Can a patient receive endotracheal intubation without cardiopulmonary resuscitation (CPR) if they consent and have no do‑not‑intubate (DNI) or do‑not‑resuscitate (DNR) order?

Can You Accept Intubation Without CPR?

Yes, absolutely—intubation and CPR are separate interventions that should be discussed and consented to independently, and a patient can consent to intubation while refusing CPR. 1

The Critical Distinction Between Intubation and CPR

The conflation of DNR (do-not-resuscitate) and DNI (do-not-intubate) into combined "DNR/DNI" orders is not evidence-based practice and frequently violates patient autonomy 2. These are fundamentally different interventions:

• CPR is specifically for cardiac arrest
• Intubation has multiple indications including respiratory failure, airway protection, severe pneumonia, anaphylaxis, and procedural sedation—most of which have nothing to do with cardiac arrest

What the Guidelines Tell Us

The 2022 Association of Anaesthetists guideline explicitly addresses this issue 1:

• Chest compressions to expedite drug circulation during low cardiac output (not cardiac arrest) are NOT the same as CPR
• An advance decision to refuse CPR does NOT normally exclude:
  • Use of cardiac arrest algorithm drugs for treating bradycardia, hypotension, or arrhythmias during anesthesia
  • Defibrillation or cardioversion for sudden arrhythmias
  • Intubation for non-arrest indications

This means the Working Party clearly distinguishes between resuscitative measures and other life-sustaining interventions.

The Real-World Problem

Research reveals alarming patterns of misunderstanding:

• 61.9% of DNR orders were documented as "DNR/DNI" in progress notes 2
• Of these combined orders, 26% had NO documentation of informed refusal of intubation for non-arrest situations 2
• This means 16.1% of patients could be inappropriately denied intubation they would have wanted 2

Physicians systematically under-offer interventions to DNR/DNI patients beyond just CPR and intubation—including central lines, ICU admission, dialysis, and surgical consultations 3, 4—even when these interventions may be desired and beneficial.

Patient Preferences Are Often Misrepresented

When actually surveyed, patients with documented DNR/DNI orders frequently want interventions:

• 58% wanted intubation for angioedema (highly reversible)
• 28% wanted intubation for severe pneumonia
• 20% wanted trial resuscitation for cardiac arrest 5

The desire for intervention correlates with reversibility of the condition 5, suggesting patients make nuanced decisions that combined DNR/DNI orders cannot capture.

How to Approach This Correctly

Each intervention must be discussed separately:

1. Ask specifically about CPR for cardiac arrest scenarios

2. Ask separately about intubation for:

   • Respiratory failure from pneumonia
   • Airway protection (stroke, altered mental status)
   • Anaphylaxis/angioedema
   • Procedural needs (surgery, imaging)
   • Other reversible conditions

3. Document each decision independently in the medical record

4. Avoid combined "DNR/DNI" terminology that obscures patient preferences

5. Explain that refusing CPR does NOT automatically mean refusing intubation for other indications

Special Perioperative Considerations

For surgical patients with pre-existing DNACPR orders 1:

• Intraoperative cardiac arrest has high survival rates due to reversible causes (anesthesia response, vagal stimulation, hypoxia, hemorrhage) and immediate detection/treatment
• It is usually appropriate to suspend DNACPR recommendations during the perioperative period
• This suspension must be discussed and agreed upon with the patient
• Clear documentation of when the order resumes is essential

Common Pitfalls to Avoid

• Never assume DNR means DNI or vice versa
• Don't use "DNR/DNI" as shorthand without separate documentation of each preference
• Don't withhold potentially beneficial interventions based solely on code status without explicit discussion
• Recognize that 52% of patients and family members cannot correctly distinguish DNR from DNI definitions 6, requiring clear, repeated explanations
• Involve palliative care early for complex goals-of-care discussions—over half of patients with partial code orders never received palliative care consultation 7

The Bottom Line for Clinical Practice

Document code status as separate, specific orders:

• "DNR" (no chest compressions, no defibrillation for cardiac arrest)
• "Allow intubation for respiratory failure, airway protection, and reversible conditions"

Or conversely:

• "Full code for cardiac arrest"
• "No intubation under any circumstances"

This granular approach respects patient autonomy, prevents inappropriate withholding of desired care, and avoids imposing unwanted interventions.