The man arrived at the hospital unconscious, without identification, with a high level of alcohol in the blood.
He was 70 years old, had a history of lung disease, heart problems and diabetes, and three words tattooed in large, black letters across his chest: "Do not resuscitate."
Doctors at Jackson Memorial Hospital in Miami, Florida, were not sure how to proceed.
The message on his chest was clear, and he had his (presumed) signature underneath, but they had no way of knowing whether the tattoo was sincere, or was done impulsively .
Efforts to contact the man's relatives were unsuccessful. The doctors administered some treatment to increase their level of consciousness, but never became receptive enough to talk and discuss their wishes at the end of life.
"Initially we decided not to honor the tattoo, invoking the principle of not choosing an irreversible remedy when faced with uncertainty," they wrote in a letter published in the New England Journal of Medicine on Thursday.
"This decision left us in conflict, due to the extraordinary effort of the patient to make known his presumed advance directive, therefore, the ethical consultation was requested."
After reviewing the case, the ethics consultants They advised the doctors to respect the man's tattoo "not resuscitate".
"They suggested that it was more reasonable to infer that the tattoo expressed a genuine preference … and that the law is sometimes not agile enough to support patient-centered care and respect for the best interests of patients "they wrote.
Man's health deteriorated, and he later died, without being resurrected.
Before dying, the medical staff discovered that, in fact, he had filled out a form with the intention of expressing his wishes at the end of his life, which were consistent with his tattoo.
What would happen in Australia?
Different states and territories have different laws when it comes to advance care planning and legal directives.
However, there are common principles, which include respect for the right of an adult who has the mental capacity to plan in advance. for your health care.
"The ethic of the community is that the patient's autonomous decision must be taken care of by a medical team," said Ian Olver, an oncologist and bioethicist at the University of South Australia.
"But you" I have to be able to really determine what that decision is. "
To do this, according to the common law, doctors must be satisfied with three things: that a person was competent when they made the directive; it was an informed choice, and that applies to the situation they are currently in.
"The doctor has to try to determine what the patient's wishes are … so in this case, look for family members, look to his family doctor, looking for documentation to prove and reinforce the directive was a very sensible decision, "said Professor Olver.
While physicians, such as Jackson Memorial Hospital, sought advice from a medical ethics team, the professor Olver said it was unlikely to happen in Australia.
"A lot of the hospitals have treatment ethics committees where they set an ethical policy. But it is not common for there to be an ethicist for a situation like this. "
Professor Olver said that doctors were more likely to have to make a decision, especially in emergency situations.
" You should make a call, and if there is enough uncertainty, I think the call might be to make what you need to do medically, and you will solve it later.
"But in other cases where, perhaps the opportunity for & # 39; [successful] resuscitation is very small and the patient's wishes seem clear, the spirit of the community is to pay attention to the patient's wishes", He said.
Make clear the wishes of end of life
Although rare Professor Olver said it was worth examining the case of EE. UU To see what improvements could be made to advance the care planning processes.
"Highlight where we may need to improve, make sure the patient's wishes are known and communicated," he said. .
Making an advanced care plan is a good place to start, and it is important to be specific and spread it widely, he said.
"It's worth your GP to know if there's a copy, and certainly relatives, you should have a copy."