’m gonna bet this tattoo doesn’t even meet Florida s laws. At the very least , if they thought the issue was gray enough they should have respected the law.

  4. My take following your outline:
    1. As Miracle Max said, “Mostly dead is slightly alive.” While this guy appears to have come to the ER mostly dead, there was some chance to save him and depriving him of that without being as sure as possible of his intentions would be wrong. That’s one reason the law is so specific. Additionally, breaking the law is unethical in itself.

    2. The one I really wanted to comment on. Reference 2 in the NJEM article is from “J Gen Intern Med. 2012 Oct; 27(10): 1383 DNR Tattoos: A Cautionary Tale.” A few excerpts; “Physical examination revealed a “D.N.R.” tattoo on his chest”, “he indicated that he would want resuscitative efforts initiated in the event of a cardiac or respiratory arrest”, “he explained that he had lost a bet playing poker with fellow ancillary hospital staffers while inebriated in his younger years; the loser had to tattoo “D.N.R.” across his chest”, and most germane “He stated he did not think anyone would take his tattoo seriously and declined tattoo removal.” The photo accompanying the article shows a clear, large, block letter, in red ink “D. N. R.” tattoo.

    3. Pretty much covered by 2.

    4. Possibly true. Ethics consultants are not necessarily employees of the hospital. In the case discussed here, the man at age 70 would almost certainly be covered by Medicare making finances less of an issue anyway. I think the ethicists in this case did not do sufficient research. Had they done so, they would have found the article I discussed in 2. and be faced with an actual example in which the presence of a do not resuscitate tattoo was definitely not indicative of the patient’s true wishes. Taking that fact into consideration, should have lead to the same conclusion the doctors treating the patient initially came to, “We initially decided not to honor the tattoo, invoking the principle of not choosing an irreversible path when faced with uncertainty.”

    5. Always.

    • “I think the ethicists in this case did not do sufficient research.”

      How much time did they have? If this was an emergency room resuscitation situation, that would sort of imply that the decision needed to be made rather quickly. I’m frankly a little surprised they had time to consult with ethicists at all. Does the ER keep an ethicist on call, or was the ethics consultation done after the fact?

      • I originally found the reference in the NEJM article which linked to the J Gen Intern Med article. Of course the ethicist wouldn’t have had that. I did a search on Pub Med Central at the National Library of Medicine database and found the article in less than a minute searching on “dnr tattoo” and the same search term on Google turned up a 2012 journal article and a number of pictures of DNR tattoos on page 2. Basically, the time it takes to do a search these days is so brief that I feel it is pretty much standard of care to do one whenever the internet is available. The few times I was involved with an ethics consultation (as the doctor not the ethicist) it was not an emergency. At medical centers there is almost always somebody on call to cover consultations but in this particular case I have no real knowledge of the time frame. I wish they had specifically mentioned it but the article suggests it didn’t take very long. The article does mention that there was time to admit him to the ICU and treat him there.

  5. Hypothetically, does the ethics calculus change at all if the emergency room was at the time swamped with critical cases? Would it be more ethical then to respect the wishes embodied by the tattoo and prioritize other patients, especially ones who didn’t express an aversion to medical intervention? Does one allow another patient to die while saving one who appears to not want to be saved?

  6. Oh for Pete’s sake, if you want a DNR on file, fill out the proper paperwork. Your chest, on a drunk weekend in Key West, does not count as paperwork.

    The ER should have known this… being an ER and all. They see everything.

    THIS tripped them up?

    • I’m curious about the “proper papework”… Is there a system in place such that any doctor can look it up quickly when such a decision has to be made? How would the doctor know if an unconscious patient can’t tell them he has a DNR? What if the person is travelling to another state?

      Maybe there actually is a role for tattoos in this area. Perhaps a specific tattoo design, required to be in a specific location on the body, could serve as a legal DNR order. Seems far more reliable than relying on paper records. Obviously, you wouldn’t *require* the tattoo, but for those who feel strongly about it, couldn’t that be a viable option?

      • ”Maybe there actually is a role for tattoos in this area.”

        Veddy interestink!

        Darwin would’ve called it an ‘exploitable niche.’

        It’s not outside he realm of possibility that there are “Body Art” aficionado/enthusiast/entrepreneurs, trade rent-seekers, & seed money vultures, with the insurance industry and federal regulators sure to follow, mulling the opportunity of filling it as we speak.

