Headlines were made recently when a man was admitted to a hospital unconscious with a high blood alcohol level and a history of serious heath complications. The bigger complication, though, was that his chest bore a tattoo reading, "Do Not Resuscitate." It presented an ethical dilemma for physicians that has been discussed ad nauseam since that day. Bioethicists view it as a textbook, worst-case scenario, and as such, a study was conducted and published in The New England Journal of Medicine, exploring the medical and ethical dilemmas implicated by a tattoo.

The study was conducted by experts at the University of Miami, and it said physicians caring for the patient weren't inclined to heed the tattoo because there was no way to confirm the man's wishes. "We initially decided not to honor the tattoo, invoking the principle of not choosing an irreversible path when faced with uncertainty," the study reads. The physicians elected, instead, to administer antibiotics among other things. Even so, the hospital's ethics consultant felt differently.

"After the ethics consultants advised us to honor the patient's do not resuscitate tattoo. They suggested that it was most reasonable to infer that the tattoo expressed an authentic preference, that what might be seen as caution could also be seen as standing on ceremony, and that the law is sometimes not nimble enough to support patient-centered care and respect for patients' best interests. A DNR order was written," the study says. The state Department of Health in Florida had a DNR order for the patient after all, so they would've been able to proceed with resuscitation; however, the patient died without ever undergoing the procedure.

DNR order laws tend to be fairly convoluted, and they differ from state to state in the US. A study published in the Journal of General Internal Medicine found that "Clinicians are morally and legally obligated to respect the preferences of patients to forgo life-sustaining treatment." Ordinarily, this indicates that an official signed a DNR agreement, particularly a Physician Order for Life-Sustaining Treatment. There wasn't any precedent for tattoos being legally binding regardless of how apparent the patient's intentions might seem.

The article in the Journal of General Internal Medicine reads, "The emergency responder may wonder. (D)o the letters stand for Do Not Resuscitate? Or Department of Natural Resources? Or someone's initials? Second, the tattoo may not result from a considered decision to forego resuscitation. Errors in interpretation may have life and death consequences." It's what the ethics consultants had to take into consideration that physicians hadn't yet.

According to the published study on the incident, the ethics consultants "suggested that it was most reasonable that the tattoo expressed an authentic preference, that what might be seen as caution could also be seen as standing on ceremony, and that the law is sometimes not nimble enough to support patient-centered care and respect for patients' best interests." The ethics of DNR orders, in general, is now being scrutinized even more than usual due to the added attention to the no-longer hypothetical scenario in which a DNR tattoo has to be taken seriously.

The incident harkens back to a popular DNR story bandied about in the summer from the UK where the proper term is Termination of Resuscitation. Sudden-onset cardiac arrest accounts for almost 100,000 deaths every year in the UK, and resuscitation practices in the UK have a poor success rate despite improvement. This partly stems from poor allocation of ambulances, which yields almost certain poor outcomes in transporting patients according to a recent article from the Journal of Emergency Medical Services.

Now, clinical decision rules pertaining to TOR have been validated for out-of-hospital cardiac arrests, and these CDRs relieve the healthcare system and particularly ambulance resources of a burden with which the system has, heretofore, failed to cope. These TOR CDRs also diminish the number of blue-light transports on the road and thereby contribute to public safety given that these transports are otherwise risky. The proposed guideline has been found to align well with preexisting TOR guidelines. The British Resuscitation Council says that evidence is a bit more murky, however, about when is an appropriate time to desist resuscitation.

In the UK, the most recent and definitive study on the subject was published this past summer. Researchers relied on a retrospective cohort study to review adult OHCA cases throughout a 26-month period of time. They aimed to discern the disparate, identifying features of adult OHCA. They also applied two TOR guidelines to the dataset. In light of the ethical struggle with this issue Stateside, it's relevant to note that the British study was approved by the University research ethics board as well as NHS. They took data for the study from the North West Ambulance Service NHS Trust. The Trust's paramedic and technician staff are combined as one and governed under the auspices of the TOR guideline.