When a tattoo says ‘do not resuscitate’
When a Florida man was brought into an emergency room with a do not resuscitate (DNR) tattoo on his chest along with a signature, a team of physicians found themselves at an ethical crossroad. Should the tattoo be honoured as an official request to not resuscitate, or should every attempt be made to save the man’s life?
The case, outlined Thursday in the New England Journal of Medicine, describes doctors initially trying to save the man’s life. The team requested an ethics consultation and later decided to honour the tattoo and stop resuscitation efforts. Hospital documentation was found to confirm the man’s wishes, and he died shortly after.
“The tattoo was such a dramatic display of rejection,” said Dr. Kenneth Goodman, director of the Institute for Bioethics and Health Policy at the University of Miami, and co-author of the report. “I think this was someone who really didn’t want to be resuscitated.”
But Goodman acknowledged the situation is tricky because it’s difficult to assess whether a tattoo is indicative of a person’s current wishes.
“The ethical standard is, you should do to an unconscious patient what they would want if they were conscious,” he said. “But the problem with all advanced directives — even a document signed with a witness — is that someone can change their mind at any time.”
In Canada, there’s been a steady rise in medical tattoos, but they’re not necessarily having the intended effect.
Dr. Bojan Paunovic, executive member of the Canadian Critical Care Society and an ICU physician, says that while a tattoo would grab his attention and prompt him to look for documentation, it certainly wouldn’t be the determining factor in his decision on whether to resuscitate.
“Unless the Supreme Court says a tattoo is a legally binding document, then it’s nothing more than an expression of emotion,” says Paunovic. “A tattoo doesn’t obligate a physician to not provide care if they don’t have more information, and I wouldn’t advise my colleagues to be worried that they’ll have to justify their actions.”
Paunovic says knowing context is critical when it comes to any type of DNR order, even if it takes the form of a signed document.
“When I read a document, I don’t just say ‘this is what I will or won’t do’ because DNRs are not black and white,” he says. “People will write things like ‘I’ll be on dialysis but only for a week,’ so they think they’ve thought things through, but it’s really more confusing for the physician.”
He also said that when a medical situation actually presents itself, many people change their minds about how to proceed. Paunovic recognizes that expressing your wishes in a hospital setting can be frustrating, but doesn’t think tattoos are the answer.
“Things like better communication in hospitals need to be addressed, but I don’t think (getting DNR tattoos) is the way to fix it.”
Osborne Barnwell is a lawyer who works on cases of medical malpractices, and says it doesn’t seem like a tattoo alone would be enough to justify a physician from refusing to resuscitate.
“I would argue that in the absence of a clear indication that the tattoo represents a patient’s current position, then the doctor would be well within their rights to proceed (in caring for the patient).”
The concern of whether a tattoo represents a patient’s current wishes has previously been documented. In 2012 an article was published about a man who had a DNR tattoo on his chest, but still wanted to be resuscitated — the tattoo was the result of a lost poker bet.
And removing a tattoo isn’t easy — it can take several sessions, and is both expensive and painful.
Matt Kim has been a tattoo artist for 15 years, and has only done one DNR tattoo, but says it’s not uncommon for people to regret a tattoo.
“I do quite a few coverups, that’s for sure,” he says.