Tattooed DNR plunges doctors into ethical conundrum


By Tessa Hoffman

7 Dec 2017

Having an end-of-life directive tattooed on your body may provide peace of mind – but spare a thought for those tasked with interpreting it.

A case report published in the NEJM highlights the ethical conundrum faced by staff at a US emergency department after the arrival of an unconscious 70-year-old man with the words “do not resuscitate’ accompanied by a presumed signature inked across his chest.

The man had a history of chronic obstructive pulmonary disease, diabetes mellitus, and atrial fibrillation.

Upon arrival he had an elevated blood alcohol level and within hours developed hypotension and an anion-gap metabolic acidosis (pH of 6.81).

Doctors initially opted not to honour the tattoo’s directive, invoking the principle of not choosing an irreversible path when faced with uncertainty.

But the decision left them conflicted.

They considered the patient’s extraordinary effort to make his presumed advance directive known.

But they also considered a case report about a person whose DNR tattoo did not reflect his current wishes.

The doctors called on their ethics consultants, who suggested it was most reasonable to infer that the tattoo expressed an authentic preference, and the hospital authorised a DNR.

The hospital subsequently tracked down the patient’s “out-of-hospital” DNR order authorised in Florida and the patient died in hospital, without undergoing cardiopulmonary respiration or advanced airway management.

But the tattooed DNR request “produced more confusion than clarity, given concerns about its legality and likely unfounded beliefs that tattoos might represent permanent reminders of regretted decisions made while the person was intoxicated,” wrote Dr Gregory Holt and his colleagues from the University of Miami.

“Despite the well-known difficulties that patients have in making their end-of-life wishes known, this case report neither supports nor opposes the use of tattoos to express end-of-life wishes when the person is incapacitated,” the authors concluded.

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