What to do when a patient is intubated (insertion of an endotracheal tube) but had a do-not-intubate (DNI) order?

Management of a Patient Intubated Against Their Wishes

When a patient has been intubated despite having a do-not-intubate (DNI) order, the endotracheal tube should be removed immediately after appropriate preparation for extubation, including administration of opioids and benzodiazepines to prevent dyspnea and anxiety during the process.

Initial Assessment and Communication

1. Verify the DNI status:

   • Confirm the existence of the DNI order in the medical record
   • Speak with family members to understand the patient's previously expressed wishes
   • Determine if the DNI order was properly documented before intubation

2. Immediate team communication:

   • Call for an urgent interdisciplinary meeting including the attending physician, nursing staff, respiratory therapist, and palliative care specialist
   • Notify hospital ethics committee if available
   • Discuss the error transparently with the family 1

Preparation for Extubation

Once DNI status is confirmed, prepare for immediate extubation:

1. Medication preparation:

   • Administer adequate opioid therapy for prophylaxis of dyspnea
   • Provide benzodiazepine therapy for prophylaxis of anxiety 1
   • Titrate to patient comfort, accepting that any unavoidable life-shortening side effects should be tolerated in this context

2. Family preparation:

   • Inform family members about the physical reactions that may occur during extubation
   • Explain the process and what to expect
   • Ensure family has appropriate emotional support 1
   • Allow family to be present if they wish

Extubation Process

The responsible physician should personally conduct and accompany the extubation process:

1. Immediate extubation approach:

   • Ensure adequate symptom management before removing the tube
   • Monitor for signs of distress and adjust medications accordingly
   • This task should not be delegated to nursing staff alone 1

2. Post-extubation care:

   • Continue symptom management with focus on comfort
   • Consider non-invasive ventilation (NIV) only if it would provide symptom relief without prolonging the dying process 1
   • High-flow oxygen therapy may be used for symptom reduction but should be the last option 1

Special Considerations

1. If patient is stable after extubation:

   • Initiate palliative care consultation if not already involved
   • Establish clear goals of care moving forward
   • Document the incident and corrective actions taken

2. If patient deteriorates rapidly:

   • Focus on comfort measures only
   • Avoid reintubation or other invasive interventions
   • Ensure adequate sedation to prevent suffering

Documentation and System Improvement

1. Document thoroughly:

   • Record the circumstances of the unintended intubation
   • Document all discussions with family
   • Note the decision-making process for extubation

2. System review:

   • Conduct a root cause analysis to prevent similar incidents
   • Review processes for communicating advance directives
   • Consider implementing verification steps before emergent intubation

Common Pitfalls to Avoid

1. Delaying extubation due to concern about immediate deterioration - this prolongs a treatment the patient explicitly refused 1

2. Failing to provide adequate symptom management during extubation - this can cause unnecessary suffering 1

3. Delegating the extubation process to junior staff or nursing - the responsible physician should personally conduct this process 1

4. Poor communication with family - transparent, empathic, and authentic communication is essential 1

5. Continuing mechanical ventilation because it's already initiated - this contradicts patient autonomy and wishes 1

By following this approach, the healthcare team respects the patient's previously expressed wishes while ensuring comfort and dignity during the extubation process.