Moving Us Closer To Osler
A Miller Coulson Academy of Clinical Excellence Initiative

Sacred or Stigma? A New Realm of Expression


In 2018, do not resuscitate options are broad—distillation of the letters DNR do not provide enough guidance, and tattoos have yet to be validated as a definitive expression of this wish.

What would you do?

What would YOU do if you came to guide the care of a critically ill patient, one you had never met, with whom you had no relationship, one who has known history of advanced medical ailments, who has a tattoo that states “DO NOT RESUSCITATE”?

Recently, a medical team at the University of Miami faced this exact situation and it sparked angst, debate. Initially, the physician team did not wish to honor the tattoo because this was clearly not a normal mode of communication and uncertainty remained. To choose to honor the tattoo would go along an irreversible path.

An ethics consult disagreed; they felt that the act of tattooing this suggested that it was reasonable to infer that this was his true preference.

Again, what would you do? What would you do if this patient (with or without a tattoo), clearly severely intoxicated, was shouting “DO NOT RESUSCITATE ME”? What if they were psychotic (off meds)? Had known depression? Possibly delirious from the critical illness? Given his history, it is reasonable that this could be his true preference but how can you be sure?

Respecting patient’s preferences

We must respect and honor our patient’s preferences. Yet, there are degrees of resuscitation. Do we intubate? Do we do CPR? Do we shock? Do we use pressors? Would you want an operation? If this is a reversible condition, would you choose to suspend your DNR for treatment?

None of this can possibly be addressed by this patient’s tattoo. In fact, today, I cannot write an order as simple as DO NOT RESUSCITATE in the chart. As an Acute Care Surgeon (Trauma, Emergency Surgery and Surgical Critical Care), I live at this threshold all too often. Very few patients have clarity on this issue when not faced with crisis, let alone when in the throes of critical illness. Further, we face over and over conflict when one beside provider “clearly understood” the patient’s preference of limiting heroic care, and the surrogate (spouse, sibling, adult child) interpret wishes differently once the patient can no longer appropriately communicate.

Tattoos are no longer rare, nor do they carry the social stigma they once did. Many are true works of art. Many are sacred to their hosts; there are religious devotions and remembrances that are quite touching. We also know that many tattoos, thought to be a good idea at the time, are frequently the cause of regret in hindsight. It is because opinion and circumstance change.

While it is indeed reasonable to infer that this particular tattoo may have been planned with deeper consideration than most, in 2018, the convention has yet to include a tattoo as a final word. How would you feel about a tattoo that stated “STONE COLD KILLER”? A swastika? A misogynist statement? (I have seen each of these in the last month). Would you give them the same absolute consideration without lucid discussion?

The best way to honor a patient’s wish

This gentleman’s tattoo was ultimately proven to be consistent with his wishes; the team was able to locate an appropriate legal document that corroborated his preference.. This, in my opinion, is our very best way to honor his values. We care for and support this patient and, equally vital, confirm his wishes as soon as we can. We must have faith that anyone who has put the forethought and effort into such a tattoo, has also pursued the appropriate legal route to stand behind his “projected” preference (either by documentation or via identified surrogate). We should also continue to proffer this dilemma for consideration. I doubt that this was the first nor will it be the last time this occurs.