Pathologist Dr. Ed Friedlander displays his tattoo with a medical directive to not use CPR, which appears to be a growing
trend in North America. (Charlie Riedel/Associated Press)
If your spouse’s initials are “D.N.R.,” you should probably think twice before tattooing them on your chest. Then again, if your end-of-life plans include a do-not-resuscitate order, maybe it’s not such a bad idea after all.

It appears the tattoo craze has expanded beyond mere aesthetics into medicine. Some people are setting down advance directives on skin in addition to paper. Others are opting for tattoos on their wrists instead of MedicAlert bracelets, favoring ink over jewelry. Though there are advantages to turning your epidermis into a medical record — you can’t accidentally leave your forearm at home — some health professionals fear that paramedics and emergency physicians might not notice the tattoos, let alone treat them as proper instructions.

“Emergency responders understand the concept of MedicAlert bracelets and they look for them on the wrist. It is possible that some have learned that people are using tattoos but the chances of them looking for it are much less,” says Robert Ridge, president and CEO of the Canadian MedicAlert Foundation. “There is no overriding body that governs emergency services in Canada, so when something changes there is no national means to communicate it. Getting every emergency responder to look for something new can be a challenge.”

The days of tattoos being associated only with bikers and ex-cons are long gone. Now tattooing is firmly planted in the mainstream. A woman is as likely to have one as a man. There are reality television shows about tattoo artists. Celebrities sport tattoos, including the popular actress Angelina Jolie, who has nearly a dozen. Many professional athletes are covered in more ink than an incontinent squid.

In the United States, 36% of people in the 18–25 age bracket have a tattoo, and that percentage increases to 40% for people between the ages of 25 and 40, according to the Pew Research Center in Washington, DC (http://pewresearch.org/databank/dailynumber/?NumberID=237). By contrast, only 10% of people aged 41–64 have one.

So perhaps it should come as little surprise that some young people with allergies or conditions such as diabetes have no qualms about tattooing that information on their bodies. Some people prefer tattoos because they can’t wear jewelry to work (electricians, for example) or because bracelets and necklaces are easily broken and lost during certain sporting activities, such as surfing. Others simply like the look of a tattoo more than jewelry.

Tanyss Christie, a 35-year-old, got a tattoo last year that declares she has type 1 diabetes. “I have a friend and she got one, too, after she saw mine,” says Christie, a mother of two. “I got a little bit different of a design for mine. It’s close to a MedicAlert bracelet, but with a little twist [see picture below].”

Mike Hillier, a 29-year-old, also has type 1 diabetes. He was diagnosed late, at age 24, and never took to wearing a MedicAlert bracelet, despite being encouraged to do so by his mother and doctor. “I never really wore mine, and I was looking to get another tattoo anyway,” says Hillier, a technologist with a satellite broadcasting company. “I wanted it to be something that actually meant something.”

How many people have medical tattoos? It’s difficult to say. There is no organization keeping track. At very least, it appears to be a trend on the rise, if the extensive gallery on the website for the group Diabetes Advocacy is any indication (www.diabetesadvocacy.com/tattoos.htm). Still, despite becoming more popular, medical tattoos are still relatively rare, according to those who work in the ink trade. 

Beyond anecdotes, however, there is little information available on medical tattoos. If you conduct a search for data on the topic in medical literature, you might just see digital tumbleweeds roll across your screen. There is one 20-year-old paper, though, that presented the case of an aging emergency physician with a symbol indicating “do no defibrillate” on his chest (West J Med 1992;156:309-12). The primary purpose of the tattoo wasn’t to offer directions, however, but rather to “make a principled statement about the futility in emergency departments of continuing ACLS [advanced cardiac life support] on patients who do not respond to prehospital resuscitative efforts.”

Though relatively rare, it is still time that medical researchers pay more attention to patients who use their bodies to relay important medical information, says Dr. Saleh Aldasouqi, an associate professor of medicine at Michigan State University in East Lansing and the medical director of the Sparrow Diabetes Center. 

“This is something of medical relevance. I’m not promoting it. I’m just reporting something that I see on my patients, and I see it as a problem because they are doing it without medical advice,” adds Aldasouqi, one of the few academics to ever write about medical tattoos (Am Fam Physician 2011;83:796). “We are burying our heads in the sand if we are saying this is not occurring and we don’t have to worry about it.”

The problem with MedicAlert-type tattoos is that, unlike bracelets and necklaces, there are no guidelines regarding their design or location on the body. Indeed, a Google Image search reveals medical tattoos on upper backs, shoulders, wrists, forearms and chests. Some are simple, others elaborate. Some are black, others exploding with colour.  There are medical tattoos featuring ribbons, angel wings, snakes, horses, butterflies, skulls, hearts and even the cartoon character Hello Kitty. You see more fonts than in a word processor drop-down menu. A medical tattoo may also be hard to spot on a person with many other tattoos.

“This thing has to be standardized,” says Aldasouqi. “We have to at least teach and educate emergency personnel so they become more aware.”

As for the legal ramifications of ignoring a do-not-resuscitate tattoo, that is another matter altogether. Those types of tattoos, however, appear to be very rare. There is the odd case that pops up and makes a splash in the popular media. Dr. Ed Friedlander, a 60-year-old pathologist in Kansas City, Missouri, has a “No CPR” tattoo on his chest. Then there is Joy Tomkins, a senior citizen in Norfolk, England, who has “Do Not Resuscitate” tattooed over her heart and the letters “P.T.O.” (for “please turn over”) on her upper right shoulder.

But emergency personnel are not obligated to follow a tattooed directive, which does not carry the legal weight of a written, properly authenticated do-not-resuscitate document, according to Dr. Philip Goscienski, a retired pediatric infectious disease specialist from San Diego, California. Furthermore, it could lead to trouble if a person loses consciousness for a reason unrelated to a medical condition.