Is A Tattoo a Valid DNRO?

By law and training, doctors and emergency medical technicians must do all they can to save lives. That includes administering CPR in the event of cardiac or pulmonary medical emergency. CPR can be withheld only if medical personnel can verify that the patient has a valid Do Not Resuscitate Order (DNRO).



DNRO's are kept in medical charts and by bedsides in hospitals, nursing homes and other medical facilities. When emergency medical personnel are summoned to homes, they look for it on refrigerators or at bedsides. If there's any doubt that a valid DNRO exists, they will err on the side of caution and provide resuscitation.


But what happens if there is no document - just a tattoo?  This is precisely what happened in a case recently reported in the New England Journal of Medicine: 


An unconscious 70-year-old man was brought into a Florida emergency room, unaccompanied by family or friends. He had pulmonary failure, and an elevated alcohol blood level. He had the words Do Not Resuscitate, and his signature, tattooed across his chest. The physicians now faced a perplexing ethical quandary. The tattoo is not a legally binding document; but presumably, this man had wanted the tattoo applied. Even so, did the tattoo reflect the patient's current wishes? Might he have changed his mind and just failed to have the tattoo removed? Erring on the side of caution, the physicians went ahead a treated him with antibiotics and other life-saving measures.


Later, the hospital’s social work department delivered the definitive answer. Through the Florida Department of Health, they were able to confirm that the patient had a DNRO. The physicians ceased treatment, and the patient passed on.


That was a case in which a tattoo accurately reflected an individual's wishes. But another curious incident demonstrates that's not always the case. "DNR Tattoos: A Cautionary Tale," published in the Journal of General Internal Medicine in 2012, describes a 59-year-old man admitted to the hospital for a leg amputation. He suffered from diabetes and chronic non-healing wounds. During the admission process he insisted he wanted CPR in the event of cardiac or pulmonary arrest. But here's the curious part: he also had the letters "DNR" tattooed on his chest. When puzzled staff inquired about it, the patient explained he'd gotten the tattoo years ago as a result of losing a bet in poker game. Medical staff suggested he have it removed, but the patient declined. He insisted the tattoo was obviously a joke and no one would ever take it seriously.


If you are one of the many millions of Americans who would prefer to avoid CPR under certain circumstances, or if you are the health care surrogate or proxy for someone who would want to avoid such measures, no need for a tattoo. What you do need is a Do Not Resuscitate Order. Here are some specifics you will need to know about this important document:

• The Florida Department of Health DNRO form (#1896) may be downloaded, or call the department to request a form at 800-226-1911 or 850-245-4440, ext. 2795.

• The form must be signed by you and your physician (but it does not need to be notarized). 

• To be valid, the form must be printed on YELLOW paper.

• At the bottom of the form is a “Patient Identification Device” which may be detached from the form, laminated and worn around your neck, clipped to clothing or bed, etc., so it is always with you.

For more information on the DNRO, check out the Florida Department of Health's frequently asked questions about DNRO's.

For information on all types of medical advance directives, click here. 

When advance directives are ignored

When we discuss end-of-life wishes with clients, some clients say they want everything possible done to keep them alive, regardless of their physical condition or possible outcome. If they can hang on for a while longer, they reason, there might be some medical advance around the corner that restores their health. If that is your inclination, you have every right to direct your health care providers to pull out all the stops.

On the other hand, you also have the right to reject extraordinary medical procedures that could result in what you consider an unacceptable quality of life. In my experience, that attitude is far more common. But disturbingly, according to an April 10, 2017 New York Times article, the right to refuse medical treatment is sometimes not honored, even when patients have made the appropriate legal preparations. The logic of many medical providers seems to be to err on the side of caution: After all, someone who has been resuscitated can be disconnected from life support, but you can't bring someone back from death. 

One instance mentioned in the article is that of Beatrice Weisman. In 2013, at age 83, Weisman was hospitalized after having a severe stroke. A resident of Maryland, she had a Physician's Order for Life Sustaining Treatment, or POLST. (POLST is under development in Florida but not yet available here. In states that do permit them, a seriously ill or frail patient or his/her health care surrogate may establish, in consultation with the individual's doctors, guidelines for the types of treatments the patient should or should not receive. The POLST is different from the advance directives now available in Florida because it is an actual physician's medical order, an official part of the patient's medical record.)

Weisman's POLST indicated she was not to receive CPR in the event of pulmonary or coronary failure. It was located in her medical chart at her bedside. Nonetheless, when hospital staff found her in bed turning blue, they rushed to save her. She was defibrillated and received epinephrine injections. Several of her ribs were broken during the administration of CPR. Weisman survived. After a few years of physical therapy and round-the-clock care - paid for out-of-pocket by her family - she remains bedbound, attached to a feeding tube and catheters, and suffering from dementia. The family has sued the hospital for keeping her alive against her express wishes. Says her son: "I'm happy to see my mother each day, but I'm also seeing her suffer each day."

As we live longer and longer, it is inevitable that more cases of this type will occur. The courts seem inclined to side with plaintiffs. For example, the Georgia Supreme Court recently rejected a hospital's claim of immunity, stating, "It is the will of the patient or her designated agent, and not the will of the health care provider, that controls."

