The question of whether a person with a Do Not Resuscitate (DNR) order will be placed on a mechanical ventilator is a common source of confusion in end-of-life care. This uncertainty stems from the distinct medical and legal definitions of life-sustaining treatments. A DNR order is a medical instruction that specifically addresses what happens when the heart or breathing stops completely. Mechanical ventilation, or life support, is a treatment used to support a patient who is still alive but struggling to breathe. Understanding the scope of each order is necessary to ensure one’s medical wishes are honored during a health crisis.
Defining the Do Not Resuscitate Order
A Do Not Resuscitate (DNR) order is a formal, legally binding medical instruction to withhold cardiopulmonary resuscitation (CPR) if a patient experiences cardiac or respiratory arrest. This order only becomes active when a person’s heart stops beating or they stop breathing entirely. The primary function of a DNR is to prevent attempts at restarting life after this complete cessation of function.
The interventions prohibited by a standard DNR order are those used to reverse clinical death, collectively known as resuscitation. These measures include chest compressions, defibrillation, emergency cardiac medications, and artificial respiration methods like placing a breathing tube during a code. The DNR is a clear statement that the patient chooses a natural death rather than aggressive, invasive attempts to prolong life when vital functions cease.
A DNR order specifies a limit on one type of intervention—CPR and its associated procedures—but does not mean “do not treat.” Other treatments, such as antibiotics, dialysis, pain management, and certain other types of life support, are still authorized and provided unless otherwise specified. The decision to obtain a DNR is typically made after discussing the patient’s prognosis and the low success rate of CPR for people with severe underlying illnesses.
The Crucial Distinction: DNR vs. Mechanical Ventilation
A standard Do Not Resuscitate (DNR) order generally does not prevent a patient from being placed on a mechanical ventilator. This is because mechanical ventilation is considered supportive care, not a resuscitation measure. A ventilator supports breathing when a person is still alive but suffering from acute respiratory failure, such as from pneumonia or a severe infection.
The ventilator is an organ-supportive therapy designed to treat a reversible condition and give the body time to heal, unlike CPR which attempts to reverse clinical death. A patient with a DNR order may temporarily be intubated and placed on a ventilator if the medical team believes the underlying cause of the breathing difficulty is treatable. This allows time for consultation during a sudden crisis.
The confusion arises because intubation is part of a full resuscitation effort if the patient is already in cardiac arrest. However, when used independently to support a failing patient, the ventilator is a form of life support distinct from the procedures prohibited by a DNR. Clarifying specific treatment preferences beyond the basic DNR order is essential.
Understanding Do Not Intubate Orders
If a patient wishes to refuse mechanical ventilation, the specific medical order required is a Do Not Intubate (DNI) order. A DNI is a directive not to perform intubation, which inserts a tube into the trachea to connect the patient to a ventilator. This order prevents the use of the breathing machine even if the patient is still alive but can no longer breathe adequately on their own.
A DNI order is often used with a DNR order, but a patient can have one without the other. Patients typically request a DNI to avoid the invasive nature and potential complications of prolonged mechanical ventilation, while remaining open to other life-sustaining treatments.
The DNI order resolves the ambiguity of the DNR regarding mechanical ventilation. Specifying “Do Not Intubate” clearly communicates the refusal of the breathing tube and subsequent ventilator support. This directive is crucial for individuals who want to avoid the most invasive forms of respiratory support.
Scope and Legal Validity of Advanced Directives
To ensure wishes regarding resuscitation and ventilation are followed, preferences must be documented using legally valid advanced directives. An Advance Directive is a legal document that outlines a person’s general healthcare wishes and often appoints a healthcare agent to make decisions if the person becomes unable to communicate.
For individuals with a serious illness or advanced frailty, a more specific, actionable medical order is recommended, such as a Physician Orders for Life-Sustaining Treatment (POLST) or a Medical Orders for Life-Sustaining Treatment (MOLST). These are often called “Portable Medical Orders” because they are standardized forms that function as a physician’s order and are valid across various care settings.
Portable Medical Orders translate the patient’s preferences into explicit instructions that must be honored by all healthcare providers, including Emergency Medical Services (EMS) personnel. Unlike a general Advance Directive, which EMS may not be required to follow, a POLST or MOLST form includes specific, pre-checked boxes for DNR and DNI status. Ensuring these forms are visible and readily available is the most practical step to guarantee wishes regarding resuscitation and mechanical ventilation are respected.