Advance medical planning allows individuals to make decisions about their future healthcare, ensuring their wishes are honored even if they cannot communicate them later. Physician orders like Do Not Resuscitate (DNR) and Do Not Intubate (DNI) are precise medical instructions designed to respect a patient’s autonomy regarding aggressive life-sustaining measures. These documents are developed through conversations between patients, or their authorized surrogates, and healthcare providers. They serve as actionable guidance for medical teams during a severe health crisis.
Do Not Resuscitate (DNR) Orders
A Do Not Resuscitate (DNR) order is a medical directive instructing healthcare providers to withhold specific interventions if a patient experiences cardiac or respiratory arrest. This order applies only when the heart stops beating or the patient ceases breathing.
The procedures prohibited under a DNR order encompass measures used to revive a patient. These include chest compressions (CPR), electrical cardioversion (defibrillation), and the administration of emergency cardiac medications. The order also prohibits the insertion of a breathing tube for mechanical ventilation.
The intent of this order is to prevent invasive and often unsuccessful procedures near the end of life. Prioritizing comfort and a natural death is the goal, especially since the success rate of CPR is low for individuals with chronic or terminal illnesses.
Do Not Intubate (DNI) Orders
A Do Not Intubate (DNI) order is a narrowly focused medical instruction that specifically prohibits the insertion of an endotracheal tube. This tube is placed into the patient’s trachea and connected to a mechanical ventilator, a machine that takes over the work of breathing.
The DNI order communicates the patient’s wish to avoid this invasive procedure, even if they experience severe respiratory distress or failure. A DNI order does not automatically preclude all other forms of respiratory support. Patients may still receive non-invasive assistance, such as oxygen therapy, Continuous Positive Airway Pressure (CPAP), or Bilevel Positive Airway Pressure (BiPAP).
If a DNI order exists without a corresponding DNR order, the patient can still receive chest compressions, cardiac medications, and defibrillation if their heart stops. This means the patient accepts resuscitation but refuses the invasive component of mechanical ventilation.
Navigating the Difference and Scope of Care
The primary difference between these directives lies in their scope and the clinical situation they address. A DNR order addresses the full spectrum of resuscitation measures needed following cardiac or respiratory arrest. A DNI order, in contrast, addresses the need for mechanical ventilation, which may arise from respiratory failure before the heart stops.
While a DNR order usually includes a prohibition against intubation, a patient may choose a DNI order separately. This means a patient might consent to receiving full CPR, including chest compressions and drugs, but refuse to be placed on a ventilator. This individualized approach allows for tailored care preferences depending on the patient’s specific health condition and goals.
A common misconception is that a DNR or DNI order signifies a decision to withdraw all medical attention. This is incorrect, as these orders are not “Do Not Treat” orders; they only withhold the specific life-sustaining procedures related to cardiac arrest or mechanical ventilation. Patients with these orders continue to receive comprehensive medical treatments aimed at improving their condition and maintaining comfort, such as:
- Pain management
- Diagnostic testing
- Antibiotics to fight infections
- Fluid administration
- Other appropriate routine care
The focus shifts from aggressive life-prolonging measures to palliative and comfort care, ensuring the patient’s remaining time is managed with dignity and symptom control.
Creating and Documenting the Orders
Establishing a DNR or DNI order requires a formal process centered around informed consent and documentation. The directive must be discussed with the patient, or their authorized healthcare surrogate, to ensure they fully understand the risks and benefits of withholding these procedures. For the order to be legally and medically valid, it must be signed by a licensed physician or another authorized healthcare professional. These orders are then placed directly into the patient’s medical record.
In many states, these orders are documented on specific forms known as Physician Orders for Life-Sustaining Treatment (POLST) or Medical Orders for Life-Sustaining Treatment (MOLST). These forms are often printed on brightly colored paper to ensure they are easily identifiable by emergency medical services. Because they are physician orders, they carry more weight in an emergency than a general advance directive.
A crucial element of these documents is their portability, meaning they are designed to travel with the patient and be honored across different care environments, including hospitals, nursing homes, and private residences. The patient or their surrogate maintains the right to revoke or change the directive at any time through a discussion with their physician.