A Do Not Intubate (DNI) order is a specific type of advance directive that communicates a patient’s wishes regarding life-sustaining medical intervention. This formal, physician-written instruction is placed in a patient’s medical chart. It ensures that personal preferences for care are respected, particularly when a patient cannot communicate their decisions. Understanding the DNI order is an important part of advance care planning for individuals facing serious illness or future critical care scenarios.
Defining Do Not Intubate
The DNI order specifically prohibits intubation, which is the insertion of a flexible plastic tube into the patient’s airway (trachea). This procedure, also called endotracheal intubation, secures an open airway and is necessary when a person experiences respiratory failure or cannot breathe independently. The tube is inserted through the mouth or nose, passing through the vocal cords and into the windpipe.
Once the tube is in place, it is connected to a mechanical ventilator, a machine that takes over the work of breathing. This process supports the patient until they can recover enough to breathe on their own. A DNI order instructs healthcare providers not to initiate this invasive mechanical support, even if the patient’s breathing stops completely. Refusing intubation often reflects a patient’s preference to avoid the complications and prolonged life support associated with mechanical ventilation.
DNI Compared to DNR
The DNI order is often confused with a Do Not Resuscitate (DNR) order, but they address different scopes of medical intervention. A DNR is a broader directive that instructs medical staff not to perform cardiopulmonary resuscitation (CPR) if a patient’s heart or breathing stops. CPR includes emergency procedures such as chest compressions, cardiac drugs, defibrillation, and intubation.
The DNI order is narrower, focusing solely on refusing the breathing tube and mechanical ventilation. While a patient with a DNR order will not receive intubation, a patient can choose to have a DNI order without a DNR order. This allows the medical team to use other life-saving measures, such as chest compressions and cardiac medications, if the heart stops, but prohibits placing the breathing tube. This distinction is significant for patients who want aggressive resuscitation for a potentially reversible crisis, yet wish to avoid the long-term dependency associated with mechanical ventilation.
Establishing and Documenting the Order
Establishing a DNI order involves a direct discussion between the patient and their physician about the patient’s prognosis, values, and goals of care. The physician must write the order in the patient’s medical record for it to be recognized and followed by all healthcare providers. The DNI order is a formal medical instruction, not just a personal request, and must be clearly documented.
The patient must have the mental capacity to make this decision, demonstrating an understanding of the medical consequences of refusing intubation. If the patient is incapacitated, the decision must be made by a legally designated surrogate, such as a medical power of attorney or healthcare proxy, who is familiar with the patient’s wishes. These directives are typically included in a comprehensive advance healthcare plan or a state-specific form like a Physician Orders for Life-Sustaining Treatment (POLST). A DNI order is not irreversible; the patient or their surrogate can choose to revoke or change the order at any time.
Care Provided Under a DNI Order
A common misunderstanding is that a DNI order signifies a complete cessation of medical treatment, but this is not the case. The order restricts only the use of intubation and mechanical ventilation, which are highly invasive forms of life support. Patients with a DNI order continue to receive all other necessary medical interventions aimed at treating the underlying condition and ensuring comfort.
The care provided includes managing symptoms, administering antibiotics, providing intravenous fluids, and ensuring effective pain control. Patients may also receive less invasive respiratory support, such as supplemental oxygen or non-invasive positive pressure ventilation (NIPPV), like BiPAP or CPAP. These methods assist breathing without requiring the insertion of a tube into the trachea. The goal of care remains to provide dignity and comfort while addressing all treatable medical issues within the bounds of the patient’s directive.