Miami Doctors Allow Man To Die Because Of “Do Not Resuscitate” Tattoo On Chest

nejmc1713344_f1-800x601Doctors at the Jackson Memorial Hospital faced a novel issue when a 70-year-old man was brought into the emergency room after being found intoxicated and unconscious on the street.  (The man lived at a nursing home and had a history of pulmonary disease).  The doctors were working to assist the man when someone noticed a large chest tattoo reading “DO NOT RESUSCITATE.”  It even had a tattoo signature.  After consulting an “ethics expert,” the hospital treated the tattoo as a viable DNR form and allowed the man to die. In my view, the expert was wrong on the law if his decision was based solely on the tattoo.

Florida agencies have a specific form and states:

Do Not Resuscitate Order—Form 1896 (Multilingual)
Important! In order to be legally valid this form MUST be printed on yellow paper prior to being completed. EMS and medical personnel are only required to honor the form if it is printed on yellow paper.

The form has a place for a physician’s signature and required showings of informed consent.  Florida does not recognize a metal DNR bracelet or necklace.  A patient may carry a “patient identification device”, a smaller version of DH Form 1896 for their wallet or even a chain.

The problem is that “Do Not Resuscitate” teeshirts and tattoos are common jokes.  There was no way that the staff could determine if this was a joke or waiver.

A similar case was discussed in a 2012 article in the Journal of General Internal Medicine, involving a 59-year-old patient.  He had “D.N.R.” tattoo across his chest but he said the tattoo was a joke and the result of losing a bet in poker. 

In this case, there are reports that the the hospital may have been able to secure an DNR order from the patient that was signed previously.  That would obviously impact the decision greatly and support a DNR decision. It would be the waiver not the tattoo that should be determinative.

The question is whether to err on the side of life and the answer in my view is clearly yes.  The staff should not have made an assumption that this tattoo was meant as a substitute of a DH Form 1896 or constructive waive of resuscitation.

The controversy was discussed in the New England Journal of Medicine,

What do you think?

72 thoughts on “Miami Doctors Allow Man To Die Because Of “Do Not Resuscitate” Tattoo On Chest”

  1. My Advanced Medical Directive to health care providers specifies that all attempts at resuscitation are to cease after 6 weeks of trying to bring me back.😉

    1. As a member, on a jury, where you have a defendant, sitting before you, accused of murder, and you observe the word, MURDERER, tattooed across his forehead or neck, would you declare. . .well, it can’t be any clearer? Insist that this man has, by the obvious tattoo, confessed? Stated a fact? Know, with a certainty, that one coerced him to tattoo that on his body? That he, indeed, did, in fact, murder the victim? Of course, you would not convict someone based on some words, scrawled across some lunatic’s body part. Why would you, then, so easily allow the life, of an innocent man, be determined by that same kind of scrawl? You have no way to determine or interpret the motive or meaning behind the tattoo, in either case.

  2. To me the presence of the tattooed signature makes all the difference. Anything else could have been a joke, but with the underlined word and the signature his intent was very clear. It was not modified or lined out, which would have been fairly easy to do. So considering that the whole point of the form is to make a patient’s desires clear to the medical personnel working on him, this tattoo served the same purpose.

    The fact that he had an actual DNR on file removes any other doubt. He may have known how difficult it can be to find paperwork, and how sometimes even the most clear suggestions are ignored in a crisis situation.

  3. If he did the tattoo as a joke then he will suffer the consequence. If it was done to prevent a family coming in to a hospital room and insisting on keeping him alive when he really wants to die then let him die. How is a Doctor to know? If he changed his mind after getting the tatto, then he should have had it tattooed over. Where would you keep this yellow piece of paper, on you all the time?

  4. This involves a number of screw ups. The potential for screw ups should be rectified with this yellow paper BS. A form, properly filled out, and signed by the individual and others if necessary, presented at the moment, should be sufficient, regardless of the color of the paper. However, tattooing this sort of stuff on one’s chest is not the same as fixing a ‘do not remove helmet in case of accident’ on a motorcycle helmet. In the case of the helmet, there is no mistake as to the intent. It can only mean one thing. In the case of the tattoo, the guy could have been drunk, could be trying to be a ‘badass’, could have once been sincere but no longer tip broke to afford a removal, etc. The hospital was wrong: morally, legally, ethically, etc. The only person who can make that decision is the individual on the brink at that time. He was out cold, not available for consultation.

