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The Case of the “Do Not Resuscitate Tattoo” and Massachusetts Health Care Documents

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The Tattoo

Recently in Florida, a 70-year-old man collapsed and was taken to the emergency room. On the man’s chest, doctors discovered a tattoo with the words, “Do Not Resuscitate,” with the word, “Not,” underlined, as well as what appeared to be his signature. According to one doctor, the man was suffering from numerous health problems including pulmonary disease, diabetes, and heart disease. He was living in a nursing home but was found unconscious and intoxicated lying out in the street. He was also at the hospital with no identification, family, or friends. Doctors were unable to help the patient regain consciousness and were therefore unable to discuss care and treatment options with him.

What is a DNR order? Typically, a Do Not Resuscitate Order is a medical order written by a doctor instructing various health care providers not to provide CPR if a patient’s breathing or heart stops. It is rather limited in scope.

Outside of hospitals, Florida requires DNR orders to be printed on yellow paper and signed by a physician and the patient or a health care agent. However, inside a hospital, doctors are given more discretion. They usually talk to a patient when conscious, or the patient’s family and friends to determine what are the patient’s end-of-life wishes.

The doctors faced an ethical dilemma. On one hand, the doctors were asking themselves whether the tattoo accurately reflects what the patient would want in this situation. Some people have tattoos added to their bodies to express themselves or for various cultural, religious, or other personal reasons. On the other hand, as one doctor noted in a recent New England Journal of Medicine article, some people believe tattoos “might represent permanent reminders of regretted decisions made while the person was intoxicated.” According to a 2012 article in the Journal of General Internal Medicine, there was a 59-year-old man with “D.N.R.” tattooed on his chest, but he was conscious and told doctors he wanted life saving measures to be taken, if necessary.  

In the current case, the doctors initially decided not to honor the tattoo for the time being, trying to revive the patient, “invoking the principle of not choosing an irreversible path when faced with uncertainty.” The doctors consulted an ethics expert who advised them to honor the tattoo, suggesting that it could be reasonably inferred that this is what the patient would want. Simultaneously, social workers from the Florida Department of Children and Families obtained this patient’s out-of-hospital DNR paperwork which was executed in accordance with Florida standards and was consistent with the patient’s tattoo.

After receiving the patient’s paperwork, doctors ended the life-saving measures and allowed the man to die the next morning. Although the patient’s DNR paperwork was found in this case, many wonder whether doctors would have still felt comfortable allowing this patient to die solely based on the DNR chest tattoo. Based on the commentary from the doctors, the DNR tattoo likely convinced the social workers to inquire whether he had executed a DNR. Without the tattoo on the chest, the existence of a DNR order might not have been discussed since the doctors’ and first responders’ first instinct is to save the patient.


Some may ask what happens if this situation is encountered in Massachusetts. The answer to that question is unclear. In all likelihood, similar to Florida, Massachusetts doctors and social workers would at least commence a search for a legally binding DNR.

In Massachusetts, five different types of documents are commonly used pertaining to health care issues, which are health care proxies, living wills, in-hospital Do Not Resuscitate Orders, Comfort Care DNR verification forms, and Medical Orders for Life-Sustaining Treatment (MOLST).

In general, the health care proxy is a form which allows someone to designate an individual to make medical decisions on his or her behalf in the event the individual is unable to do so. The health care proxy could include entering into a Do Not Resuscitate Order with a doctor. Living wills, which are documents that allow people to state their wishes for end-of-life medical care, are by themselves non-binding in Massachusetts. However, living wills can be helpful to one’s health care agents and doctors when making end-of-life medical decisions.

An in-hospital DNR order is one issued by a doctor when the patient is in a hospital setting after the doctor consults with the patient to ensure the patient has given informed consent to the order. These orders are valid in what are called institutional settings, namely hospitals and licensed nursing homes. Despite these forms, EMTs and paramedics were unable to honor any DNR orders like these in a non-institutional setting such as one’s home or an assisted living facility.

In 1999, Massachusetts enacted its Comfort Care DNR Protocol. Its purpose is to provide verification of DNR orders so that first responders may honor these in a non-hospital setting. The requirements for execution are similar to DNR orders, requiring the signature of a physician or physician’s assistant. By 2010, Massachusetts had expanded upon this and enacted a law providing for a Massachusetts Medical Orders for Life Sustaining Treatment form (MOLST). This form allows the patient to identify various life-sustaining treatments that he or she wishes to allow or not allow. The traditional DNR orders merely address the cardiopulmonary resuscitation (CPR). In addition to CPR, the MOLST also addresses the use of dialysis, artificial nutrition and hydration, among others. At the end of the MOLST form, there is a section allowing the patient to list “other treatment preferences specific to the patient’s medical condition and care.”

You should consider discussing these estate planning issues with your attorney and physician to see that the proper documents are in place to carry on your health care treatment preferences.

About the Author

Christopher R. Mitchell is admitted to the Massachusetts bar and concentrates his practice in the areas of estate planning, trust and estate administration, tax planning, and business succession planning.

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