Tattoo

When A Tattoo Means Life Or Death. Literally

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The man was unconscious and alone when he arrived at University of Miami Hospital last summer. He was 70 years old and gravely ill.

“Originally, we were told he was intoxicated,” remembers Dr. Gregory Holt, an emergency room doctor, “but he didn’t wake up.”

“He wasn’t breathing well. He had COPD. These would all make us start to resuscitate someone,” says Holt. “But the tattoo made it complicated.”

The tattoo stretched across the man’s chest. It said “Do Not Resuscitate.” His signature was tattooed at the end.

“We were shocked,” remembers Holt. “We didn’t know what to do.”

The tattoo, and the hospital’s decision about what it required of them, has set off a conversation among doctors and medical ethicists around the country about how to express one’s end-of-life wishes effectively, and how policymakers can make it easier.

In the U.S., the standard way to tell doctors you want to be allowed to die is to sign an official form saying you don’t want to be resuscitated. That means, among other things, you don’t want doctors to do CPR or use a ventilator to keep you alive if you stop breathing.

But signing the official form doesn’t guarantee your wishes will be followed. If you lose consciousness and end up in the emergency room, for example, the form may not come with you, in which case many doctors err on the side of intervening.

“A lot of doctors say, ‘Look, you can always be dead later. Don’t take a course that’s irreversible,’ ” explains Dr. Kenneth Goodman, a longtime medical ethicist for the University of Miami hospital and the man Dr. Holt called when he saw the man’s tattoo. It was his job to figure out the best course of action, and quickly — the man seemed to be dying.

“Our big concern was, is this real?” remembers Holt. The only previous example they could find in the medical literature was a case from 2012, in which a man with a chest tattoo that read “D.N.R.” told doctors it was the result of a drunken bet, and that it didn’t reflect his wishes.

And, even if this tattoo was real, it was initially unclear whether it should carry the same weight as an official form stating the same thing.

After The Cranberries And Pie, Take Time To Talk About Death

“My thoughts were these,” explains Goodman. “He’s gone through the trouble of getting this tattoo that says please don’t do this to me, and he’s probably seen it pretty frequently since then. I suppose every time one’s looking in the mirror one would see this.”

In that way, the tattoo might be more likely to reflect the man’s current wishes than a form, which he might have signed and forgotten to update. “If we take a piece of paper at face value even if he might have changed his mind, we really should take this tattoo at face value, even if he might have changed his mind,” Goodman says.

Goodman advised the doctors to take the tattoo seriously. The man got sicker and sicker overnight. They didn’t do CPR. The man died. And social workers eventually found the man had an out-of-hospital form on file with the Florida Department of Health that backed up his tattoo.

Holt published a case study about the patient in The New England Journal of Medicine in November, thinking it might be helpful for other doctors. Since then, he and Goodman say they have heard from a wide range of doctors and ethicists.

“It started a good conversation” about how to help people express their end-of-life wishes in productive ways, Holt says. Tattoos, he and Goodman both say, are not the answer. Although the tattoo ultimately worked in this case, “the long and short of it is that I don’t think it’s a useful thing. It really gave us more pause than help,” Holt says.

What would really be helpful is an easy way to access official forms from everywhere. Ideally, EMTs and ER docs could both know instantly what care an unconscious person wants.

“Imagine an ordinary patient who has a preference never to be resuscitated, and that is in her record,” says Goodman. “Why then, that ought to be something you can call up anywhere.” Some states have attempted to do that by establishing electronic registries for a type of directive called a POLST form, which is meant to be used by very old or sick people.

Oregon’s registry has increased the odds that people get the care they want, and since California launched a pilot registry in 2016, some doctors say they have seen fewer patients who choose to wear their preferences on their bodies — etched in bracelets, mostly, not tattooed on their skin.

When A Tattoo Means Life Or Death. Literally

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Doctors in Miami found that a man’s tattoo expressing his end-of-life wishes was more confusing than helpful.

The man was unconscious and alone when he arrived at University of Miami Hospital last summer. He was 70 years old and gravely ill.

“Originally, we were told he was intoxicated,” remembers Dr. Gregory Holt, an emergency room doctor, “but he didn’t wake up.”

“He wasn’t breathing well. He had COPD. These would all make us start to resuscitate someone,” says Holt. “But the tattoo made it complicated.”

The tattoo stretched across the man’s chest. It said “Do Not Resuscitate.” His signature was tattooed at the end.

“We were shocked,” remembers Holt. “We didn’t know what to do.”

The tattoo, and the hospital’s decision about what it required of them, has set off a conversation among doctors and medical ethicists around the country about how to express one’s end-of-life wishes effectively, and how policymakers can make it easier.

In the U.S., the standard way to tell doctors you want to be allowed to die is to sign an official form saying you don’t want to be resuscitated. That means, among other things, you don’t want doctors to do CPR or use a ventilator to keep you alive if you stop breathing.

But signing the official form doesn’t guarantee your wishes will be followed. If you lose consciousness and end up in the emergency room, for example, the form may not come with you, in which case many doctors err on the side of intervening.

“A lot of doctors say, ‘Look, you can always be dead later. Don’t take a course that’s irreversible,’ ” explains Dr. Kenneth Goodman, a longtime medical ethicist for the University of Miami hospital and the man Dr. Holt called when he saw the man’s tattoo. It was his job to figure out the best course of action, and quickly — the man seemed to be dying.

