Earlier this May, Gregory Holt had just finished doing the morning rounds at Miami’s Jackson Memorial Hospital, when he got a call about a new patient in the emergency room. He went down with seven colleagues to find an unconscious 70-year-old man with breathing problems and signs of septic shock. He was alone and had no identification. His blood was full of alcohol, and its pressure was dropping. And when the doctors peeled back his shirt, they found a tattoo, running along his collarbones.
It said: DO NOT RESUSCITATE.
The NOT was underlined. There was a signature under the final word.
Holt was shocked. “We’ve always joked about this, but holy crap, this man actually did it,” he says. “You look at it, laugh a little, and then go: Oh no, I actually have to deal with this.”
By default, doctors would treat patients in this man’s condition as if they were “full code”—that is, they’d want everything possible done to prolong their life. “When faced with uncertainty, you pick the choice that’s not irreversible,” Holt explains. “So let’s do everything we can and when the dust settles, we can determine what the patient wanted if it wasn’t clear from the beginning. The tattoo threw a monkey wrench into the decision.”
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.”
It’s the discussion that matters, not the words on the form (or the tattoo), says Joan Teno from the University of Washington, who studies end-of-life wishes. And in many cases, those discussions don’t happen, or aren’t respected. In a study of bereaved family members, she found that one in 10 say that something was done in the last month of a patient’s life that went against their wishes. “The fact that someone has to resort to a tattoo to have their wishes honored is a sad indictment of our medical system,” Teno says. “We need to create systems of care where patients have the trust and confidence that their wishes will be honored. That’s the important message from this case.”