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:
BEST PRACTICES
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!