Honor the DNI Order and Provide Palliative Care with Symptom Management
The nurse should honor the patient's DNI order (Option D) and immediately initiate palliative measures including non-invasive ventilation (NIV) for symptom relief and opioids/benzodiazepines for dyspnea and anxiety, while compassionately explaining to the family that the patient's documented wishes must be respected. 1
Legal and Ethical Framework
The patient's autonomy is paramount in this situation. The DNI order represents the patient's documented preference regarding invasive mechanical ventilation and must be honored, regardless of family wishes. 1 Ventilation therapy should be discontinued or withheld if it is not desired by the patient, even when the medical team or family believes it could extend life. 2, 1
The essential principle is that while patients cannot insist on specific treatments, their refusal of interventions like intubation must be respected. 2, 1 This is not 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 alone. 1
Immediate Clinical Management
Symptom-Directed Palliative Interventions
The nurse should immediately implement the following:
- Administer opioids for dyspnea prophylaxis, titrated to relieve respiratory distress without causing excessive sedation. 2, 3
- Add benzodiazepines for anxiety reduction and to provide sedation if the patient shows signs of distress. 2, 3
- Consider NIV as a palliative intervention to reduce symptoms of dyspnea, not to prolong the dying process. 2, 1
Role of Non-Invasive Ventilation
NIV can be offered as an alternative to invasive mechanical ventilation in patients with DNI orders, as it respects the patient's wishes while potentially providing benefit. 2, 1 In patients with progressive pulmonary fibrosis and respiratory distress, NIV has been shown to improve dyspnea scores and may reduce morphine requirements while maintaining better cognitive function. 2
Critical caveat: NIV should be used to relieve dyspnea symptoms, not to unnecessarily prolong a dying process. 2, 1 If NIV causes mask discomfort or other troubling consequences without adequate symptom relief, it should be discontinued. 2
Communication with Family
The nurse must engage in transparent, empathic, and authentic communication with the son. 2 Key points to address:
- Explain that the patient made this decision when she was conscious and alert, and healthcare providers have an ethical and legal obligation to honor her wishes. 1
- Reassure the family that "not intubating" does not mean "doing nothing"—aggressive symptom management will be provided to ensure comfort. 2
- Inform the family about what to expect during the dying process, including possible physical reactions such as changes in breathing patterns, to help them understand these are part of the natural process rather than signs of suffering. 2, 3
Palliative Care Consultation
A palliative care consultation should be obtained immediately, as clinicians delivering care to patients with advanced disease should have ready access to palliative medicine expertise. 2, 1 The palliative care team can provide:
- Coordinated interdisciplinary care including nursing, social work, and chaplaincy services. 2
- Expert symptom management guidance. 2
- Support for the family during the dying process. 2
Common Pitfalls to Avoid
- Do not frame this as requiring family consent: The DNI order stands unless there is clear evidence it no longer reflects the patient's wishes, which cannot be established since the patient is now in respiratory distress. 1
- Avoid "prognostic pessimism" bias: Even if the nurse believes the patient might survive with intubation, 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. 2, 1
- Never perform a "slow code" or partial resuscitation: This creates moral distress for staff and does not serve the patient's interests. 4
Anticipatory Symptom Management Protocol
If the patient's condition continues to deteriorate, implement the following evidence-based protocol:
- Six hours before anticipated death: Stop enteral feeding, reduce parenteral fluids, consider furosemide if overhydrated, ensure adequate sedatives and opioids are available. 3
- Thirty minutes before anticipated respiratory failure: Administer anticholinergic agents (e.g., butylscopolamine) to reduce bronchial secretions and prevent "death rattle." 3
- Continuous monitoring: Assess for signs of dyspnea, pain, and anxiety, titrating medications accordingly. 2
Documentation Requirements
Document the following in the medical record: