Slide 1: 70 year-old male with COPD, diabetes, and atrial fibrillation brought in to the ED unconscious found to have DNR tattooed across his chest.

Slide 2: What do you do?
A. Respect the tattoo as a DNR
B. Ignore the tattoo. It is not a legal DNR; the patient should be full code
C. Freak out, call Ethics

Slide 3: As clinicians, it is our ethical responsibility to respect patients’ wishes – even when they are incapacitated. We encourage patients to make these wishes clear via advanced directives.

When no directive is available, the best practice is to provide treatment since the alternative is irreversible.

Questions inevitably arise when desires around life-saving measures are expressed unconventionally.

Slide 4:
Tattoos, like advanced directives, are often meant to durably reflect someone’s values.

However, tattoos (and advanced directives!) can also reflect:

Past values that are no longer accurate

Decisions made without complete understanding

Slide 5:
Adjust your expectations
View end-of-life decisions as a process of continuous consent. Revisit the topic early and often, as patients’ values may change over time.

Ask for understanding
Asking patients to explain in their own words often reveals critical lapses you don’t want to miss.

Brush up on your local DNR policy
Policies regarding out-of-hospital directives are regulated at the state level. Knowing the legal framework may help you feel more comfortable with understanding where (if anywhere) ink fits in!

The Food For Thought

On this Food For Thought: a man with a DNR tattoo brings up a challenging ethical dilemma. While not a legal advanced directive, could a tattoo accurately reflect a person’s current values and end of life desires? To what extent should it be respected? It’s also a good reminder that even legitimate advanced directives can be flawed representations of a person’s goals. Remember that end of life care should be a process of continuous consent – not something tattooed permanently on your skin OR your medical record.


  • Holt GE, Sarmento B, Kett D, Goodman KW. An Unconscious Patient with a DNR Tattoo.N Engl J Med. 2017 Nov 30;377(22):2192-2193. PMID 29171810 .
  • Gysels M et al. MORECare research methods guidance development: recommendations for ethical issues in palliative and end-of-life care research. Palliat Med. 2013 Dec;27(10):908-17. PMID 23695828.
  • Holt GE, Goodman KW, Olvey SE, Kett D. Nonstandard do-not-resuscitate orders. Curr Opin Anaesthesiol. 2019 Apr;32(2):179-183. PMID 30817392.

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