When a patient arrives at hospital unconscious, it’s assumed that doctors should do all they can to revive her or him. But what if that patient has the words “Do Not Resuscitate” tattooed across their chest?

That was the dilemma that recently faced a team of doctors at Jackson Memorial Hospital in Miami. A 70-year-old patient had arrived in the emergency room with breathing difficulties, low blood pressure that was still dropping, and a high blood-alcohol level. He also had a history of COPD (chronic obstructive pulmonary disease), diabetes, and a heart condition called atrial fibrillation.

Writing about the incident in the New England Journal of Medicine, the doctors say they initially decided to ignore the tattoo and began trying to revive him. They write that they were working on the principle of “not choosing an irreversible path when faced with uncertainty.”

But the doctors say the tattoo left them with an ethical debate. Should they interpret the tattoo as the man’s genuine wishes? What if he had changed his mind since getting the tattoo? What were their legal obligations in this case—or were there any?

The doctors were unable to revive the man to ask him about his wishes, and they could not make contact with his next of kin.

But they noted the man had clearly made an “extraordinary effort” to make his end-of-life wishes known; the word “not” in “do not resuscitate” was underlined, and he had even added his initials as a signature.

The doctors called in the hospital’s social workers to discuss the ethics of the situation. After reviewing the case, the team decided that it made sense to assume that the tattoo expressed the man’s “authentic preference” to not be resuscitated, and a DNR order was written for the man.

Not long after, the social work team learned that the man had in fact signed an official Florida state DNR order. The man’s health deteriorated throughout the night, and he died without undergoing CPR or intubation to assist his breathing, the doctors reported.

In Canada, the Canadian Medical Association has a policy that if a patient requests an “advance directive” detailing what medical procedures they do or do not want in the event they become incompetent, physicians should assist them in drawing up these orders and should also strive to honour them.