In Florida, patients can ask not to be resuscitated by filling in an official form and printing it on yellow paper. (Yes, it has to be yellow.) Only then is it legally valid. Clearly, a tattoo doesn’t count. And yet, the patient had clearly gone through unusual effort to make his wishes known. The team members debated what to do, and while opinions differed, “we were all unanimous in our confusion,” says Holt.

They decided to temporarily ignore the tattoo, at least until they could get advice. In the meantime, they gave the man basic treatments—antibiotics, an IV drip, an oxygen mask to help him to breathe, and adrenaline for his plummeting blood pressure. But they avoided putting a tube down his throat and hooking him up to a ventilator. “It would have hurt to see a man with a DNR tattoo having a tracheal tube hanging out of him,” Holt says.

All of this bought them enough time to get a hold of Ken Goodman, the codirector of the University of Miami’s ethics programs. “My view was that someone does not go to the trouble of getting such a tattoo without forethought and mindfulness,” Goodman says. “As unorthodox as it is, you do get a dramatic view of what this patient would want.”

But tattoos are permanent and desires are fleeting, so the team pondered whether the words actually represented the man’s desires. And there’s good reason to be cautious. Back in 2012, Lori Cooper at the California Pacific Medical Center was caring for a (conscious) patient who was going to have a leg amputated, when she noticed a “DNR” tattoo on his chest. The man revealed that he got the tattoo after losing a poker bet many years ago, and actually, he would very much like to be resuscitated if the need arose. “It was suggested that he consider tattoo removal to circumvent future confusion about his code status,” Cooper wrote. “He stated he did not think anyone would take his tattoo seriously and declined tattoo removal.”

Holt’s unconscious patient couldn’t weigh in, but social workers used his fingerprints to track down his identity. He had come from a nursing facility, and to everyone’s immense relief, they had an official DNR form for him, printed on the requisite yellow paper. The man’s condition deteriorated, and he passed away in the night.

The team did the right thing, says Nancy Berlinger from the Hastings Center. They provided basic care to buy time, called for an ethics consult, and got social workers involved. “Even if the records weren’t there, it was right to honor the patient’s preferences,” she says. “Paper gets lost, and some people do not trust paper. This man may have been trying to safeguard against that, and [the tattoo] might have been the most reliable way to make his voice heard. It was right to take it seriously.”

But Lauris Kaldjian, an ethicist at the University of Iowa, says he wouldn’t have honored the tattoo without finding the official form. A DNR order isn’t an end in itself, he says. It’s a reflection of a patient’s goals—how they want their life to end. Patients are meant to discuss those goals with a physician so they can hear all the options available to them, and make an informed decision; the physician must then sign the order. “That’s not meant to be a paternalistic move,” Kaldjian says. “It’s meant to give evidence that a rational discussion was had, and I don’t think tattoo parlors are a place to have to have a code-status discussion.”