Of course, being revived against one's wishes is not always a function of overeager doctors and hospital staff.  It is all too common for a healthy person to have a valid living will prepared, yet fail to notify his/her family or health care agent that it exists, or where it can be found. Many people just stick it in a file cabinet or lock it up in a bank vault, and forget about it. And once someone becomes cognitively incapacitated, he/she may not be able to tell others that the document even exists. 

Your best bet to ensure your end-of-life wishes are honored is to make sure your physicians, family, friends and health care agent know about your advance directives, where they are located, and how they can be accessed. Some suggest downloading the documents to your mobile phone and to your loved ones' mobile phones, too.

Read about the various types of Florida advance directives here.

Read the original New York Times article on this subject here.

Read about the POLST form, currently in the planning stages in Florida, here.

911 call should prompt Florida seniors to consider two important issues

The February 26 death of 87-year-old Lorraine Bayless is fueling a heated public discussion that this Florida elder law attorney believes is long overdue.

If you are not familiar with the news story, here's the short version: Bayless lived at an independent senior residence in Bakersfield, California. When she collapsed in the dining room last week, the staff person in charge called 911. The employee identified herself as a nurse but apparently, was not actually serving in that capacity at that moment. When the 911 dispatcher asked her to perform CPR, or to find someone who could, she refused, saying that would be against facility policy. By the time the EMTs arrived, Bayless was not breathing. She died at the hospital soon after. Whether she would have survived and in what condition had CPR been promptly administered are questions that remain unanswered. (To read a partial transcript of that call, click here.)

The facility's parent company confirmed that the employee was following policy, but at the same time said she misunderstood the policy. Bakersfield, California authorities conducted an investigation and just yesterday announced there are no grounds for criminal charges. Professionals in the long-term care community have expressed both outrage and support for the facility's action, or should I say, lack of action.

And Bayless' family? It supports the facility's actions, stating, "It was our beloved mother and grandmother's wish to die naturally and without any kind of life prolonging intervention...We understand that the 911 tape of this event has caused concern, but our family knows that mom had full knowledge of the limitations of Glenwood Gardens and is at peace." It is unclear whether Bayless had a Do Not Resuscitate Order, and if so, if it was on file with the facility or anywhere else.

This unfortunate event gives rise to two important points every Florida senior and family should consider:

Think about whether you want a Do Not Resuscitate Order: 

A Do Not Resuscitate Order, referred to as a DNR or DNRO, is available through physicians and medical facilities. It must be signed by the physician, and also by the patient or his/her health care agent or health care surrogate. The DNRO requests that CPR be withheld if the person experiences respiratory or cardiac failure. It should be readily available to Emergency Medical Technicians; without seeing it, paramedics are required to administer CPR.

Many Florida seniors incorrectly believe that a Do Not Resuscitate Order applies only to a person who is in a terminal or vegetative state only. Florida law has changed and that is no longer the case.  For example, one of my clients, in her 80s and healthy, insists on having one. She plays tennis three times a week - her only concession to aging is that she now plays doubles - and if she can help it, doesn't want those tennis games replaced with doctor's visits. She unabashedly tells me her desire is to pass away on the tennis court, and hopes her DNRO will keep the paramedics at bay. And she's not alone: see my prior blog post about the "Grandmother with the DNRO tattoo."

The choice of whether to have a DNRO is one only you can make. We do not know if Mrs. Bayless had a DNRO. But if you or your loved one choose to have one, it should be kept on file with your physician and kept handy for the paramedics to see. 

Read the fine print before you move into a senior facility:

You should be aware of the differences between "independent living" and "assisted living." Independent living facilities do NOT provide medical care to residents, and are NOT regulated by the State of Florida as assisted living facilities are. The Bayless family apparently grasped this distinction, but for the general public, the line between the two types of living arrangements tends to be fuzzy, for several reasons:

First, Continuing Care Retirement Communities often include independent living, assisted living and nursing home care. Thus, seniors who buy into these communities to ensure a lifetime of care may overestimate the kind of care available at the independent residence.

The distinction is further blurred because many independent living residences provide certain safety features, such as emergency pull cords and 24-hour staffing, and amenities like meals.  In fact, the definition of "assisted living" has become so blurry in the public's mind that the Veterans Administration recently had to clarify what constitutes custodial care and medical care for those seeking V.A. pension benefits.  But most independent living facilities are, essentially, apartments designed for older residents, pure and simple. Most are apartments for seniors.

The bottom line is, read the fine print, so you know what kind of care you or your loved one can expect. 

The Grandmother With the DNR Tattoo

"I was born an animal... and I don't want to die a vegetable." So says 81-year-old Joy Tomkins, explaining why she has the words "Do Not Resuscitate" prominently tattooed in blue over her heart.

A British grandmother, Tomkins is not terminally ill. But she's hoping that if anything happens to her, the tattoo will ensure that extraordinary measures won't be taken to keep her alive.

I don't know how British law works. But Stateside, Tomkins' plan wouldn't work. To withhold resuscitation, medical personnel must see a valid Do Not Resuscitate Order - on paper, not on your skin! A physician must sign the DNRO, and you (or your health care power of attorney) must also sign.The document states that in the event of cardiac or respiratory arrest, resuscitative techniques should not be used.

The DNRO is not the same as a Living Will. To learn more about these and other health care documents,  click here.