Making decisions about medical interventions, especially those related to life support, requires clear communication of personal wishes to healthcare providers. Among the specialized medical orders that guide care in a crisis, the Do Not Resuscitate (DNR) and Do Not Intubate (DNI) orders are frequently discussed. While both are directives to limit specific life-sustaining treatments, they apply to different clinical events and prohibit distinct medical procedures. Understanding the precise scope of each order is necessary for patients, their families, and medical teams to align care with individual values.
Defining the Do Not Resuscitate Order
A Do Not Resuscitate (DNR) order is a formal medical instruction directing healthcare providers not to attempt cardiopulmonary resuscitation (CPR) if a patient’s heart stops beating or their breathing ceases. This order applies specifically in the event of a cardiac or respiratory arrest. The existence of a DNR order means that no attempts will be made to restart the heart or breathing once they have failed.
CPR is a comprehensive set of procedures designed to restore circulation and breathing, including chest compressions, artificial ventilation, specialized cardiac medications, and electrical defibrillation.
A DNR order prohibits this entire sequence of life-saving interventions, covering all components of resuscitation efforts, including intubation. Importantly, a DNR order does not mean “do not treat”; it only limits interventions during cardiopulmonary arrest, allowing other medical treatments, such as antibiotics or pain medication, to continue.
Defining the Do Not Intubate Order
The Do Not Intubate (DNI) order is a narrowly focused medical directive, specifically prohibiting the placement of an endotracheal tube. Intubation involves inserting a tube into the trachea to secure an airway, connecting the patient to a mechanical ventilator during severe respiratory failure.
A DNI order instructs the medical team to forgo this invasive procedure, even during severe breathing difficulty. It does not prohibit other forms of life support. The patient may still receive supportive care, including oxygen therapy, IV fluids, cardiac drugs, and non-invasive breathing assistance like BiPAP or CPAP masks.
The intent of a DNI order is to prevent the patient from being placed on a ventilator. A patient with a DNI order may receive aggressive medical care, including chest compressions and cardiac drugs, if their heart were to stop. The DNI order is a selective limitation focusing only on airway management.
Navigating the Difference in Treatment Scope
The fundamental distinction between the two orders lies in the scope of prohibited interventions and the clinical situation in which the order takes effect. A DNR order is a complete prohibition on resuscitation efforts, triggered only when the heart or breathing has stopped. A DNI order prohibits only intubation and can be relevant even when the patient’s heart is still functioning.
If a patient experiences full cardiac arrest, a DNR order instructs personnel to withhold all components of CPR, including chest compressions and intubation. If a patient only has a DNI order, the medical team is still obligated to provide full resuscitation, including chest compressions and cardiac medications, but must avoid placing a breathing tube.
A common clinical divergence occurs when a patient suffers severe respiratory failure while the heart is still beating. A patient with a DNR order will typically be managed with comfort measures and supportive care only, implying a broader goal of allowing a natural death.
In this same scenario, a patient with a DNI order may receive aggressive medical treatment to support failing lungs, short of intubation. They can be treated with intravenous medications and non-invasive ventilation. This demonstrates that a DNI order allows for selective treatment, focusing efforts on maintaining life without mechanical ventilation.
The DNI order is often a component of a DNR order, meaning a patient who is DNR is almost always also DNI, as intubation is part of CPR. However, a DNI order can stand alone, allowing the patient to receive aggressive life-sustaining treatment, such as defibrillation or chest compressions.
Documenting Your Wishes
Formal documentation of these preferences is essential to ensure they are legally recognized and honored by healthcare providers. Advance Directives are legal documents that allow an individual to specify healthcare wishes if they become unable to communicate. These typically include a Living Will, which outlines treatment preferences, and a Durable Power of Attorney for Healthcare, which designates a decision-maker.
A DNR or DNI order is a specific medical order, not a legal document like a Living Will, and must be signed by a physician or authorized practitioner. The order is placed in the patient’s medical chart, making it immediately actionable by the medical team. While an Advance Directive provides guidance, the DNR or DNI order directly instructs the medical team on actions to take in a crisis.
For patients with a serious illness or advanced frailty, more portable and specific forms exist, such as Physician Orders for Life-Sustaining Treatment (POLST) or Medical Orders for Life-Sustaining Treatment (MOLST). These forms translate the patient’s wishes into standardized medical orders that travel with the patient. This ensures choices regarding resuscitation and intubation will be respected by emergency medical services personnel outside of a hospital setting.