Consumers are often told, "Put it in writing." But in the case of a hospitalised Florida man facing death, displaying his wish by having it tattooed on his chest wasn't good enough.
And other doctors agree that publishing your resuscitation preference via a simple tattoo is not the best idea compared to having a living will or healthcare directive readily available.
The 70-year-old had "Do Not Resuscitate" on his chest - complete with an apparent signature and the word "not" underlined.
But that failed to convince doctors to withhold treatment after he was brought to Miami's Jackson Memorial Hospital drunk, dying and unconscious on a Saturday morning.
A tattoo might seem like a clear way to make your wishes known, and doctors themselves often joke about inking "DNR" on their chest.
In this case, "When the guy comes in, we looked at the tattoo and we said, 'We've always talked about this, but we've never seen one.' And then it struck us. We had to think about whether this was real or not," said Dr. Gregory Holt, co-author of the case report in The New England Journal of Medicine. "Suddenly this novelty we've always joked about became a pressing decision. So it got real for us real fast."
The problem with a tattoo: it's a little too permanent.
Sometimes patients change their mind about what kind of treatment they're willing to endure in a health crisis, Holt told Reuters Health by phone.
For example, "When something happens and people can't breathe, they just want to breathe well. So a lot of times people want to reverse their code status," he said.
Holt's other concern at the time was whether the tattoo was done when the patient was drunk, or acting on a whim.
Dr. Lori Cooper, now an endocrinologist in private practice in Seattle, came face-to-face with the problem as a chief resident at California Pacific Medical Center in San Francisco. A 59-year-old patient with "D.N.R." tattooed on his chest told her he wanted to be resuscitated if he developed cardiac or respiratory arrest.
His tattoo was there because he lost a bet playing poker. He declined the suggestion to have it removed, saying he didn't think anyone would take it seriously. Cooper reported the case in 2012 in the Journal of General Internal Medicine.
"We deal with code status so much and everyone says, 'I'm just going to tattoo it on myself.' But that. . . creates a lot of confusion," she told Reuters Health by phone. "It can change with the person's health at the time, or their age, and you have to ask if it reflects their wishes down the road."
"It's not a great idea," she said.
In her patient, resuscitation never became an issue. But for Holt's patient, the hospital had to scramble to confirm that his tattoo reflected his wishes.
Initially, the Holt team worked to keep him alive, "but in the beginning we didn't do everything. We left it a little bit open" while consulting with ethicists, who suggested withholding treatment, Holt said.
Eventually, another do-not-resuscitate form filled out by the patient was located and he was allowed to die without extraordinary efforts being made.
"The burden really was on the doctors and the health care providers to prove that it wasn't his wish, rather than to prove that it was his wish," said Dr. Gary Winzelberg, director of the Hospice and Palliative Medicine Fellowship Program at the University of North Carolina at Chapel Hill, who was not involved in either case.
If people feel strongly and want a DNR tattoo, "They should have some advanced directive, or power of attorney, or a medical order, or some other type of order that providers will find if they go looking," said Rebecca Walker of the Center for Bioethics at UNC.
"We run into this even in with people with forms," Winzelberg told Reuters Health by phone. "How certain are we that this is their current wish today? Unless a family member or loved one can tell us otherwise, we need to respect people's wishes."
Because living wills and healthcare directives can get misplaced, loved ones may not be immediately available, and people can become critically ill far from home, doctors say there's not a foolproof system.
Holt said the country might want to follow in the footsteps of Oregon, where an online registry allows people to record their wishes and allows emergency rooms to quickly find those requests.
Ideally, such a registry would use fingerprints and facial recognition software so an emergency department can speedily identify the latest preferences of an unconscious patient, he said. "You could even have a video, so you know someone didn't get the password and change the preferences because they wanted an inheritance."