This paper is a comprehensive look on medical tattoos, particularly do not resuscitate order (DNR) and No Cardiopulmonary resuscitations (CPR) tattoos. The main objective of this project was to examine and to dissect cases to discover the ethical or legal issues surrounding tattoos for the basis of medical treatment or lack thereof. The principles of ethics: beneficence, respect, non maleficence, medical equity and the application of principles: informed consent, optimization, medical confidentiality, value of life were used to study the case. In essence, the validity of these tattoos were under review to note whether they were legally binding as DNRs are a critical step between life and death and should not be taken lightly.
Tattoos have been present from around 3170 B.C. to depict various meanings. It first began as a representation of tribal markings, religious belief and magical practices. They were also used on young girls to show puberty and then marriage and on boys to show accomplishments and ranks. Around the 1950s, tattoos were worn by the outcasts of society and prisoners and so persons opted not to get tattoos in this time because of the stigma. Then, in the 1970s it was the beginning of its use for adornment and to depict personal stories. These are just a few of the meanings tattoos portrayed over the years.
However, a new purpose has immerged for tattoos, persons are using them for medical alert notifications to healthcare professionals. A wide array of tattoos are seen such as no CPR, DNR order, diabetic, organ donor, allergies and blood types. Medical records and medical alert bracelets carry this information but, they are being tattooed for cases of emergency when a patient doesn’t have a bracelet and is incapacitated or unconscious.
The medical profession is of paramount importance because often time it is a life or death situation therefore there are laws and regulation in place that must be followed to ensure that each setting is of optimum result to protect both patient and physician and to avoid legal battles.
For a DNR order to be signed off the principles of ethics must be considered autonomy, non-maleficence, beneficence, and medical equity. Autonomy is the basis for informed consent and means that the patient has the capacity to understand and communicate effectively and an understanding of the consequences of his or her decisions. Non-maleficence means that patients should not be put in a position where they may experience unnecessary harm. Beneficence means that the care given to patients should benefit the patient. Medical equity means that patients are treated fairly and equally.
The DNR and no CPR is an advanced directive or they are ordered by a physician in the case that resuscitations will not help the underlying condition that is, it cannot be cured or managed. DNR orders are given when a person stops breathing or the heart stops beating or a patient that has a terminal illness and has instructed on record that it is there wish not to be resuscitated. DNR orders can be included in a will because it is a legal document or mentioned in medical records. DNR orders are considered as passive euthanasia and having a tattoo which can be done without regulation, is not a legal document it is merely ink placed on the body whenever and however without regulations.
- According to the Oxford dictionary
- CPR: Cardiopulmonary resuscitation
- DNR: Do not resuscitate, denoting an instruction not to attempt the resuscitation of a terminally ill patient after a cardiac arrest in hospital.
- Tattoos: Mark (a part of the body) with an indelible design by inserting pigment into punctures in the skin.
A 70 year old man was brought to the emergency room with a very elevated blood alcohol level. He had a tattoo that read, ‘Do Not Resuscitate’ with “Not” underlined and his signature below the tattoos. However, other than the signature they had no identification for this individual.
He had a pulmonary infection which lead to septic shock which resulted in multiple organ failure (MOF) and a low blood pressure.
He was difficult to revive, so the question was, should they try to resuscitate? Do they have to follow the DNR that was tattooed in large print?
This was a case that presented in Miami, Florida in 2017 at the Jackson Memorial Hospital, the doctors were baffled at this ethical issue not only because the patient’s unconsciousness and DNR tattoo but years before in 2012 there was a similar incident with a 59-year-old man with diabetes, peripheral vascular disease, dyslipidemia and hypertension who had the initials D.N.R on his chest but subsequently he wanted to be resuscitated, he had gotten the tattoo when he lost a poker bet to a fellow colleague while he was drunk.
Dr. Holt a critical care physician, was called in and he made the decision not to honor the tattoo based on the principle of not choosing an irreversible path. The patient was then treated with antibiotics, IV fluids, blood pressure medication and a breathing mask to buy time so they could have an ethics meeting to discuss the patient’s tattoo ethically and legally with an ethics professional. After the consult the ethics review decided to honor the tattoo, he passed away the next morning. His identity and official records of DNR was also discovered by social workers.
But in the case of emergency was it ethical to follow this tattoo? or if there wasn’t an official do not resuscitate order (DNR)? Below are the arguments supporting and opposing medical tattoos as legally binding.