      • Each state has their own specific requirements. Florida requires a specific form signed by patient or legal guardian and a physician and is actually a physician’s order. The form does not have to be notarized. There is no specific place the form has to be kept. Typically the patient will place the completed form somewhere readily available–suggested spots are bedroom or on refrigerator. The form also has a section at the bottom that can be filled out and torn off. It can then be carried in wallet or purse or some people laminate and wear on a chain around their neck. The completed form can be photocopied and copies are valid but must be on yellow paper. Typically patients will want all of their doctors and responsible family members to have a copy. The form does not expire. The DNR can be cancelled at any time by the person who signed by simply destroying the form. Other states do not have to honor the form and Florida does not honor DNR forms from other states. Ultimately, the responsibility for having the form available when needed rests with the patient or their guardian or family.

  7. So I want a DNR and I travel, how do I register a DNR in every location?
    Is there an app for that?

    If not, a chest tattoo for a DNR seems far better than carrying it in my wallet, especially if the signature looks reasonable.

    If it was a joke, and the man was not treated due to that joke, do you know who would laugh loudest at the outcome?

    If it’s a valid DNR and you don’t treat him, you’ve gone against his wishes.
    If it’s a joke DNR and you don’t treat him, you’ve made him happy and given his kin and drinking buddies a great story to tell.

    • If your are coming to Florida and want to be DNR, then you will need to fill out the Florida form. The only legal DNR in Florida is on that specific form on yellow paper or a photocopy on yellow paper. A tattoo of DNR in Florida is definitely not a valid DNR and I suspect not in other states.

      I think a tattoo could be useful In alerting medical personnel to the fact that you have filled out a legal DNR so that they make an effort to find it as happened in this case. I wish the report had been clearer as to how and where the DNR was located as they are not required to be filed with the state.

      The general rule in our society is that anyone who appears to need medical care should be treated. If you show up in an ER unconscious, the presumption is you wish to be treated. If you do not wish to be treated, you must take an active role to ensure that your wishes are known.

      You should also have a designated health care surrogate to ensure that your wishes regarding medical care are followed in case you are not able to speak for yourself. The fact is that most people who end up in the position of being gravely ill and decisions needing to be made about care do not have a DNR order.

    • “So I want a DNR and I travel, how do I register a DNR in every location?”

      I bet the percentage of DNR’s who travel is less than the percentage of the trans crowd that wants to inconvenience the whole rest of the community over bathrooms.

      When you are discussing numbers that small, the ethics boil down to: Hey DNR guy, if you don’t make prior arrangements on your own, you don’t get to complain if you are resuscitated while travelling.

  8. I can see both sides, but if there is no DNR on file officially, the guy has no valid complaint when he’s resuscitated. His relatives, on the other hand, might have legal grounds to sue if he isn’t.

    Other than DNRs, some people with medical conditions that complicate treatment get tattoos so doctors don’t have to find out the hard way what treatments they’ll react badly to. People who don’t want tattoos can instead get nifty little metal bracelets, which have the benefit of being standardized and officially recognized (though I suppose you could do that with tattoos as well). Ultimately, a tattoo or bracelet that calls attention to an official document is likely the best combination.

    • The ethics of this all boils down to “what method of making a DNR agreement with doctors” is commonly accepted by the community. Then it boils down to the choices individuals make the consequences of those choices within the community framework.

      If some day the community decides that a tattoo is an acceptable means of communicating medical wishes and needs as well as an acceptable means of surrendering authority to doctors in the case of being non-responsive, then that’s fine. The flip side of that is: Ironic Tattoo Wearers lose the right to complain if their Ironic Tattoo gets them not-resuscitated.

      Currently, the community does not deem a DNR tattoo as an acceptable means of doing so. The flip side of which is: the DNR tattoo wearing guy doesn’t get to complain if he is resuscitated though his DNR tattoo was supposed to be taken seriously.

  9. A pal of mine recently inherited a medic alert bracelet from a buddy of his who died. It states he is medically an asshole. The original guy wore it daily. My pal thought he might wear it, but decided it might delay real treatment in an emergency. Some docs and EMTs think medic alert bracelets are ignorable. They’ve told me so, which makes me glad I don’t need one.

    • I have seen such ‘medic alert’ jewelry that have relevant medical data on an integrated USB drive; and/or a link to a website with such info (and login credentials for doctors to access them)

      Such sites would also have numbers to call with questions, next of kin information, and all manner of things. (A DNR could be placed there, I would suspect)

      For what it is worth, anyway. YMMV

  10. For all they knew that was the name of his favorite indie thrash band! Save his life, and when he comes to, offer him the proper forms to fill out so he can die quietly next time, if he so desires.

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