Do Not Intubate (DNI)

What is a DNI order?

A DNI order is authorized by a doctor. Therefore, it’s a medical order just like one for a prescription. A DNI order means that:

• Your loved one has decided against having a breathing tube inserted into their windpipe (trachea), the passage to their lungs. This may be needed if:
  • Their breathing has stopped.
  • There’s a chance breathing will stop because of an infection like pneumonia.
• Your loved one may still receive cardiopulmonary resuscitation (CPR) to hopefully get their heart beating again or breathing to resume. It includes:
  • Chest compressions.
  • Mouth-to-mouth breathing or breathing supported with a manual pump.
  • NOTE: These will not happen if your loved one has a DNR.

DNI pros and cons

Making a decision about a DNI means knowing about its benefits as well as its downsides.

The pros of your loved one having a DNI include:

• Knowing that a tube will not be inserted into their windpipe against their wishes.
• They are still able to have CPR if their heart or breathing stops.
  • This includes chest compressions.
  • It also includes mouth-to-mouth breathing and/or assistance with a handheld pump. No tubes are placed in their airway.

The cons of a DNI are that your loved one:

• Will not receive mechanically assisted breathing to help when they’re still breathing but need a boost.
• This might happen when they have a lung infection from which they are likely to recover.
• May not be offered other forms of care while in the hospital because of having a DNI. This might include transfer to an intensive care unit where your loved one will have close monitoring.

Where do I find a DNI form?

Some states, such as New York, have a DNI form to be completed with your loved one’s doctor. In most circumstances, the conversation about a DNI takes place with a physician.

• The DNI form signed with your loved one’s primary care provider (PCP) is for use in community settings.
  • This means that if your loved one collapses while out and about or at home, emergency personnel will not insert a tube.
  • If they are admitted to the hospital, the staff there will ask your loved one about their wishes during their admission.
• You may also find guidance that your loved one’s DNI wishes are written as part of their healthcare advance directives.

Things to Consider Before Making a DNI Decision

There are decisions your loved one will make as part of talking with their doctor about making a DNI order. It’s important that information is clearly presented. Points to think about ahead of time are:

• Do they want to have CPR if their heart or breathing stops?
  • If they want CPR, they will tell the doctor they don’t want a DNR.
  • In this case they understand that they will likely have chest compressions. They may need mouth-to-mouth breathing, or a mask and handheld pump to aid breathing.
• Your loved one then needs to decide about having a tube placed in their airway to help them breathe.
  • This might be temporary to keep their airway open with a plastic tube.
  • This means they will be attached to a ventilator to breathe mechanically for them.
  • It’s important to know that intubation and being on a ventilator helps people recover from pneumonia.
  • If your loved one does not want any of these steps to be taken, then they will want a DNI order.
• There are questions to ask the doctor as part of making this important decision:
  • What are the chances of a full recovery after being intubated because breathing stops?
  • What about recovery chances after being intubated for pneumonia or due to a heart condition?
  • How long is a person usually intubated and on a ventilator because of illness?
  • If not a full recovery, what might life be like after being intubated?

Does each state have their own DNI laws?

States have laws that doctors follow to make sure that patients like your loved one know about their healthcare choices.

• Many of these, like discussions about DNI, apply when people go into the hospital.
• The laws may vary about what happens in the community.
  • This affects the care given by emergency personnel when your loved one has collapsed or been in an accident.

What is the difference between DNR and DNI?

The differences between a DNR (Do Not Resuscitate) and DNI can be confusing because one may affect whether the other is used.

The DNR is signed when your loved one has decided not to have cardiopulmonary resuscitation if their heart stops beating or they stop breathing.

• That means emergency personnel will not do anything to stimulate the heart or the lungs to work again.

The DNI means that your loved one does not want a tube placed in their airway. Here are two examples that can happen:

• Your loved one doesn’t have a DNR, but does have a DNI. In that case, they can be resuscitated, but not be intubated if they need help breathing with a ventilator.
• Your loved one has pneumonia and a DNR and DNI.
  • Their heart and breathing have not stopped.
  • Their breathing may improve if they can be intubated so the ventilator can help them breathe.
  • This gives medications time to work without added stress to their heart and lungs.
  • In this case, the DNI needs to be revoked for your loved one to be placed on a ventilator.

Can you be DNR but not DNI?

Yes, your loved one can have a DNR order, yet chooses not to have a DNI order. They want to have a tube placed in their airway so a ventilator can help with their breathing, as in the case of receiving treatment for pneumonia.