Blog Post

Do Not Resuscitate Tattoo Sparks Legal and Ethical Dilemma

Imagine: you are an emergency room doctor and an unconscious 70-year-old man arrives. He has an elevated blood alcohol level, a history of chronic obstructive pulmonary disease (COPD), diabetes, and atrial fibrillation. He has no identification. No friends. No family. He does, however, have a tattoo that reads: “DO NOT RESUSCITATE” along with his signature.


Do Not Resuscitate orders (DNRs) are standard in the medical field and often arise in cases of terminal illness or incurable diseases. Many people sign DNRs because they do not want their doctors and family members to keep them alive if they are in a persistent vegetative state with little to no hope of recovery – or at least recovering to the extent they can enjoy a decent quality of life. However, usually these DNRs are signed documents, not signed tattoos.


The doctors in Florida that were faced with this real-life dilemma asked themselves whether the tattoo clearly reflected the patient’s wishes and whether they should honor it. Furthermore, were they legally required to honor it? In an article published by the New England Journal of Medicine, the doctors explain what happened. Initially, they decided not to honor the tattoo erring on the side of caution when faced with a life-or-death decision. Clearly, the patient had gone to extraordinary measures to get a tattoo presumably reflecting his wishes, but how were they to know whether the tattoo was the result of a drunken whim while out on the town long ago or whether it was a clear directive to medical professionals? In 2012, a man with “D.N.R.” tattoed on his body said he did want life-saving measures taken and the tattoo was the result of a bet gone wrong.


The doctors chose to take the issue to ethics consultants while they kept the man alive who advised the doctors to honor the tattoo because it was “most reasonable to infer that the tattoo expressed an authentic preference.” Thus, the doctors entered a DNR order. Later, the department of social work was able to obtain a copy of the patient’s DNR order which was consistent with the tattoo. His status deteriorated through the night and the doctors did not perform any life-saving or life-sustaining procedures on him.


Certainly, having ethics consultants sign off on the DNR helped the doctors’ decision in this matter and finding the DNR later confirmed that decision, but it begs the question: what if there were no ethicists and no written DNR? Would the tattoo be legally sufficient to act upon?


The short answer is “no”, at least not in Florida. Pursuant to state law, a person can only request to not be resuscitated by signing a specific yellow DNR form. Absent the form, the tattoo would not be legally binding meaning if doctors kept him alive, they wouldn’t be liable for doing so, which can be punishable by a hefty fine. Other states require forms as well, but living wills and other advanced directives can be substituted.


In North Carolina, the Right to a Natural Death Act recognizes a patient’s right to die peacefully and naturally. This legislation helps promote self-determination in the last stage of life and was created so patients can make their end-of-life plans known. The Act provides protection from liability to medical providers in “circumstances involving withholding or withdrawing extraordinary means of life support or artificial nutrition or hydration from an incompetent patient who is terminally or incurably ill, comatose, or in a persistent vegetative state.” Such “extraordinary measures” basically mean some sort of intervention that postpones death by performing a vital function on behalf of a patient, such as a feeding tube.


In North Carolina, a physician can issue a DNR order at the request of a patient. They can also put it into place if the patient is close to death and unable to communicate, but has a living will or other advanced directives that make the patient’s wishes clear. A health care power of attorney can also request a DNR.


At the end of the day, tattoos are no substitute for frank conversations with friends and family about what your end-of-life wishes are. Nor are they a good substitute for an actual written, legal DNR or other advanced directives. To obtain North Carolina’s portable Do Not Resuscitate form, click here.




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