Doctors at Jackson Memorial Hospital weren’t sure if the tattoo truly reflected the man’s wishes. Dr. Gregory Holt, a University of Miami assistant professor who worked on the case this summer, said doctors kept the man alive while referring the matter to an ethics team.

Holt, who helped write a case study published last week in The New England Journal of Medicine, said the ethics team eventually decided the tattoo reflected the man’s wishes. He had underlined the word “not” and added a signature. The man later died without intervention.