“Our big concern was, is this real?” remembers Holt. The only previous example they could find in the medical literature was a case from 2012, in which a man with a chest tattoo that read “D.N.R.” told doctors it was the result of a drunken bet, and that it didn’t reflect his wishes.

And, even if this tattoo was real, it was initially unclear whether it should carry the same weight as an official form stating the same thing.

After The Cranberries And Pie, Take Time To Talk About Death

“My thoughts were these,” explains Goodman. “He’s gone through the trouble of getting this tattoo that says please don’t do this to me, and he’s probably seen it pretty frequently since then. I suppose every time one’s looking in the mirror one would see this.”

In that way, the tattoo might be more likely to reflect the man’s current wishes than a form, which he might have signed and forgotten to update. “If we take a piece of paper at face value even if he might have changed his mind, we really should take this tattoo at face value, even if he might have changed his mind,” Goodman says.

Goodman advised the doctors to take the tattoo seriously. The man got sicker and sicker overnight. They didn’t do CPR. The man died. And social workers eventually found the man had an out-of-hospital form on file with the Florida Department of Health that backed up his tattoo.

Holt published a case study about the patient in The New England Journal of Medicine in November, thinking it might be helpful for other doctors. Since then, he and Goodman say they have heard from a wide range of doctors and ethicists.

“It started a good conversation” about how to help people express their end-of-life wishes in productive ways, Holt says. Tattoos, he and Goodman both say, are not the answer. Although the tattoo ultimately worked in this case, “the long and short of it is that I don’t think it’s a useful thing. It really gave us more pause than help,” Holt says.

What would really be helpful is an easy way to access official forms from everywhere. Ideally, EMTs and ER docs could both know instantly what care an unconscious person wants.

“Imagine an ordinary patient who has a preference never to be resuscitated, and that is in her record,” says Goodman. “Why then, that ought to be something you can call up anywhere.” Some states have attempted to do that by establishing electronic registries for a type of directive called a POLST form, which is meant to be used by very old or sick people.

Oregon’s registry has increased the odds that people get the care they want, and since California launched a pilot registry in 2016, some doctors say they have seen fewer patients who choose to wear their preferences on their bodies — etched in bracelets, mostly, not tattooed on their skin.

Nanoparticle Scientists Warn Tattooed Folks: Ink Doesn’t Stay Put

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Recently, European scientists bombarded tattooed corpses with X-rays from a particle accelerator. While it could have been a scene for an upcoming goth body horror movie, it was actually a study meant to benefit living humans with tattoos. This grisly experiment helped European nanoparticle researchers understand how tattoo ink travels in human bodies over time.

 tattoo

In a study published in the journal Scientific Reports on Tuesday, a team of French and German researchers reports that nanoparticles found in some tattoo inks can migrate away from the skin — and accumulate in lymph nodes.

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This team, made up of members from the European Synchrotron Radiation Facility in France, and the German Federal Institute for Risk Assessment, Physikalisch-Technische Bundesanstalt, and Ludwig-Maximilians University, used synchrotron X-ray fluorescence to detect the moving pigment particles in the corpses.

Butterfly-Heart-Neck-Tattoo
Some ink particles can travel to the lymph nodes, like those under the ears.

First, the scientists took samples of lymph nodes and skin from four tattooed donor cadavers and one un-tattooed control cadaver. Then, they examined the skin and lymph nodes to see whether the pigments present in the skin were also in the lymph nodes. If that were the case, it would suggest that particles in the ink had indeed migrated through the lymphatic system to the lymph nodes, which filter lymph, the fluid that carries white blood cells through the body to fight infections.

Sure enough, they did find particles in the nodes, confirming their long-held suspicion that pigment particles accumulate there.

“We found a broad range of tattoo pigment particles with up to several micrometers in size in human skin but only smaller (nano)particles transported to the lymph nodes,” write the study’s authors. They suspect that the larger particles — those up to a micrometer across — can’t travel through the lymphatic system. Which is a good thing, because they found that just the small particles had caused the tattooed donors’ lymph nodes to become enlarged.

In particular, the researchers found elevated levels of titanium dioxide — a white tattoo ink pigment that’s added to other pigments to create various color shades — in the skin and lymph nodes of tattooed donors but not in the control sample.

tattooed skin pigments
Scientists found that some pigments in tattoo ink can migrate from the skin into the lymph nodes.

Unsettling as it may be for people with tattoos to learn that their ink isn’t staying put, it’s actually not that surprising that tattoo pigment particles can be found in the lymphatic system. When foreign matter like tattoo ink is traumatically inserted into the body, this system’s action kicks into high gear in its attempt to expel invaders.

Until now, this kind of research had been challenging to conduct. The scientists needed to test actual biological tissues, but that presented a dilemma.

“The animal experiments which would be necessary to address these toxicological issues were rated unethical because tattoos are applied as a matter of choice and lack medical necessity, similar to cosmetics,” the study’s authors write.

Admittedly, this is a small sample size, so these findings are far from being the final word on the matter, and this paper definitely doesn’t support some advocates’ argument that tattoo ink can cause cancer. But it does confirm that tattoo pigments can both travel in the body and accumulate in lymph nodes, which could be worrisome.

“In future experiments we will also look into the pigment and heavy metal burden of other, more distant internal organs and tissues in order to track any possible biodistribution of tattoo ink ingredients throughout the body,” write the authors.