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A recent report in the New England Journal of Medicine highlighted a case of a patient who presented to the Emergency Department, unconscious, with a Do Not Resuscitate tattoo sprawled across his chest. The 70 year old man was quite ill on arrival. His blood alcohol level was high. He had COPD, diabetes, and atrial fibrillation. In the ICU he was noted to have hypotension and anion gap metabolic acidosis with pH of 6.81. “All efforts at treating reversible causes of his decreased level of consciousness failed to produce a mental status adequate for discussing goals of care.” 

The staff decided initially to not honor the DNR tattoo. The words Do Not Resuscitate were inked. With a replica of his signature. This was a serious tattoo. 

The staff placed the patient on empiric antibiotics, IV fluids, and vasopressors while they awaited an ethics consultation. He was also treated with bilevel positive airway pressure.  

The staff did not want to commit to an irreversible path if the tattoo did not reflect the patient’s current wishes. 

The ethics consult suggested that it was reasonable to infer the tattoo represented an authentic preference.  

Subsequently, the social work department obtained a copy of his Florida Department of Health “out-of-hospital” DNR order, which was consistent with the tattoo. The patient’s clinical status deteriorated throughout the night, and he died without undergoing cardiopulmonary respiration or advanced airway management. 

The case report continued the authors were relieved to find his written DNR request, especially because a review of the literature identified a case report of a person whose DNR tattoo did not reflect his current wishes. 1 

Once inked, it would be difficult to reverse the apparent intent and meaning on the patient’s chest. But, that may not be much different than a patient who has signed a DNR request (Advanced Directive) in the past and has changed his mind without changing the documentation. How is it any different? Sure, we rely on family/friends to update. But, if there is any ambiguity, the law supports honoring the directive.  

The authors likely violated the intended advance directive on the patient’s chest. But, I understand why. They were not prepared to give that message the same import an Advanced Directive might have had in a past medical record primarily because of unfamiliarity.  

I’m guessing, without any evidence, the patient had a negative resuscitative experience in a hospital in the past and did not want to repeat that experience. Hence, he took the extraordinary step of making a permanent mark on his body. Ironically, the steps the patient took caused the medical staff to second guess this wishes. 

What do you think? Share your comments below.


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