Do Not Resuscitate – read my DNR tattoo

If you feel very strongly about something, you want your conviction to be perfectly clear to all. Surely one of the clearest ways to make your view known on a particular issue would be to have it tattooed onto your body. Well, someone actually did that.

A 70-year-old man, suffering from various life-threatening conditions, wound up unconscious at a hospital casualty department in the US state of Florida. Clear instructions were tattooed on his chest: “Do Not Resuscitate”. The word “Not” was underlined, with his signature underneath. Photos of this man’s tattoo can be seen all over the internet, with the message clearly readable (and his signature blurred out).

DNR tattoo on man's chest

The tattoo that caused all the trouble – credit: arstechnica

It’s called a DNR for short

A DNR, as it is known, is a legal document by patients or their loved ones to instruct doctors not to use “extraordinary means” to try to bring them back to life if their heart stops or they have trouble breathing. A DNR typically aims to prevent medical professionals from aggressively attempting to prolong a patient’s life.

The case of the Man With The DNR Tattoo has gone down in medical history.

“We’ve always joked about this, but holy crap, this man actually did it. You look at it, laugh a little, and then go: Oh no, I actually have to deal with this.”

critical-care physician Gregory Holt

Dr Holt wrote in the New England Journal of Medicine that confusion about how to respond to this DNR tattoo arose “given concerns about its legality and likely unfounded beliefs that tattoos might represent permanent reminders of regretted decisions made while the person was intoxicated”.

So the doctors’ suspicions that the patient’s tattoo was DUI – Done Under the Influence – made them distrust the instructions clearly inscribed on his body. They decided instead to invoke the principle of “not choosing an irreversible path when faced with uncertainty” and tried (unsuccessfully) to resuscitate him.

Example of a DNR order

Example of a DNR order – credit: Wikipedia

This incident raises the question whether, in this era of online signatures and Tweeted government statements, a document must still be written on paper to be legal. Does the rather judgmental principle of “Tattoo Regret” override a tattooed declaration? Or does the considerable effort taken to get a tattoo indicate strong enough commitment for such a DNR to be obeyed?

After considerable liaison with bioethics consultants, this story ended with the tattoo eventually being honoured. The decision was aided by social workers finally locating the patient’s written DNR. Therefore he was allowed to die as per his request, without further efforts at resuscitation.

That’s not the end of the story for me, though. I still have more questions. Was it a violation of the patient’s privacy to post all those close-up photos of his tattooed chest on the internet? What if the patient had been female, or underage – would such photos have been considered immodest or prurient?

A Cautionary Tattoo Tale

Law relies on precedents and there is one to cite here. The Journal of General Internal Medicine chronicled an incident 5 years ago of patient with the same kind of DNR tattoo, also on his chest. This patient arrived at the hospital still able to talk, and he explained that his tattoo should be ignored because it was the result of losing a bet while playing poker.

Uh-oh, I see another ethical quandary arising. What if the patient had been unconscious and his tattoo had been heeded and he died? Could the poker players who enforced his tattooing be prosecuted as accessories to a crime – manslaughter, if not murder?

To DNR or not to DNR is a question of obvious interest to older people, some of whom believe that elderly patients are wrongly considered to have authorised DNRs. The chief executive of Britain’s Action on Elder Abuse calls it “passive euthanasia”.

“DNRs do have a place in hospitals but only with the patient’s or family’s agreement. It’s our right to decide the care we receive or don’t receive. I’d say to anyone with an elderly relative in hospital, check their notes to see if a DNR form is there.”

CEO of UK Action on Elder Abuse Gary Fitzgerald

The US National Institute of Health is also critical of the way DNRs are implemented in hospitals.

“DNR discussions do not occur frequently enough and occur too late in the course of patients’ illnesses to allow their participation in resuscitation decisions”.

Journal of General Internal Medicine, 2011

CPR vs DNR

Judging from the way they dramatically bring people back to life on TV and movies, you might be tempted to opt for CPR rather than DNR. Off camera, however, statistics don’t show a great success rate. According to the British Medical Association only 15-20% of those who get this kind of treatment go home.

Cardiopulmonary resuscitation machine

Cardiopulmonary resuscitation (CPR) gear – credit: whydon’tyoutrythis.com

Another interesting statistic concerns most doctors’ own preference. Research published in the top medical journal PLOS One showed that some 88% of physicians have signed DNRs.

“Our study raises questions about why doctors continue to provide high-intensity care for terminally ill patients, but personally forego such care for themselves at the end of life.”

– “Do Unto Others: Doctors’ Personal End-of-Life Resuscitation Preferences and Their Attitudes toward Advance Directives” –  Vyjeyanthi S. Periyakoil, Eric Neri, Ann Fong and Helena Kraemer

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