A recent case study in the New England Journal of Medicine is getting a lot of attention for the ethical and legal questions is raises. A 70-year-old man in Florida was found unconscious on the street and transported to hospital. He arrived with no identification, family or friends and, with one possible exception, had no way of communicating with the medical team. The possible exception was a tattoo of the words, “Do Not Resuscitate” on his chest. The word ‘Not’ was underlined, and the tattoo even included a signature.

Unfortunately for all involved, the man’s condition deteriorated quickly and the care team was faced with the unenviable task of deciding whether to honour the tattooed instructions. While the meaning of the words was perfectly clear, the intention behind them was anything but. Was the tattoo a joke or was it serious? Did it reflect the man’s current wishes or his previous wishes? Was he opposed to being resuscitated even if he would not suffer any permanent physical or mental injuries?

To make matters more complicated, the treating doctors were aware of a previously reported incident involving a 59 year old patient who had “D.N.R” tattoo across his chest but said he wanted life-saving measures to be taken if he needed them. He had reportedly only gotten the tattoo because he had lost a bet playing poker.

Florida requires do-not-resuscitate orders to be printed on yellow paper and signed by a physician. As the tattoo did not satisfy these requirements, the treating doctors requested an opinion from an ethics consultant. With very limited information, the consultant concluded it was “most reasonable to infer that the tattoo expressed an authentic preference” and should be honoured. Fortunately, the issue was subsequently resolved when social workers managed to locate the man’s formal do not resuscitate paperwork shortly before he died.

A news article about the story is available here:


The moral of this cautionary tale is that DNR tattoos create more confusion than clarity and should be avoided.

Proper advance care planning often involves appointing an attorney for personal care and ensuring that your attorney is kept fully informed of your health care wishes so that they can make appropriate decisions should you be unable to. If you do not appoint an attorney for personal care, then your substitute decision maker for health decisions will be determined according to default ranking list in section 20 of the Ontario Health Care Consent Act. If you do not have an attorney for personal care, and do not wish to appoint one, then it is important to know who your default substitute decision maker will be and to keep that person informed of your health care wishes.