Due to an ageing population and the evolution of medical treatment, people are increasingly formulating and asserting their end of life decisions. A ‘Do Not Resuscitate’ directive is now common. Although most frequently seen on a physical document, there are also tattoos stating ‘Do Not Resuscitate’ or sometimes it is simply the letters ‘DNR’ on a person’s chest.

People believe that these tattoos (compared to paperwork and medical bracelets) cannot be misplaced, removed or lost. Emergency responders are also unlikely to miss a tattoo on a person’s chest when attempting to resuscitate. Although a patient may see these tattoos as adding clarity to their convictions, these tattoos are presenting confusion for doctors and emergency responders.

A valid heath care directive (such as a DNR) must be respected by health care professionals. Providing life-saving treatment contrary to a valid directive may be considered an assault. Therefore, for the person providing a DNR and for the doctors respecting it, it is essential that the directive be valid and clear.

Clarity is made more difficult by the fact that in Australia there is inconsistency in law and terminology across all States and Territories. In the ACT, a written health direction must be signed by the maker of the direction and be witnessed by two other people at the same time and in each other’s presence.[1] The health professional must not withhold medical treatment unless they believe on reasonable grounds that the direction has complied with the above conditions and that the person has not revoked the direction.[2]

There are various legal issues with ‘DNR’ tattoos.

Firstly, many of these tattoos merely state ‘DNR’ or an alternative formulation with the same meaning. Some tattoos may have a signature below the letters but are extremely unlikely to have the signatures of two witnesses. Therefore this will not satisfy the law in the ACT as to valid written health directions. Studies have also shown that a substantial percentage of patients change their minds as to preferences for attempted resuscitation. Amending or revoking a written health directive or a medical bracelet would normally be relatively straightforward. The cost and effort of removing a tattoo is not always practical. This poses the question – how can such a “directive” be confirmed as still being current?

Secondly, the intentions and reasoning of a tattoo are not as clear as an executed legal document. A recent incident in the USA demonstrates the issues. In that case, a conscious man admitted to hospital had ‘DNR’ tattooed on his chest as a result of losing a badly conceived drinking game and whose preference was actually for resuscitation. The man had stated that he did “not think anyone would take his tattoo seriously”.[3] If the patient is unconscious, it is impossible to determine in the available short time frame whether the tattoo was intended to be a binding directive.

Thirdly, there are capacity issues that need to be examined for such a serious end of life directive. Advanced health care directives are usually executed in the presence of a health care professional or a lawyer who as part of the process assess the capacity of the person to make such a direction. It would be practically impossible to ascertain whether a person had capacity at the time of getting a tattoo perhaps many years later when it might become applicable. Would the alternative be having a health care professional or lawyer to sit with you at the time of the tattoo and document the procedure? That leads to the further question of how would this be subsequently confirmed in an emergency situation?

Finally, especially if no signature is marked on the tattoo, it is difficult to confirm whether the person was influenced into making the decision to get a DNR tattoo. In a time where there is a prevalence of Elder Abuse we must ask additional questions. What are the checks to ensure the letters “DNR” was tattooed on a person without the influence of another and in circumstances where the person clearly understood the potential significance of the DNR tattoo?

Many people who find the tattoo appealing strongly desire not be resuscitated and value the ability to direct their end of life. However, a ‘DNR’ tattoo in the ACT is unlikely to be a clear direction and may result in your wishes not being carried out. These tattoos can cause confusion in a time where urgency is essential no matter what your wishes are. The only way to ensure that your directives are carried out is by having an advanced care directive.