End-of-life care decisions are formalized through medical orders that ensure a patient’s wishes are honored when they cannot speak for themselves. These physician orders provide instructions to healthcare providers regarding life-sustaining treatments. Two frequently discussed orders are the Do Not Resuscitate (DNR) and Do Not Intubate (DNI), which govern specific actions during a medical crisis. The key difference lies in the breadth of interventions each order covers.
Scope of DNR and Scope of DNI
A Do Not Resuscitate (DNR) order is a comprehensive medical directive instructing healthcare providers to withhold cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. This order prohibits a wide range of interventions, including chest compressions, artificial ventilation, and defibrillation (electrical shock) to restart the heart. The DNR order is a broad instruction that dictates no attempts will be made to restore a patient’s heart function or breathing once they have completely stopped.
The Do Not Intubate (DNI) order is a more limited and specific directive. It prohibits the single action of endotracheal intubation, which is the placement of a tube into the windpipe to connect a patient to a mechanical ventilator. A DNI order allows a patient to avoid the potentially invasive and long-term consequences associated with mechanical ventilation, which can include complications and prolonged dependency.
These physician orders are often documented using standardized forms like Physician Orders for Life-Sustaining Treatment (POLST) or Medical Orders for Life-Sustaining Treatment (MOLST). These forms translate a patient’s preferences into medical orders that must be followed by all healthcare personnel, including emergency medical services (EMS).
How DNI Differs From DNR
The answer to whether a patient can have a DNI order without a DNR is definitively yes, and this distinction is the core difference between the two directives. A DNI order is an instruction to withhold only one specific intervention—intubation and subsequent mechanical ventilation—while allowing for all other resuscitative and life-sustaining measures. In contrast, a DNR order encompasses the prohibition of intubation along with chest compressions, cardiac medications, and defibrillation.
Having a DNI-only order means a patient consents to full resuscitation, including chest compressions, cardiac medications, and electrical cardioversion, should their heart stop. The only procedure prohibited is the insertion of a breathing tube into the trachea. This approach allows a patient to accept aggressive measures for cardiac events while rejecting the specific risks of mechanical ventilation.
A patient may choose a DNI without a DNR because they fear the poor quality of life or long-term dependency that can follow mechanical ventilation. They may still want the chance of survival offered by chest compressions and medications, even though CPR success rates are generally low. The DNI order allows for a middle ground, maximizing the chance of recovery from a treatable condition without risking the complications of being on a ventilator.
Medical Response to a DNI-Only Order
The existence of a DNI-only order significantly alters the medical team’s protocol during a crisis, creating distinct scenarios based on the nature of the patient’s decline. If a DNI-only patient experiences respiratory distress, healthcare providers will aggressively use non-invasive measures to support breathing. This includes high-flow oxygen, inhaled medications, and non-invasive positive pressure ventilation (NIPPV) devices like BiPAP or CPAP.
If the patient’s respiratory function continues to decline despite these maximal non-invasive efforts, the medical team is legally bound to stop treatment before performing intubation, respecting the DNI order. The patient will receive comfort care, but the prohibited procedure will not be initiated. This scenario highlights the DNI order’s function as a clear boundary for treatment, rather than a blanket refusal of all care.
Conversely, if the DNI-only patient suffers a cardiac arrest, the medical team must initiate full advanced cardiac life support (ACLS). This involves immediate chest compressions, administration of cardiac drugs, and the use of a defibrillator. The only difference from a full resuscitation is that a breathing tube cannot be placed. Airway management during CPR will be limited to less invasive techniques like a face mask or laryngeal mask.