What to do with a COPD (Chronic Obstructive Pulmonary Disease) patient with a recorded Do Not Intubate (DNI) order whose condition is deteriorating, but intubation might prolong their life?

Respect the DNI Order

You must respect the patient's Do Not Intubate (DNI) order and not proceed with intubation, regardless of the team's belief that it might prolong life. The patient's documented wishes take precedence over medical team assessments of potential benefit 1.

Ethical and Legal Framework

• Patient autonomy is paramount: The DNI order represents the patient's documented preference regarding invasive mechanical ventilation and must be honored 1.
• Ventilation therapy should be discontinued or withheld if it is not desired by the patient, even when the medical team believes it could extend life 1.
• The essential principle is that while patients cannot insist on specific treatments, their refusal of interventions like intubation must be respected 1.

Alternative Management Strategy

Instead of intubating, you should implement the following approach:

Non-Invasive Ventilation (NIV) as Bridge Therapy

• NIV can be offered as an alternative to invasive mechanical ventilation in COPD patients with DNI orders, as it respects the patient's wishes while potentially providing benefit 1.
• NIV in DNI patients shows meaningful outcomes: 25-35% leave the hospital alive, approximately 15% survive at least one year, and 10% may survive 5 years or more, particularly those with COPD and low APACHE scores 2, 3.
• NIV should be used to relieve dyspnea symptoms, not to unnecessarily prolong a dying process 1.

Family Communication Requirements

• You should consult the family to inform them of the situation and the care plan, but not to override the patient's DNI decision 1.
• Family members should be informed about possible physical reactions and the focus on symptom management 1.
• Importantly, research shows that family proxy decisions often disagree with patient preferences (uniform disagreement in one study), reinforcing why the patient's documented wishes must guide care 4.

Symptom Management Focus

• Opioids should be administered for dyspnea prophylaxis, sometimes combined with benzodiazepines for anxiety reduction 1, 5.
• Oxygen therapy, positioning, and fans directed at the face provide additional dyspnea relief 5, 6.
• Anticholinergics for secretion management as death approaches 5.

Critical Timing Considerations

• The use of NIV may allow time to establish or reconfirm patient preferences regarding escalation of care, but only if the patient has capacity to participate in this discussion 1.
• If the patient lacks capacity and the DNI order exists, the order stands unless there is clear evidence it no longer reflects the patient's wishes 1.

Common Pitfalls to Avoid

• Do not frame this as a "family decision": While family input is valuable for understanding the patient's values and providing support, the DNI order is the patient's decision 1.
• Avoid "prognostic pessimism" bias: Clinicians consistently underestimate survival in COPD exacerbations (predicting 49% survival when actual was 62%), but this does not justify overriding a DNI order 1.
• Do not equate "prolonging life" with benefit: Quality of life and patient autonomy take precedence over duration of survival 1, 5.

Documentation Requirements

• Ensure palliative care consultation is obtained, as clinicians delivering ventilatory support should have ready access to palliative medicine 1.
• Document transparent, empathic communication with the team and family about the care plan 1.

The correct answer is A: Respect his DNI. Option B (consulting family) is appropriate for communication and support purposes but not for decision-making authority. Options C and D directly violate medical ethics and patient autonomy.