In recent years, body art in the form of tattoos and piercings has increased in popularity and societal acceptance. We’re now seeing more patients than ever with tattoos on visible areas of the body. But can the words of a tattoo found on a patient be helpful to EMS providers? What about a so-called “medical tattoo” that says “Do Not Resuscitate” (DNR) emblazed across the patient’s chest—can that be honored as a valid instruction not to begin CPR if the patient is in cardiac arrest?
Certainly tattoos that give information about a patient’s medical history, such as an allergy or chronic medical condition like diabetes or a seizure disorder, can be helpful to EMS. But the law generally doesn’t recognize a statement on a tattoo as a lawful “advance directive” that an EMS provider can rely on when making treatment decisions. But seeing one should initiate questions of the patient and family about whether the patient does in fact have an actual and valid advance directive in place.
Most state laws specify precisely what types of out-of-hospital advance directives are acceptable—usually bracelets, cards and completed paper forms. DNR laws typically require the patient to be in a “terminal” condition as certified by a physician, which is another reason a DNR tattoo wouldn’t be an appropriate notification to healthcare providers. Unless tattoos are specifically enumerated by your state law as an acceptable form of a DNR or other treatment-limiting “order,” then EMS providers would have no right or obligation to honor them. Doing so could expose you and your agency to potential liability for negligence and wrongful death claims.
Put simply, tattoos that attempt to give medical instructions are very unreliable. The patient may be simply using the acronym “DNR” or the words “Do Not Resuscitate” as a form of “artful expression”—a certain point of conversation at any party! Or the permanence of a tattoo with a medical instruction may not be indicative of the patient’s current wishes. What if the patient had a DNR tattoo and then months later changed his mind and just hadn’t gotten around to having it removed or simply doesn’t care to go through the removal procedure? EMS providers must always remember, too, that even in the face of a valid DNR order or other advance directive such as a limitation on invasive medical procedures, that if the patient is alert and has the mental and legal capacity to make a decision at the time of treatment, then those verbal wishes should be honored. A competent patient has the right to revoke an advance directive at any time.
If an EMS provider encounters a tattoo that may provide a clue or insight into a patient’s condition, like a tattoo on the wrist of an unconscious patient that says “diabetic” (as opposed to purported medical instructions limiting treatment), it could certainly provide a clue to help guide assessment and treatment of the patient. But if the patient isn’t exhibiting signs or symptoms of a diabetic emergency, it wouldn’t be appropriate to initiate the diabetic treatment protocol merely because of a tattoo labeling them as a diabetic.
The key is to consider a tattoo with supposed medical information as just one piece of information to be factored into the overall assessment and treatment of the patient. Always “treat the patient and not the tattoo.” The tattoo can—at best—only give you information about a potential condition you need to consider, like diabetes or a seizure disorder. A critical point to remember is that there’s a difference between a tattoo that purports to give medical instructions that an EMS provider shouldn’t follow (such as a DNR tattoo) and a tattoo that could provide potentially useful information about the patient’s past medical history that may be helpful in the course of providing care to the patient.
So what do you do if you see “NO CPR” tattooed across the chest of a cardiac arrest patient? Don’t rely on that alone to determine your next steps. Inquire and ask questions to see if there’s a valid—and legal—advance directive in place. And follow your protocols for initiating resuscitation if there’s no valid DNR order under your state advance directive law.
Pro Bono is written by attorneys Doug Wolfberg and Steve Wirth, founding partners of Page, Wolfberg & Wirth (PWW), a national EMS industry law firm. Visit the firm’s website at www.pwwemslaw.com. Check out the new fourth edition of The Ambulance Service Guide to HIPAA Compliance now available from PWW.