Based on the Florida case and the 2012 case there is significant debate surrounding medical tattoos. Regarding the argument for honoring the tattoo, firstly there are medical alert bracelets and necklaces but they are expensive especially for the persons that are allergic to cheaper materials, they are broken often and professions such as electricians cannot wear jewelry and in the case of emergencies the proper paperwork might not be close to the individual or lost whether it may be in a purse or in a wallet so having a tattoo will be permanent and present with the individual. Also, having a tattoo would not cause emergency physicians great emotional and moral stress resulting from resuscitating a patient to find out after that the patient had a legal DNR document that was not available in the emergency department, in other words, wasting time when this time could be used on other patients. Additionally, some healthcare professionals think that a DNR tattoo expresses an authentic preference because for someone to sit and get a tattoo with do not resuscitate they must have greatly considered the seriousness and consequences of this action.
The defensive against medical tattoos being legally binding is plenty. Firstly it’s argued that medical alert necklaces and bracelets or medical records carry all the relevant information so why are they being tattooed. Tattoos are expensive to be removed therefore it is not easily reversed so if a patient changes his or her mind it cannot be changed or cancelled like with a legal document or medical record that can be deleted or burnt. Also, if the tattoo is simply DNR, there is no way to positively know that it means “do not resuscitate” while it might seem obvious, medical decisions should never be made by guessing alone because the initials could stand for something else. Another issue is having a DNR tattoo is that it lacks specificity. It is an ambiguous term which could mean a patient wants chest compressions, but not a breathing tube, respirator or drugs, a tattoo cannot show this so physicians cannot understand the full meaning. Even DNR tattoos with a signature do not signify that it is a legal contract, this signing has to be witnessed to make it valid and a physician would not know that by just looking at the tattoo. Then there is the fact that anyone can get a tattoo whether they are sane or healthy, young or old, joking or serious, there is no strict regulation and standardization for tattoos based on DNR orders, as seen in the 2012 case where the tattoo was done while the individual was inebriated and had lost a bet. Additionally, it would be difficult to find medical tattoos on a person with multiple other tattoos.
For a DNR to be legally binding the principles of ethics should be followed. The patient should be in full control of his or her choice and understand completely the risk of survival and possible treatment and make the decision that they do not want to be resuscitated, so they have full autonomy and have give informed consent. The usual conditions for DNR orders are when it will not restart the heart or breathing, when there is no benefit or when the DNR order outweighs the burdens. This means the respect and value of life is evaluated also. It cannot be known if all these principles are followed while getting a tattoo as it is not authorized by a doctor.
Another disadvantage is that DNR tattoos and no CPR tattoos may lead to premature death because which cause of death that is not resisted is not on the DNR tattoo. This means if an individual had a car accident and their heart stopped the DNR and no CPR tattoos would cause the patient to die when a simple resuscitating efforts could recover the patient or say a patient was accidentally electric shocked would he or she wants to be revived if they could? Or would they want all forms of life support and medical aid to be provided? These questions are not answered by DNR tattoos. Persons randomly getting a tattoo do not ponder on these other situations that can occur so provisions are not made which inadvertently would lead to premature death and one of the aim of a doctor is to prolong life so it is not ethical to blindly follow a tattoo.
Medical tattoos for example, DNR orders and no CPR are not legally binding, this is because the tattoos do not follow the criteria and ethics principles of autonomy, medical equity, beneficence and non maleficence, therefore if a DNR tattoo is ignored there cannot be any legal ramifications for the medical staff. Honoring these tattoos can cause legal issues because it is a path of irreversibility so to be on the side of caution medical personnel’s should not follow these tattoos when they are encountered. Tattoos on the body can however, be used as a medium to covey the information or message to search for the medical records and follow up on the patient’s wishes but the tattoo cannot be used for the basis of treatment or lack of treatment.
Medical tattoos such as No CPR and DNR, even though there are only a few cases, are becoming more prevalent and the only thing that can be done if medical tattoos are found is to educate emergency personnel and medical staff to search for the tattoos and then gather the relevant information to support the tattoo. The best way as a patient to ensure that the wishes of DNR or no CPR is followed is to have a medical bracelet or necklace or a wallet card that clearly states name, medical preference and any diseases, allergies and blood type. The DNR order should be clear to the type of resuscitation that is prohibited or to the resuscitation that are allowed, in what conditions and it should be approved by a licensed physician who has had a discussion outlining all the consequences and benefits with or without resuscitation.
In the future medical tattoos may be used as a way of treating patients but for this to occur medical tattooing would have to be standardized, meaning they could only be done by medically approved tattoo artists after the DNR or no CPR is approved by a doctor in order to follow the principles of ethics and assigning case number so that there are not forgeries.
- Cooper, L. & Aronowitz, P. J GEN INTERN MED (2012) 27: 1383. https://doi.org/10.1007/s11606-012-2059-8
- Ober, V. and Cambron,C. (2005). Legal Implications and Ethical Considerations of “Do Not Resuscitate”. [Archive] Florida.