  5. Sad case. It could either, as Nick has pointed out, be a fail safe DNR that he would always carry with him, or a bad joke tattooed while drunk. Someone found intoxicated and passed out in the street may not have a history of making great choices. Someone could have tattooed this on him in jail or while he was passed out some other time. Perhaps he was indigent and lacked the funds to get it removed. The doctors would have absolutely no idea if that was even his signature. A notarized document, with witnesses, at least gives some indication that he proved his identity and opinion at some point in time.

    I do think that the reason why they are so careful with the formatting of DNR is to avoid mistakes and ensure that the form is taken seriously and not forged, in elder abuse, for example. On the other hand, we have no idea if the man moved here from another state which could have had very different laws regarding final health decisions.

    I think the law is clear on DNR forms, and this would not comply. I also think that the doctors should not be prosecuted, as they had a good faith excuse. If anyone is so foolish as to tattoo a signed DNR directive on his chest, but didn’t really mean it, then there are consequences.

  6. The tattoo is meaningless and should have been treated as such by the hospital. How many times has JT posted photos of defendants, in mugshots, with any array of words and slogans, foolishly, tattooed across their foreheads or necks? We, simultaneously, laugh and pity those strange enough to tatto a word, such as, MURDERER, across their necks, while we question the sanity and mental health of these individuals who engage in such absurdities. The bottom line is that there are valid and just reasons and explanations as to why legal documents, such as wills and healthcare directives, have the very specific restrictions and rules that are associated with them. Not every expression is considered valid in terms of distributing possessions or declaring end of life wishes. For example, not just any piece of paper, scrawled with someone’s wishes, is deemed to be a valid and true will and there are a multitude of reasons for the associated restrictions. Safeguards are in place so that one can easily determine the true intent and desires of the person executing such a document–an individual deemed to be of sound mind at the time of signing–where witnesses and a notary help to lend additional reliance to the words reduced to paper. And, imagine, a will only speaks to one’s possessions and the distribution of nothing more than mere possessions. How much more careful, must society be, in deciphering the wishes that one has with regard to life and death decisions? In my opinion, the hospital made a huge mistake in following some tattooed words and using those words to determine end of life wishes, as I strongly suspect that the “ethics expert”–alluded to in the article–was no more than a retired or semi-retired physician, who sits on the ethics board of the hospital, with little, if any, legal training or expertise. When a loved one was in the hospital, I, unfortunately, had the opportunity to meet and speak with one the hospital’s “ethics experts”–in a word, he was, clueless. Simply, clueless. His opinions were not based upon any set of ethics, unless, of course, saving money, for the hospital, is what he considered to be, ethical. The hospital was probably going to lose money on this guy, probably living in a nursing home, broke and on Medicaid. It was more advantageous to let him go and not keep losing money on his care. No one will say that, but I will. If the tattoo had, instead, read–I’M THE HEIR TO A VAST FAMILY FORTUNE AND A BILLIONAIRE. DO NOT RESUSCITATE–the outcome would have been vastly different.

  7. From the NEJM:

    “They suggested that it was most reasonable to infer that the tattoo expressed an authentic preference, that what might be seen as caution could also be seen as standing on ceremony, and that the law is sometimes not nimble enough to support patient-centered care and respect for patients’ best interests.”

    Also from the article:

    “A DNR order was written. Subsequently, the social work department obtained a copy of his Florida Department of Health “out-of-hospital” DNR order, which was consistent with the tattoo. The patient’s clinical status deteriorated throughout the night, and he died without undergoing cardiopulmonary respiration or advanced airway management.”

  8. what Nick & Chris said: “The man paid money to have this declaration permanently tattooed on his body” ” If the victim did not agree with the tattoo message, he could have a line tattooed through the statement.”

