A “Do Not Intubate” (DNI) order is a specific medical instruction documented in a hospital setting that reflects a patient’s wishes regarding life-sustaining procedures. This order communicates that the patient does not consent to a particular invasive intervention in the event of respiratory distress or failure. The DNI order is a formal part of advance care planning, ensuring that a patient’s autonomy is respected even if they become unable to communicate their preferences. Understanding this term can reduce confusion and anxiety for patients and their loved ones during a serious illness.
What “Do Not Intubate” Specifically Means
The DNI order is a direct prohibition against endotracheal intubation. This procedure involves inserting a plastic tube through the patient’s mouth or nose and down into the windpipe (trachea) to secure the airway. Intubation is typically performed when a patient is experiencing severe respiratory failure and cannot maintain adequate oxygenation or ventilation. Once the tube is placed, it is connected to a mechanical ventilator, which assists or takes over the work of breathing. The DNI order prevents the initiation of this specific invasive support, avoiding the potential complications, discomfort, and long-term consequences associated with mechanical ventilation.
The Critical Distinction: DNI Versus DNR
A common point of confusion is the difference between a DNI order and a Do Not Resuscitate (DNR) order. A DNR is a broader instruction that prohibits the entire process of cardiopulmonary resuscitation (CPR) if the patient’s heart stops beating or they stop breathing. CPR encompasses a range of interventions, including chest compressions, cardiac drugs, electrical shock (defibrillation), and intubation.
A DNI order, in contrast, is much more specific, prohibiting only the placement of the breathing tube and the subsequent use of mechanical ventilation. Under a DNI order alone, other life-saving measures may still be employed if the patient experiences a cardiac or respiratory event. For instance, the medical team may still perform chest compressions, administer cardiac medications, or use a defibrillator to try and restart the heart.
The ability to choose a DNI without a full DNR allows a patient to reject the highly invasive nature of mechanical ventilation while still consenting to other forms of resuscitation. This distinction is significant because a patient may be experiencing severe breathing difficulty while their heart is still beating. A DNI order ensures the patient’s preference to avoid the ventilator is honored, even before a full cardiac arrest occurs.
Establishing the DNI Order
The establishment of a DNI order is a formal process rooted in patient autonomy and communication with the medical team. The decision begins with a detailed discussion between the patient and their physician about the benefits and risks of intubation and the overall goals of care, including prognosis and quality of life considerations.
For a DNI order to be legally and medically valid, a physician must document it and place it into the patient’s medical record. If the patient is conscious and has the capacity to make decisions, they can directly request the order. If the patient is unable to communicate their wishes, the decision falls to a legally authorized surrogate decision-maker or healthcare proxy, who is tasked with speaking on the patient’s behalf.
These preferences are often formalized through specific documents, such as a Physician Orders for Life-Sustaining Treatment (POLST) or a Medical Orders for Life-Sustaining Treatment (MOLST) form, which vary by state or jurisdiction. These orders are not permanent and can be reversed or withdrawn by the patient or their proxy at any time if their preferences change. The process ensures that the patient’s wishes regarding invasive respiratory support are clearly understood.
Other Medical Care and Treatment That Continues
A common misunderstanding is that a DNI order signals a withdrawal of all medical care, which is not the case. The DNI order is highly specific and only addresses the single intervention of intubation and mechanical ventilation. All other medical and nursing care aimed at maximizing comfort, treating reversible conditions, and managing symptoms continues fully.
Patients with a DNI order still receive comprehensive care. This includes medications (such as antibiotics and pain relief), routine hospital care, intravenous fluids, nutritional support, and diagnostic testing.
Non-invasive respiratory support may also still be used to assist breathing. This includes supplemental oxygen delivered via a nasal tube or face mask, and non-invasive ventilation methods like BiPAP or CPAP.