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The Man with the DNR Tattoo

By Michael Cook

Should doctors follow the instructions of a tattoo when facing end-of-life decisions?

Doctors at a Florida hospital’s emergency department were startled to discover the words “DO NOT RESUSCITATE” tattooed on an unconscious man’s chest. The word “not” was underlined. Beneath this imperative was his signature, also tattooed.

“We’ve always joked about this, but holy crap, this man actually did it,” one of the doctors who treated him said. “You look at it, laugh a little, and then go: Oh no, I actually have to deal with this.”

The 70-year-old man had no identification. His blood alcohol was high. His health was very bad, with a history of chronic obstructive pulmonary disease, diabetes and an irregular heart rate.

Should they respect the request or not? The default position for contemporary ethics is always to respect a patient’s autonomy.

Autonomy be damned, the doctors thought.

They kept him alive, invoking the principle of not choosing an irreversible path when faced with uncertainty. In a case report in the New England Journal of Medicine, they say that he was placed on antibiotics and given oxygen, an IV drip and adrenaline. But he wasn’t intubated or put on life support.

This gave them enough time to consult an expert from the University of Miami’s ethics programs. His advice was to honour the request. True, the unknown patient had not filled out Florida’s official advance directive form, but a tattoo indicated “forethought and mindfulness”.

Fortunately, with the help of social workers, the hospital managed to identify him. The patient had wandered away from a nursing home and – to the doctors’ relief – he had actually completed an official “do not resuscitate” form. He died later in the day.

There is a serious side to this peculiar anecdote. For many people, resuscitation after a stroke or paralysis or some other misadventure is the worst of nightmares. Being kept half-alive and completely dependent on machines and intensive nursing is the dark side of modern medical advances. Furthermore, in countries where euthanasia is legal, there is pressure for doctors to honour advance euthanasia directives of patients who have declined into dementia.

Useful as they are, the problem with advance directives is illustrated by another tattoo story. In 2012, California doctors reported in the Journal of General Internal Medicine that a 59-year-old man had been admitted to hospital for a below-the-knee amputation due to chronic ulcers. He wanted to be resuscitated in the event of heart or lung failure.

But, like the other patient, he also had a DNR tattoo on his chest, only the acronym, but to hospital staff its meaning was crystal-clear.

It turns out that the man had once worked in a hospital himself in his younger years. At a boozy poker party with his mates, he lost a bet. He paid it off by tattooing “D.N.R.” across his chest.

This is a bit dangerous, the doctors told him. What if we had followed your instructions? Why don’t you get the tattoo removed? But the patient declined: who in their right mind would ever take a DNR tattoo seriously? It was a good question, but the answer is clear: doctors would.

This illustrates a drawback with all advance directives. People change their minds more quickly than they change their tattoos or formal instructions. They may not be a faithful representation of the frame of mind of a patient at the very moment when they are most needed. A heart attack victim may want to cling to life; a quadriplegic may settle into his new circumstances; a demented person may be happy. Binding instructions for doctors written months or even years before may be wrong.

Advance directives are useful, but it’s probably better to appoint a guardian who takes an unconscious patient’s wishes into account in the light of changing circumstances. But if you insist on a DNR tattoo, add a codicil: “Do not resuscitate (and I got this tattoo when I was sober)”.


Michael Cook is editor of BioEdge, an online bioethics newsletter.