DNR tattoos: DOA in Virginia? (2025)

Byline: Virginia Medical Law Report

By Brandy Burnette Balding

A "do not resuscitate" tattoo on a Florida patient'schest was the subject of much discussion after a November 2017 casereport in the New England Journal of Medicine.1 This pa- tient'stattoo should not be viewed as an isolated peculiarity. Virginia healthcare providers should understand the issues implicated by such a tattoo.Does a DNR tattoo meet the legal requirements for an advance directiveunder Virginia law? Probably not. Should Virginia providers thereforeignore a patient's DNR tattoo? No, not necessarily.

Reported DNR tattoos

A 70-year-old intoxicated and unconscious man was found on thestreet and brought to a Florida emergency department. The man had noidentification, but had a potentially identifying mark: a tattoo on hischest containing the phrase, "Do not resuscitate," followed bya signature. The patient was later diagnosed with septic shock andhypotension. To allow the providers time to evaluate what to do, theyprovided relatively non-invasive care to the patient. He was givenantibiotics, intravenous fluids, supplemental oxygen through a breathingmask, and medication for low blood pressure. The providers wanted toavoid intubating the patient until they had further information from thepatient, his family or friends, other health care providers, or anethics consult.

The ethics consultants recommended honoring the patient'stattoo, and a DNR order was written. The patient's medical teamlater received assurances about the patient's DNR choice when theyobtained a copy of a valid DNR order from a nursing facility where thepatient had recently been. The DNR order was honored, and the patientdied without life-prolonging intervention.

While evaluating options, the Florida medical team learned about aCalifornia case where a patient's DNR tattoo did not reflect thepatient's position on resuscitation. The Journal of GeneralInternal Medicine published a case report in 2012 about a 59-year-oldmale who presented for below-the-knee amputation with the letters"D.N.R." tattooed on his chest.2 Fortunately, this patientcould explain the tattoo and his treatment preference. He did not thinkthe tattoo would be taken seriously, and he wanted resuscitativemeasures to be taken if he was arrested. This patient did notpermanently alter his body to communicate his end-of-life medicalpreferences. This patient indelibly stamped his skin with these threemeaningful letters to make good on a bet he lost during a poker gamewith fellow hospital employees.

The California patient's scenario highlights the uncertaintyand confusion that may arise from DNR tattoos. The painful process ofgetting a DNR tattoo on one's chest may reflect a deliberate,mindful choice. On the other hand, the tattoo may outlast thepatient's choice. Changing one's mind about end-of-lifetreatment decisions is often much easier than removing a tattoo.

Validity of DNR tattoos under Virginia law

The DNR tattoos reported in Florida and California do not satisfyVirginia's advance directive statutes. At a minimum, a writtenadvance directive must be (1) signed by the adult patient, and (2)witnessed and signed by two individuals older than 18 years. (3) TheFlorida patient's tattoo contained the patient's signature,but not the signatures of two qualified witnesses. The Californiapatient's tattoo contained no signatures.

These tattoos are therefore deficient advance directives underVirginia law. Virginia providers encountering patients with thesetattoos would have no legal obligation to withhold resuscitativemeasures.

Responding to a DNR tattoo

Even if no legal obligation is triggered by these DNR tattoos,providers should not wholly ignore the message behind such tattoos.Communicative, oriented patients should be asked whether they authorizelife-prolonging procedures, including cardiopulmonary resuscitation.When patients cannot communicate or are incapable of making an informeddecision about their health care treatment, DNR tattoos should serve asa springboard for further actionif time permits. Medical teams shouldreview available medical records for copies of these documents.

They should inspect patients' belongings for advance directivedocuments or durable do not resuscitate ("DDNR") orders andjewelry. Medical teams should contact patients' friends, familymembers, and other health care providers to learn about the meaning ofthe tattoos and the existence of advance directives, living wills, DDNRorders, and medical power of attorney documents.

Providers should query Virginia's Advance Health CareDirective Registry. Providers should also consider consulting the ethicscommittee, patient care consulting committee, or legal counsel and beginidentifying statutorily authorized substitute decision-makers.

Finally, medical teams should document each step taken to ascertainthe patient's choice.

When time is short, the appropriate response to a DNR tattoo isless clear. The medical professionals who have publicly commented on theFlorida and California examples suggest that patients should be givenbasic care to buy additional time for medical teams to investigate.Alternatively, these professionals suggest medical teams follow thetreatment course which is reversible.4

Conclusion

DNR tattoos, like those discussed in this article, are not likelyvalid in Virginia. Nevertheless, they cannot be ignored. They musttrigger some action by providers. In short, providers should view DNRtattoos as a beginning point, rather than the final proclamation ofpatients' decisions on life-prolonging care. Providers'actions should reflect that patients can trust them to honor clearlycommunicated treatment choices.

ENDNOTES

1 Gregory E. Holt, et al., An Unconscious Patient with a DNRTattoo, 377 New England Journal of Medicine 21922193 (2017).

2 Lori Cooper & Paul Aronowitz, DNR Tattoos: A Cautionary Tale,27 Journal of General Internal Medicine 1383 (2012).

3 Virginia Code 54.1-2982 and 54.1-2983.

4 See Holt, supra note 1; Alexander K. Smith & Bernard Lo, TheProblem with Actually Tattooing DNR across Your Chest, 27 Journal ofGeneral Internal Medicine 12381239 (2012); Ed Yong, What to Do When aPatient Has a 'Do Not Resuscitate' Tattoo, The Atlantic, 2017,https://www.theatlantic.com/health/archive/2017/12/what-to-do-when-a-patient-has-a-do-not-resusci-tate-tattoo/547286/ (last visited Jan 15,2018); Lindsey Bever, A Man Collapsed with 'Do NotResuscitate' Tattooed on His Chest; Doctors Didn't Know Whatto Do, The Washington Post, December 1, 2017,https://www.washingtonpost.com/news/to-your-health/wp/2017/12/01/a-man-collapsed-with-do-not-resuscitate-tattooed-on-his-chest-doctors-didnt-know-what-to-do/?utm_term=.6039a576c1e9 (last visited Jan 15, 2018).

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