By Jackie Glover, PhD
(October 2018) The patient arrives in the emergency room unconscious and in dire straits, and he has DO NOT RESUSCITATE tattooed across his chest.
What should health care providers do? Honor the tattoo as if it were a legal document? Ignore it? Proceed with aggressive treatment? Provide comfort care? Seek an ethics consult?
Earlier this year, I assembled a panel on the Anschutz Medical Campus to consider these questions from the provider, ethical and legal perspectives. While their reasoning varied, each panelist agreed: A tattooed DNR is not an automatic directive that a provider can rely on.
We began our conversation with the perspective of an artist who provides medical tattoos, including DNR tattoos on rare occasions. As the lead artist and clinician at Skin Holistic Dermagraphics in Boulder, Tara Gray-Wolfstar, RN, explained that some tattoo artists will ink a DNR onto a person without knowing its potential effect or sometimes without even ascertaining the client’s reasoning. Gray-Wolfstar said she will only tattoo DNR for patients who have terminal medical conditions and who have otherwise completed valid DNR orders.
David Nowels, MD, MPH, associate professor of family medicine and the palliative medicine fellowship director at the School of Medicine, noted that a DNR typically reflects a patient’s wishes at a moment in time, but he added that patient preferences often change over time. As a member of a palliative care team, he recognized many DNRs are ambiguous. He recommended clinicians use the DNR to start a conversation if possible about what the patient understands and desires to control regarding interventions.
Because a DNR, in its ideal form, represents a patient’s expression of an autonomous medical decision, Julie Swaney, MDiv, manager of UCHealth University of Colorado Hospital Spiritual Care Services, explained context matters and that it’s necessary to understand why a patient might have a DNR tattoo. She recalled a case in which a patient with a tattooed DNR later explained that he got it because he lost a bet. He said he never expected anyone to take the tattoo seriously. Without knowing the patient’s perspective and story, a provider can do more harm than good.
Finally, CU Vice President and University Counsel Patrick O’Rourke discussed the legal framework. While a provider might rely upon a tattooed DNR to defend a lawsuit brought by a patient’s surviving family, a provider can also point to the ambiguity in the scope of a tattooed DNR with regard to the level of treatment. In such cases, a jury likely would understand why a provider was hesitant to focus exclusively on a tattoo to dictate a course of medical care.
In the final analysis, a tattooed DNR is only a clue that a patient may not want specific interventions. But that tattoo alone cannot express a patient’s motivations. Providers should use the tattoo as an invitation to open a broader conversation, including with the patient’s family members and caregivers if they can be located. While respecting the patient’s autonomy, providers must observe their own ethical obligations.
Jackie Glover, PhD, is professor of pediatrics, philosopher ethicist at the Center for Bioethics and Humanities, and co-medical director of the UCH ethics consult.
Listen to the session, including audience members’ reactions and the panelists’ reaction to their comments →