Doctors at a University of Miami hospital faced a tricky situation when an unconscious man with a "Do Not Resuscitate" chest tattoo was brought into the emergency room. The patient, who was unresponsive and had an elevated blood alcohol level, left the ER doctors facing an ethical dilemma. Should they honor the man's apparent DNR request or play it safe and ignore it?
The medical staff's ethical conundrum was described in a case study published this week in the New England Journal of Medicine. In it, the authors recounted that the unnamed 70-year-old man, a diabetic, was brought into the emergency room in an unconscious state. He had a history of pulmonary disease and had an irregular heart rate.
An accompanying photo showed that the patient had the words "DO NOT RESUSCITATE" tattooed on his chest. The word "NOT" was underlined, and the man's signature was tattooed underneath "RESUSCITATE."
Shortly after the man was brought to the hospital, his condition began to deteriorate, and doctors had to figure out whether they should perform dramatic medical interventions to keep him alive. They couldn't find any form of identification and were unable to immediately locate the patient's family members.Not knowing whether the tattoo was a genuine DNR request, the doctors at first began lifesaving efforts, administering intravenous fluids and antibiotics. However, they also requested a consultation with the hospital's ethics team.
"We initially decided not to honor the tattoo, invoking the principle of not choosing an irreversible path when faced with uncertainty," the doctors wrote in the case study.
"This decision left us conflicted owing to the patient's extraordinary effort to make his presumed advance directive known."
Dr. Gregory Holt, the lead author of the case study, told Gizmodo that his main concern was whether the patient's tattoo was legally acceptable.
"Florida has stringent rules on this."
In fact, DNR tattoos are not considered valid by the Florida Department of Health.
Since no one could definitively say that the man's tattoo was an actual statement of his wishes, the hospital's ethics team advised the medical staff that the "Do Not Resuscitate" tattoo was probably an accurate representation of the man's preferences and that it should be honored.
According to the ethics consultants, "what might be seen as caution could also be seen as standing on ceremony." They also advised the doctors that "the law is sometimes not nimble enough to support patient-centered care and respect for patients' best interests."
A DNR order was written, but, fortunately, someone was able to find an official copy of the patient's "Do Not Resuscitate" request from the Florida Department of Health. The man died overnight without undergoing further lifesaving efforts.
According to the doctors, they were put at ease when the DNR order was found because the situation could have ended in a very tragic manner.
"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."
Indeed, a case study published in 2012 in the Journal of General Internal Medicine described how a diabetic man who was scheduled for a leg amputation was found to have a "D.N.R." tattoo on his chest. In this case, the man was able to indicate that he, in fact, wanted to be resuscitated. He got the tattoo, he explained, after losing a bet playing poker. He told doctors that he didn't think anyone would take the tattoo seriously.