Clinicians were confronted with the question of whether a tattooed “do not resuscitate” (DNR) request on an unconscious patient should be honored. Physicians from the University of Miami in Florida related the story in a letter to the editor in the New England Journal of Medicine.

The patient, a 70-year old man, was brought into the emergency department by paramedics. He had a history of chronic obstructive pulmonary disease (COPD), diabetes, and atrial fibrillation and was found to have an elevated blood alcohol level. He had no identification or family with him, but he did have a large tattoo across his chest reading, “DO NOT RESUSCITATE,” followed by his signature.

As the patient’s condition deteriorated and social workers were attempting to locate the next of kin, the physicians had to decide whether to honor the tattooed DNR request. Attempts were made to revive the patient enough to discuss his wishes with him, but these attempts failed. The physicians were conflicted between choosing an irreversible path and the obvious efforts that the patient had made to make his presumed wishes known.

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An ethics consultation was requested, and after reviewing the case, the ethics consultants advised the hospital to honor the patient’s tattooed request. They believed that it was reasonable to infer that the tattoo expressed a sincere wish, and that “the law is sometimes not nimble enough to support patient-centered care and respect for patients’ best interests.” A DNR order was written. (Subsequently, the social workers were able to locate a copy of the patient’s Florida Department of Health DNR, which was consistent with his tattoo.) The patient died without undergoing CPR or intubation.

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The physicians concluded, however, that the “tattooed DNR request created more confusion than clarity, given concerns about its legality and likely unfounded beliefs that tattoos might represent permanent reminders of regretted decisions made while the person was intoxicated.” The clinicians noted that a search of the literature identified a case report in the October 2012 issue of the Journal of General Internal Medicine in which a 59-year old man who had “DNR” tattooed on his chest did, in fact, want resuscitative efforts. When asked why he had this tattoo, he explained that he had lost a bet while intoxicated. When the physicians suggested that he have the tattoo removed to avoid future confusion, that patient stated that he did not think anyone would take the tattoo seriously.

Bottom line: a tattoo is not the best way to make advance directives known. However, with the increased popularity of tattoos, it is possible that this will become a more common occurrence.


  1. Holt GE, Sarmento B, Kett D, Goodman KW. An unconscious patient with a DNR tattoo. N Engl J Med. 2017;377:2192-2193.