By Matthew Konya
You are dispatched to a local residence for breathing difficulty. You arrive to find a 75-year-old male in severe respiratory distress. Before you can get the patient out to your ambulance, he goes into cardiac arrest. You immediately start resuscitation efforts, you remove the patient’s shirt and across his chest is tattooed “DO NOT RESUSCITATE!”
There are no other people on scene, and you are unable to find any additional information. How would you proceed? Do you disregard the tattoo and continue resuscitation efforts? Do you honor the patient’s tattoo and stop resuscitation efforts? Contact medical command and ask for guidance? This situation is more common than one would expect.
Recently in Miami, a 70-year-old patient was brought to Jackson Memorial Hospital. The patient was unconscious and had no identification. However, the patient did have a DNR tattoo complete with the patient’s signature on his collarbone.
At first, doctors were unsure how to proceed, but after consulting with an ethics expert, they decided to honor the tattoo. It was later discovered that the patient had a valid DNR on file [1].
In the field, there is little chance that you will be able to contact an ethics expert before determining a course of treatment for your patient. However, there are several tips that can keep you and your agency out of legal liability when confronted with a DNR tattoo.
Understand that DNR tattoos can be misleading
It should come as no surprise that people, sometimes motivated by alcohol, make rash and ill-advised choices. In one such case, a 59-year-old patient was admitted to a California hospital with “D.N.R.” tattooed across his chest.
After reviewing his chart, it was noted that the patient requested resuscitation efforts in the event of cardiac or respiratory arrest. When questioned about the inconsistency between his tattoo and his chart the patient explained why he had a DNR tattoo. He had lost a bet playing poker with fellow ancillary hospital staffers while inebriated in his younger years; the loser had to tattoo “D.N.R.” across his chest [2].
The patient’s doctor suggested that the patient have the tattoo removed to avoid any confusion. However, the patient declined the advice, stating he felt that no one would take the tattoo seriously.
This is a perfect example of why EMS practitioners should never solely rely on a DNR tattoo when determining whether or not to withhold resuscitation efforts. While being cautious when dealing with DNR tattoos is a good practice, knowing your state law regarding DNRs is the best way to avoid legal liability.
Know your state DNR law
DNRs are advance directives that dictate the patient’s wishes regarding resuscitation efforts if the patient is incapable of expressing those wishes. Laws vary from state to state regarding what constitutes a valid DNR. Most states require that the patient have a terminal illness before obtaining a DNR.
Additionally, states specify what form a DNR must be in to be considered legally binding. Commonly accepted forms of DNRs include:
- Cards
- Completed official forms
- Approved necklets and bracelets
Unless your state specifically recognizes tattoos as a valid DNR, EMS practitioners should not rely on a tattoo to make medical decisions. It is important to note that some states provide legal protection to medical practitioners who provide treatment to patients with a DNR if there is uncertainty about the validity of the DNR.
DNRs are not permanent, and can be revoked at any time by the patient. While paper DNRs can be easily revoked, tattoos are harder to destroy. Patients with terminal illness can get better, or decide they want to be resuscitated. It is possible that a patient may have a valid DNR, decided to get a DNR tattoo, then revoked their DNR. The patient may not be able to get the tattoo removed [2].
This is a perfect example of how EMS practitioners could find themselves in legal trouble if they blindly follow a DNR tattoo without verifying that a valid DNR exists. So, if a patient with a valid DNR says to you, “Don’t honor that DNR, I want to live,” you should follow that verbal revocation and not honor the DNR.
Look for additional clues for DNR validity
Short of relying solely on a DNR tattoo to terminate resuscitation efforts, DNR tattoos can provide limited information about the patient. If a patient has a DNR tattoo, you should be on the lookout for other clues that the patient does not wish to have life saving measures performed – such as an official completed DNR form or a DNR bracelet.
If the patient is conscious and alert, and has a DNR tattoo, EMS practitioners should have a conversation about the patient’s wishes in the event of cardiac or respiratory arrest.
If the patient is unable to communicate, the presence of a DNR tattoo is an indication that EMS needs to gather additional information. Might the patient have a terminal condition? Does the patient have a valid DNR? Are there family or friends on scene that may know what the patient’s wishes are?
If a patient does have a DNR tattoo, it should be an indication that EMS practitioners need to ask additional questions.
Bottom line on DNR tattoos
Tattoos are likely not a valid form of DNR in your state. As such, tattoos should not be relied on by EMS practitioners. EMS practitioners should be aware of their state laws pertaining to DNRs; especially what constitutes a valid DNR.
The presence of a DNR tattoo should make you ask more questions. If your patient only has a DNR tattoo, and no form of valid DNR, you should follow your local protocols and start resuscitation efforts immediately. As with any judgment call in the field, do not hesitate to contract medical command for additional guidance if needed.
References
1. Holt GE. (2017). An unconscious patient with a DNR tattoo. “The New England Journal of Medicine” (Correspondence), 2192-2193.
2. Lo AK. (2012). The problem with actually tattooing DNR across your chest. “Journal of General Internal Medicine,” 1238-1239.
