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Posted on December 3, 2017 at 9:28 AM

Clinicians and bioethicists are widely discussing a brief case published in the New England Journal of Medicine last week.

A seriously ill patient without capacity presented to a Miami ED.  His chest has a tattoo that read “Do Not Resuscitate” accompanied by his presumed signature. The staff initially decided not to honor the tattoo. After all, it does not constitute a legal advance directive or POLST.

But after an ethics consultation, a DNR order was written, because it was most reasonable to infer that the tattoo expressed an authentic preference. This seems like the correct result. In fact, this was confirmed when the hospital later found the patient’s Florida OOHDNR.

The patient was apparently unrepresented (lacking both capacity and available surrogates).  Consequently, the staff should make the decision that best represents the patient’s values and preferences.

Some commentators expressed concern about whether the tattoo represents the patient’s preferences. Indeed, we do not know the circumstances under which the patient obtained the tattoo.  But we similarly do not know the circumstances under which patients complete advance directives. 

If we ignore evidence of patient wishes unless we are 100% confident of informed consent, we would have to ignore the overwhelming majority of treatment decisions and instructions.

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