When an unconscious patient with a “do not resuscitate” (DNR) tattoo on his chest was admitted to Jackson Memorial Hospital’s emergency room last summer, the University of Miami Miller School of Medicine clinicians faced a serious ethical question: whether or not to honor his wishes.
“We felt that the patient’s tattoo, which included his signature, was clearly a call for help,” said Gregory E. Holt, M.D., Ph.D., a pulmonary critical care specialist, who was the lead author of a letter, “An Unconscious Patient with a DNR Tattoo,” published November 30 in the New England Journal of Medicine’s correspondence section. Co-authors were Bianca Sarmento, M.D.; Daniel Kett, M.D.; and Kenneth W. Goodman, Ph.D., professor and director of the UM Institute for Bioethics and Health Policy and co-director of UM Ethics Programs.
After no next-of-kin could be located for the 70-year-old patient, who had a history of chronic obstructive pulmonary disease, diabetes mellitus, and atrial fibrillation along with an elevated blood alcohol level, the attending physicians requested a consultation with the Miller School’s bioethics team.
“After reviewing the patient’s case, the ethics consultants advised us to honor the patient’s do not resuscitate (DNR) tattoo,” said Holt. “They suggested that it was most reasonable to infer that the tattoo expressed an authentic preference, and that the law is sometimes not nimble enough to support patient-centered care and respect for patients’ best interests.”
After a DNR order was written, the hospital’s social work department obtained a copy of the man’s Florida Department of Health “out-of-hospital” DNR order, which was consistent with the tattoo. The patient died the next day.
“This was an excellent example of the role of the bioethics team in helping us think through the issues and arrive at the appropriate answer,” Holt said. “However, we need to develop and implement a better system to convey end-of-life directives more rapidly and appropriately to the medical team.”
For example, Holt said Oregon has an online registry for individuals who don’t want life-sustaining therapy, Holt said. “Every emergency room physician in that state can access that system and treat patients appropriately. It’s a model that could be tried on the state and national level.”
Reflecting on the case, Goodman said, “The lesson for all of us is to have conversations with loved ones about end-of-life preferences, especially if we want to die peacefully at home in the presence of family members – and not in a hospital with physicians and nurses struggling to infer those preferences and how to honor them.”