A 70-year-old patient with a "DO NOT RESUSCITATE" tattoo arrived unconscious and critically ill at a Florida ED—but in absence of ID or guidance from next of kin, did his tattoo count as a legally binding request? That's the conundrum that ED staff had to resolve in a case study published in the New England Journal of Medicine.

Related: URMC's prompt list for end-of-life care

The case study

According to Gizmodo, 80% of Medicare beneficiaries have said "they wish to avoid hospitalization and intensive care during the terminal phase of illness." Patients can document such wishes in a formal way through a "do not resuscitate" (DNR) order, typically created after consultation with family members and doctors.

But the Florida case presented an unusual challenge: Although the patient had "DO NOT RESUSCITATE" tattooed on his chest, he did not have any ID, and doctors were unable to contact any next of kin—making it impossible to verify if he had ever made a formal DNR request.

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The patient, a 70-year-old man, had a history of chronic obstructive pulmonary disease, diabetes, and an irregular heart rate. Without medical intervention, he would have soon died.

At first, the medical staff decided to act cautiously: "We initially decided not to honor the tattoo, invoking the principle of not choosing an irreversible path when faced with uncertainty," the study authors wrote. "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."

According to Gregory Holt, the lead author on the study, "After reviewing the patient's case, the ethics consultants advised us to honor the patient's 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 (i.e. adherence to medical tradition and norms), and that the law is sometimes not nimble enough to support patient-centered care and respect for patients' best interests."

Ultimately, before the man died, social workers discovered the patient's Florida Department of Health "out-of-hospital" DNR order. "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," the authors wrote.

Discussion

According to the authors of the study, the incident "produced more confusion than clarity," highlighting the difficulty of ascertaining a patient's end-of-life wishes.

Kerry Bowman, a bioethicist at the University of Toronto, said that this situation was extremely difficult. "Advanced directives of any kind do not override most recent expressed capable wish," he said. "In other words, [the patient] may have changed his mind and there may be no way of knowing. Tattoo regret is not rare. (The ICU team's) defense is erring on the side of life."

Ultimately, Bowman said that he agreed with the ethics consultants' decision. "My position would be if someone went to the great length of having DNR tattooed with a signature, it indicates a strong and clear wish," he said.

Melissa Garrido, an associate professor at the Icahn School of Medicine at Mount Sinai in New York City, said that since DNR requests aren't always readily available in a crisis situation, "a standardized tattoo may be a readily accessible method for communicating a strongly held care preference" (Mole, ARSTechnica, 11/30; Dvorsky, Gizmodo, 11/30).

Next, get URMC's end-of-life conversation prompts

When it comes to end-of-life care, most organizations struggle to meet patients' needs. In a recent poll, 87% of Americans age 65 and older said that they believe their doctor should discuss end-of-life issues with their patients; however, only 27% of those polled had actually discussed these issues with their doctor.

Download URMC's conversation prompts to start improving end-of-life care for patients.

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