N Engl J Med 2017; 377:2192-2193 November 30, 2017
To the Editor:
We present the case of a person whose presumed code-status preference led him to tattoo “Do Not Resuscitate” on his chest. Paramedics brought an unconscious 70-year-old man with a history of chronic obstructive pulmonary disease, diabetes mellitus, and atrial fibrillation to the emergency department, where he was found to have an elevated blood alcohol level. The staff of the medical intensive care unit evaluated him several hours later when hypotension and an anion-gap metabolic acidosis with a pH of 6.81 developed. His anterior chest had a tattoo that read “Do Not Resuscitate,” accompanied by his presumed signature. Because he presented without identification or family, the social work department was called to assist in contacting next of kin. All efforts at treating reversible causes of his decreased level of consciousness failed to produce a mental status adequate for discussing goals of care.
We initially decided not to honor the tattoo, invoking the principle of not choosing an irreversible path when faced with uncertainty. This decision left us conflicted owing to the patient’s extraordinary effort to make his presumed advance directive known; therefore, an ethics consultation was requested. He was placed on empirical antibiotics, received intravenous fluid resuscitation and vasopressors, and was treated with bilevel positive airway pressure.
After reviewing the patient’s case, the ethics consultants advised us to honor the patient’s do not resuscitate (DNR) tattoo. They suggested that it was most reasonable to infer that the tattoo expressed an authentic preference, that what might be seen as caution could also be seen as standing on ceremony, and that the law is sometimes not nimble enough to support patient-centered care and respect for patients’ best interests. A DNR order was written. 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.
This patient’s tattooed DNR request produced more confusion than clarity, given concerns about its legality and likely unfounded beliefs1 that tattoos might represent permanent reminders of regretted decisions made while the person was intoxicated. We 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.2 Despite the well-known difficulties that patients have in making their end-of-life wishes known,3-5 this case report neither supports nor opposes the use of tattoos to express end-of-life wishes when the person is incapacitated.
Gregory E. Holt, M.D., Ph.D.
Bianca Sarmento, M.D.
Daniel Kett, M.D.
Kenneth W. Goodman, Ph.D.
University of Miami, Miami, FL
5 References
1. Lande RG, Bahroo BA, Soumoff A. United States military service members and their tattoos: a descriptive study. Mil Med2013;178:921-925
2. Cooper L, Aronowitz P. DNR tattoos: a cautionary tale. J Gen Intern Med 2012;27:1383-1383
3. Kaldjian LC, Erekson ZD, Haberle TH, et al. Code status discussions and goals of care among hospitalised adults. J Med Ethics2009;35:338-342
4. Yung VY, Walling AM, Min L, Wenger NS, Ganz DA. Documentation of advance care planning for community-dwelling elders. J Palliat Med 2010;13:861-8675.
5. Teno J, Lynn J, Wenger N, et al. Advance directives for seriously ill hospitalized patients: effectiveness with the patient self-determination act and the SUPPORT intervention. J Am Geriatr Soc 1997;45:500-507