    The man was 70 and may have seen family and/or friends who were kept alive against their will so he decided to make his DNR declaration permanent

  9. It was legally and morally wrong to allow the patient to die. That was an irrevocable choice, so they should have been absolutely certain as to his intent. He could have had the tattoo made as a joke, or in a moment of despondency over the loss of a loved one.

      1. “…speaking as someone in his age group…” Hmmm! That explains your being predisposed to curmudgeonliness. As an octogenarian, I’m quite familiar with this mien. Or I should say my spouse is familiar with it.

    1. Tin, let us say the patient signed a legitimate DNR. How do you become “absolutely certain as to his intent”? At the time of death, some people change their minds and some people lack the full understanding of the DNR. If alive, conscious and mentally intact one can ask and the patient can change his mind. Absolute certainty seldom exists.

  10. I think that one should not hold paramedics and doctors liable if they ignore a tattoo DNR, but I also think they should not be held liable if they respect at tattoo DNR. If someone thinks it is funny to tattoo a DNR on their chest and have a tattoo signature, then they need to live (or not live) with the consequences of that, especially if they do not have it lined out.

    DNR’s take effort to both make, and have it available in a time of emergency, and I think that they should be generally respected.

  11. He did have the formal documents signed. The doctors provided what can be characterized as minimally invasive comfort care: IV fluids, antibiotics and CPAP support. The patient’s wishes were honored, end of case. Do you still have problems after knowing the details?

  12. “Florida agencies have a specific form and states: Do Not Resuscitate Order—Form 1896 (Multilingual)
    Important! In order to be legally valid this form MUST be printed on yellow paper prior to being completed. EMS and medical personnel are only required to honor the form if it is printed on yellow paper.”

    I don’t think that form precludes other legal ways of declaring oneself a DNR. If that were the case all those printable DNR forms posted on refrigerators in the senior condominiums would be invalid as would those documents signed in a lawyers office that were not on yellow paper.

  13. So much anarchy! Something has gone wrong with a society where people feel free to ignore duly enacted laws, each favoring their on the spot judgment.

    1. Just because a specific form must be of a certain color, what makes you think other forms aren’t valid?

  14. I agree with the doctors. You tattoo it on and sign it. It is legal. This yellow paper crap is just silly. My end of life direction is on white paper. I do not understand making end of life decisions harder for patients, which is what FL has done.

    p.s. He could have had mespo’s wife notoraize it. 😉

    1. Paul, I don’t think the yellow paper is needed. The bigger question is whether or not the individual knew what they were signing and whether the doctor’s due diligence represented the desires of the patient or the insurer (HMO)

      1. Allan – there seems to be a get out of jail free card with the “only required” clause, which means they can still honor other DNRs. However, if it is on the infamous yellow paper they must follow the DNR.

        There has been some problem with doctors and hospitals across the country NOT following DNRs and taking things into their own hands, so to speak. This may be FL solution to that problem.

        1. The physician always has some discretion. Remember, he writes the official notes.

          Let me give you an example. The patient signs the Fl DNR and tucks it away and forgets about it. At a later time while in the doctor’s office, he is asked if he wants to sign a DNR and says absolutely not. Somehow the original DNR finds its way into the hospital.

          Another thought. A DNR can be a convenient way for an HMO to save a lot of money on an expensive patient.

    2. Silly or not, Paul, the yellow paper requirement is in the Florida statute. But, my question is, would it have made the decision easier if the man had had a yellow rectangle bordered by a black line tattooed on his chest first and then had the DNR & signature tattoo applied to the “yellow paper” on his chest?

      1. Porkchop – I thought about the faux paper design on the chest for the DNR to make it more “legitimate” but disregarded in favor of DNRs from other states and the escape clause in FL law. He could have had it notarized by the governor of FL to up the ante. 😉

  15. A tattoo like that seems more persuasive than a bracelet or a piece of paper. If the victim did not agree with the tattoo message, he could have a line tattooed through the statement.

  16. I disagree. I think this trumps a DH Form 1896. The man paid money to have this declaration permanently tattooed on his body. With the screw ups I’ve seen in medical care and forms, this is a fail safe DNR.

    1. Kind of like a patient writing in sharpie “THIS KNEE!!!” right before surgery on the limb scheduled for surgery?

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