DNR Orders Explained
DNR stands for "do not resuscitate." A DNR instruction is an order written by a doctor to not perform CPR or other measures of resuscitation in the event of a medical emergency. An order will normally be issued for a specific period of time or until it is canceled by the patient or their doctor. Sometimes a DNR order will be issued in response to a patient’s wishes (alternatively, there are forms you can sign known as physician orders for life-sustaining treatment, or POLST). POLST is a legal, standardized form that is signed by your medical provider. Anyone can sign a DNR order, but this is generally reserved for patients who have serious health problems . The purpose of a DNR order is not to withhold medical care, but to avoid painful, unpleasant resuscitation techniques that have already been deemed futile.
DNR orders are typically listed in a patient’s medical record and may also be posted on the patient’s front door, visible from the outside.
When a patient needs emergency care, unless the patient has a DNR order, care will be given to the best of the medical team’s ability in accordance with standard procedures. If a DNR order is in place, however, the medical staff will not try to restart the patient’s heart if the heart has stopped beating, nor will they try to breathe for the patient if the patient’s lungs have failed.
The Emergence of DNR Ink
In the past two decades, doctors and lawyers have seen a sizable increase in a specific type of body art: do not resuscitate (DNR) tattoos. These tattoos are implemented directly on the body, usually on the torso or forearms, and display instructions to emergency medical services and hospital workers. Some people file Do Not Resuscitate Orders with their physicians or health care surrogate, but others find tattoos to be more convenient or permanent.
The reason for this body modification is simple enough: people want their final wishes to be honored. As more toys, gadgets, fashions, and medical inventions come in and out of style, an individual may fear that eventually, he or she will end up in a hospital where no one knows about his or her desires. By tattooing a DNR on their body, an individual can be assured that rejecting life-saving measures will be seen even if they cannot communicate for themselves. In fact, some people believe that a DNR tattoo is so critical that they may tattoo it in multiple visible areas.
While there is no standard design for these tattoos, most commonly include the DNR letters, skull-and-crossbones, and/or date of birth. Other common phrases are "No Code," "No CPR," or "No Pulse." The tattoo placement typically includes the chest or forearms.
It is important to note, however, that there is a major legal problem with DNR tattoos. We will cover why this is in the next section.
The Legality of Inked Wishes
Health practitioners are particularly well aware of the ongoing, and often contentious, debate about whether a Do Not Resuscitate (DNR) tattoo is legally binding. While in most states DNR tattoos are not officially recognized as medical documents – thus they require additional documentation and paperwork in order to be carried out – there are areas where these tattoos have made their way into state and local law as a legal method of directing end of life care.
In most states, however, DNR and other advance care planning directives, such as Do Not Intubate (DNI), Do Not Entertain (DNE), and so on, are only legally required to be honored if they are provided under official state law. In some states this means that the documents must be witnessed and/or notarized and filed with the department of public health, while in others the directives must be provided in a standardized format approved and sanctioned by the state. Still others require both witnessing and filing with state departments.
It is important to note that the legality is only binding at the state level. Although an individual might list their wishes in a form and put it in their wallet, and while hospitals must attempt to honor those wishes, they only have to do so "in good faith," and can generally avoid liability related to their actions. This means that emergency medical personnel may ignore a personal form if they believe that it hasn’t been updated, or if the individual has inadvertently written the wrong dates, or a family member decides that the box "shouldn’t" have been checked.
Legal complications aside, a tattoo is an inked representation of a person’s wishes, pictorially depicting their desire not to have certain treatments performed, including CPR, intubation, etc. But because a tattoo, by its very nature, is permanent, the token will not account for changes in preference. This means that a person may have the right to have their tattoo honored, but if they want to change their mind they will need to consult with a lawyer to have it invalidated and/or consult with their medical providers about how to best keep their care documents updated.
Case Law and Applications
Case studies of DNR Tattoos and Related Issues
There was a medical malpractice case in Sweden that involved a 79-year-old man named Jan Persson who had a tattoo on his chest that read "Do not resuscitate." His family placed the tattoo over his heart, in his home, as a final wish. Unfortunately, after he passed out in a restaurant, the restaurant staff called 911 and the paramedics resuscitated him. He sued the ambulance company for medical malpractice and according to The Local, Sweden’s news in English, he was awarded 1.5 million kroner ($225,000) in damages.
The first known case of a Do Not Resuscitate (DNR) tattoo occurred in 2007, on a 53-year-old Canadian man named Casey Hudson. This incident took place outside of Calgary, Alberta, but it was a foreign nurse who found the tattoo. It said STAND BACK! DO NOT RESUSCITATE. As fate would have it, Hudson went into cardiac arrest while visiting London in March of 2007. According to the article, the tattoo was ignored anyway because he was a 53-year-old healthy man, and the paramedics felt it was a joke. He survived another heart attack in 2012, and the following year, he got another tattoo, this one over the first. STAND BACK! DO NOT RESUCITATE (x 2). Both tattoos remain visible.
