Unconscious patient's 'Do Not Resuscitate' tattoo creates ethical dilemma for ER staff

Emergency room staff at a Florida hospital found an unconscious patient with "do not resuscitate" tattooed on his chest, prompting confusion and ethical concern, according to a case report in The New England Journal of Medicine.

Paramedics brought the unconscious 70-year-old man to the ER, where he was found to have an elevated blood alcohol level. The man had a history of chronic obstructive pulmonary disease, diabetes and an irregular heart rate.

The "do not resuscitate" tattoo on his chest underlined "not," and included what staff presumed to be his signature. The man arrived at the ER with no identification or family present, which prompted the social work department to assist in contacting his next of kin.

ER staff failed to help the patient regain a level of consciousness where he could adequately discuss his goals for care. The staff initially decided not to honor the patient's tattoo. They reasoned they should not make an irreversible choice due to the situation's uncertainty. However, this decision left staff conflicted and they requested an ethics consultation.

The ethics consultants advised staff to honor the patient's DNR tattoo. They reasoned staff could infer the tattoo expressed the patient's authentic preference and added that laws are not always flexible enough to respect a patient's best interest.

A DNR order was written and the social work department obtained a copy of the patient's Florida Department of Health "out-of-hospital" DNR order, which was consistent with his tattoo. The patient died after his health continued to deteriorate throughout the night, without receiving CPR.

"This patient's 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," the authors wrote. "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 case report authors noted this incident does not support or oppose the use of tattoos to express end-of-life wishes for patients who are incapacitated.

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