A 70-year-old man brought an ethical dilemma with him to the ER at the University of Miami. The man had a history of heart disease and diabetes. When doctors began to work on him, they noticed the words "Do Not Resuscitate" tattooed across his chest with an apparent signature. Some would think the message would be loud and clear, but the man was intoxicated and unresponsive.
This left doctors in a delicate position. Should they honor what they thought were the man's wishes, or perform life saving measures? What if the tattoo was a drunken joke? What if the man got the tattoo at one point in his life but had since changed his mind?
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.
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 man's condition continued to deteriorate through the night and he eventually passed away. According to Dr. Gregory E. Holt, one of the doctors who wrote the letter, these types of tattoos, although out there, are so uncommon that not many of his colleagues have seen them.