​An unconscious patient with a do not resuscitate (DNR) request tattooed on his chest “produced more confusion than clarity" in the emergency department (ED) where he was being treated, according to a November 30, 2017, letter to the New England Journal of Medicine. The patient, a 70-year-old man with a history of chronic obstructive pulmonary disease, diabetes mellitus, and atrial fibrillation, arrived at the ED unconscious with an elevated blood alcohol level. All efforts at treating the causes of his failing consciousness failed to produce a mental status capable of discussing goals of care. He presented without identification, so the social work department was called in to help identify and notify his next of kin. The tattoo on his chest read “Do Not Resuscitate" and was accompanied by what was presumed to be his signature. The authors initially decided to attempt to save the man's life, they said, “invoking the principle of not choosing an irreversible path when faced with uncertainty." An ethics consultation was also requested. After reviewing the case, the ethics consultants advised the authors to honor the patient's DNR tattoo. They said it was reasonable to infer that the tattoo represented the man's most accurate feelings and that ignoring it could be seen as “standing on ceremony." A formal DNR order was thus written out. At the same time, the social work department obtained a copy of his state department of health “out-of-hospital" DNR order, which confirmed that that tattoo did indeed indicate his true wishes. The patient's status deteriorated overnight and he died without undergoing cardiopulmonary respiration or advanced airway management. The case raised questions about the legality of a tattooed DNR order and whether it might represent a permanent, but regrettable, decision. The written DNR request left the authors feeling “relieved," because upon reviewing the literature they found a case in which a person's DNR tattoo did not represent up-to-date wishes. Ultimately, they concluded, their case neither supported nor opposed the use of tattoos to express end-of-life wishes when a patient is incapacitated.

ECRI Recommends: Despite efforts of healthcare organizations to improve the quality of care for terminally ill and dying patients, identifying patients' end-of-life wishes for medical care remains challenging in many healthcare facilities. DNR orders continue to be misunderstood, miscommunicated, and sometimes ignored, resulting in harm to patients and lawsuits against individual and institutional healthcare providers. Risk managers may wish to determine how DNR orders are actually communicated, documented in the EHR, and implemented in their facilities. When developing policy and procedure for identifying patients' end-of-life care wishes, risk managers should determine whether their state has enacted legislation that provides for a program generally known as Physician Orders for Life-Sustaining Treatment (POLST). The POLST paradigm provides a system that identifies patients' wishes regarding medical treatment and communicates and respects them by creating portable medical orders valid across all care settings, including EMS, hospitals, and nursing homes. Through the use of a POLST form, patients who have terminal progressive illness and limited life expectancy can express in detail their preferences about their end-of-life care, and their physicians can state, in detail, actionable orders for the specific treatment choices the patient would make when the patient's illness advances, including a DNR order.