A more serious case of a DNR tattoo was in 2010, when two emt’s in Boone County, West Virginia transported a 78-year-old man with a DNR tattoo. The emt’s found the tattoo on his chest, and told the ER physician, who honored it. The Pennsylvania Supreme Court ruled that the treating hospital improperly honored the tattoo. They ruled that the physician has no duty to honor a tattoo at a hospital that is initially presented with a patient in need of medical attention. The decision involved the breach of the standard of care.
In 2017, a man in Australia went into cardiac arrest at the Perth Airport. The man was resuscitated quickly, and taken to Royal Perth Hospital. He was 70 years old, and had a tattoo that said "not exploring resuscitation!" The local news reported that the tattoo did not cause any problems for either the ER or the hospital staff. He was released without incident or complication.
Australia also has a case of a DNR tattoo. In 2011, a 70-year-old Australian man died in a car accident. His family tried to sue the ambulance service for not honoring his wishes written on his chest. The tattoo said, "NO CPR" and "NOT MY AUNTIE." Without getting overly graphic, the injury was not survivable and efforts would have been futile. What the family really claimed was that the tattoo was intended to provide "cultural awareness" about their relative’s state of affairs. The Northern Territory Supreme Court ruled in favor of the ambulance service.
Alternatives to Tattoos
While the DNR tattoo movement is popular and may be the best way for some people to ensure that their wishes are honored, there are other options for individuals to express their wishes not to have resuscitation efforts made. There are legal documents, such as a Durable Power of Attorney for Health Care, which is a legal document that allows a person to appoint another person to make health care decisions for them based on their desires . It is important to note that the laws in each state regarding powers of attorney, including a Durable Power of Attorney for Health Care, are different; it is important to know the laws of the state where the person lives or is located when utilizing these tools.
Also available rather than or in addition to the DNR tattoo are wearable medical alerts. Many companies sell bracelets or necklaces that display information about the wearer’s medical needs in the event of incapacity.
Expert Insights and Moral Considerations
The advent of DNR tattoos has given rise to a host of legal and ethical dilemmas that experts are only just beginning to dissect. Chief among these is the thorny question of informed consent. The American Medical Association’s Code of Medical Ethics explicitly insists that patients must have a clear and open discussion about their end-of-life treatment options and the impact a Do Not Resuscitate order would have on their future care. The relatively recent rise of tattooing as a means to this end arguably represents a direct challenge to established standards of full-informed consent.
Dr. Michael Carome, director of the Human Subjects Research program at Public Citizen, a non-profit watchdog organization, argues that DNR tattoos complicate matters even further. "Readers of a DNR tattoo can’t determine whether or not a patient has a terminal illness. If the patient has a terminal illness, the tattoo likely would be considered valid, but if not, it might not. Having a DNR tattoo raises questions of who should be the ultimate arbiter in determining whether or not it is genuinely legally binding in any given circumstance."
All of this uncertainty impacts the decisions made by healthcare providers. "It’s a very murky issue," says Dr. Bar Siporen, one of the founders of Vital Ink, a program that offers free DNR tattoos. "Medical personnel are generally trained to be risk-averse, so there’s a reluctance to leave uncertainty on the table. If there’s a question, there’s a good chance that when a provider has to act, their first instinct will be to err on the side of providing advanced treatment."
With straightforward tattooing licenses, patients are able to attest to their competence. With the tattoo itself, patients claim something much grander: omniscience. "How do we handle a reader who misinterprets the tattoo?" asks Dr. Siporen. "We can’t assume that they understand that their directive is binding only upon specific patients, for example, or that they’ve been given a full understanding of the situation."
Ahmed Allen, a prominent Los Angeles medical malpractice attorney, echoes Dr. Siporen. He warns that "getting treatment for a life-threatening ailment can be a complicated process. Say you show up with a DNR tattoo. The staff may deem the risks of performing the surgery too great, so they don’t get involved. You pass away as a result, and suddenly, your family wants answers. Where does that leave your doctors?"
Even though DNR tattoos may be legally definable as "informed consent" or "a legally binding advanced directive," there’s no guarantee that they will actually be recognized in a court of law. Even if they are not, healthcare professionals may still be hesitant to recognize them as bona fide legal documents or binding medical directives. This is where a potentially dangerous disconnect between law and fact arises.
As Prof. Mark Rothman of Cardozo Law, who specializes in ethics and medicine, explains, "There is a real activism to tattooing, and it’s important to recognize that some people may be using these tattoos to make a statement to both the medical community and their families. To challenge very long-held legal and social norms is a risk; but in many ways, it’s a necessary one if they are to be changed."
Final Thoughts
In this article, we have walked through some of the most important considerations when it comes to making a lasting decision about your end-of-life healthcare wishes. While DNR orders are crucial documents, and can have a significant impact on your healthcare in a moment of crisis, these tattoo alternatives can also be problematic when used as a standalone document .
Because we live in a highly fluid age, our laws that affect medical practice and health care options are also subject to change. Your own estate planning needs may also evolve over time. It is critical that you make a habit of reviewing all aspects of your estate plan on a regular basis, and that you keep track of how state and federal law changes could affect your choices.