A Do Not Intubate (DNI) order is a specific medical directive used in advance care planning. This instruction is a formal request from a patient, or their legally authorized decision-maker, to prohibit the highly invasive, life-sustaining procedure of intubation. DNI stands for Do Not Intubate, representing a patient’s preference to decline mechanical ventilation if they experience respiratory failure. Establishing this order is a deeply personal decision that ensures a person’s wishes regarding end-of-life care are respected. This order is a significant component of healthcare autonomy, allowing individuals to control the extent of interventions used to prolong life.
Defining the Scope of a Do Not Intubate Order
The DNI order focuses strictly on the procedure of intubation, which involves placing a flexible tube down the patient’s trachea (windpipe). This tube is inserted through the mouth or nose to secure an open airway when a patient cannot breathe adequately on their own. Once the tube is in place, it connects to a mechanical ventilator, which takes over the patient’s breathing.
A DNI order explicitly directs healthcare providers to withhold this specific intervention. This instruction is typically invoked during acute respiratory failure, such as when oxygen levels drop severely or carbon dioxide builds up dangerously. Common scenarios include severe pneumonia, acute exacerbations of chronic obstructive pulmonary disease (COPD), or cardiac arrest.
The order prohibits the use of the breathing tube and connection to the ventilator. Patients often choose a DNI to avoid the potential complications, discomfort, and long-term dependency resulting from prolonged mechanical ventilation. This choice prioritizes comfort and a natural dying process over interventions that may only extend suffering.
Distinguishing DNI from Do Not Resuscitate Orders
The DNI order is often confused with a Do Not Resuscitate (DNR) order, but they are distinct medical instructions with different scopes. A DNR order is much broader, directing the medical team to withhold Cardiopulmonary Resuscitation (CPR) during a cardiac or respiratory arrest. CPR includes chest compressions, electrical defibrillation, and the use of cardiac drugs, all prohibited by a DNR.
A DNI order, in contrast, only prohibits the placement of the breathing tube and mechanical ventilation. The fundamental distinction is that a patient can have a DNI order without a DNR order. In this scenario, if the patient’s heart stops, the medical team would still administer chest compressions and cardiac medications to restart the heart.
If the heart is successfully restarted, the team is still prohibited from inserting the breathing tube to support the patient’s breathing. Conversely, a full DNR order includes the prohibition of intubation as part of the overall ban on resuscitation measures, making a separate DNI order usually unnecessary. Separating these two orders allows patients to fine-tune their preferences for medical intervention.
A patient may choose a DNI-only order if they have severe breathing problems but their heart is still beating strongly. This choice allows them to avoid invasive ventilation while still receiving other aggressive treatments. The choice between DNR, DNI, or both requires a detailed discussion to align medical treatments with the patient’s values and prognosis.
Establishing the DNI: Documentation and Legal Validity
For a DNI order to be legally recognized, a physician must formally document it and place it in the patient’s medical record. The process begins with a comprehensive discussion between the patient and their healthcare provider about the patient’s health status and the potential outcomes of intubation. This ensures the patient fully understands the implications of refusing this life-sustaining treatment.
The DNI order is typically recorded as a standalone order or as a component of a larger legal document, such as an Advance Directive or a Physician Orders for Life-Sustaining Treatment (POLST) form. Advance Directives, including living wills and health care powers of attorney, are created while the patient is competent to guide future care. POLST or Medical Orders for Life-Sustaining Treatment (MOLST) forms are specific medical orders that travel with the patient across different healthcare settings.
If a patient is incapacitated, the decision to establish a DNI order falls to a legally appointed surrogate decision-maker. This person is often named in a health care power of attorney document and acts as the patient’s voice. Legal requirements for these forms, including physician signatures and the need for periodic review, vary significantly by state or jurisdiction.
Supportive Medical Care Within a DNI Order
A DNI order is highly specific and does not constitute a “do not treat” order. Having a DNI means the medical team will not perform the single procedure of intubation and mechanical ventilation, but all other appropriate medical treatments are still administered. The focus of care shifts from invasive, life-prolonging measures to treatments that maximize comfort and quality of life.
A patient with a DNI order continues to receive comprehensive supportive and palliative care. This includes non-invasive oxygen therapy delivered via a nasal cannula or mask, and the administration of antibiotics for infection. Pain medication and other comfort measures are always provided to alleviate suffering and ensure a peaceful experience.
The care plan may also include intravenous (IV) fluids, blood transfusions, and other therapies that do not involve the breathing tube. The medical team manages symptoms aggressively and provides dignified care, concentrating on palliative approaches rather than cure-focused interventions. The DNI order ensures the patient’s final days are spent with maximum comfort, honoring their choice to avoid a potentially burdensome procedure.