The Nurse Must Honor the DNI Order and Provide Palliative Care
The nurse should not intubate the patient (Answer D) and should instead initiate palliative care measures including non-invasive ventilation if appropriate for symptom relief, along with opioids and anxiolytics for dyspnea and anxiety. The patient's documented DNI order represents her autonomous decision made while conscious and alert, and this must be respected regardless of family wishes 1.
Legal and Ethical Framework
Patient autonomy is paramount—the DNI order is the patient's documented preference and must be honored. 1 This is not a family decision, even though family input is valuable for understanding the patient's values and providing support 1. The essential principle is that while patients cannot insist on specific treatments, their refusal of interventions like intubation must be respected 2, 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 DNI order stands unless there is clear evidence it no longer reflects the patient's wishes 1
Appropriate Management Strategy
The nurse should implement a palliative care approach with the following components:
Non-Invasive Ventilation (NIV) as a Palliative Intervention
- 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 symptom relief 2, 1, 3
- NIV should be used specifically to relieve dyspnea symptoms, not to unnecessarily prolong a dying process 2, 1
- In patients with advanced pulmonary disease and DNI orders, NIV may be appropriate when it aims to relieve distress even with escalation limits 2
Pharmacologic Symptom Management
- Administer opioids for dyspnea prophylaxis 2, 1, 4
- Combine with benzodiazepines for anxiety reduction as needed 2, 1
- Dose finding should be done with regular monitoring of symptom burden 2
Palliative Care Consultation
- Clinicians delivering ventilatory support should have ready access to palliative medicine 2, 1
- Specialized palliative care teams should be consulted for patients with prolonged respiratory distress 2
Critical Pitfalls to Avoid
Do not frame this as a "family decision": While the son's concerns should be heard with empathy, the DNI order is the patient's decision, not the family's 1. The importance of actively involving patient/family in discussions is for understanding values and providing support, but cannot override a valid advance directive 2.
Do not assume DNI means "do nothing": Research shows that residents and providers often inappropriately withhold beneficial non-invasive interventions from DNI patients 5. The DNI order specifically addresses intubation, not all forms of respiratory support 6.
Avoid "prognostic pessimism" bias: Clinicians consistently underestimate survival, but this does not justify overriding a DNI order 1. In fact, 15% of patients with DNI orders who received NIV survived at least one year 2.
Do not equate "prolonging life" with benefit: Quality of life and patient autonomy take precedence over duration of survival 2, 1.
Communication and Documentation
- Engage in transparent, empathic, and authentic communication with both the healthcare team and the family about the care plan 2, 1
- Explain to the son that honoring his mother's wishes is the ethical and legal obligation 2, 1
- Document the decision-making process and the palliative interventions provided 1
- Inform family members about possible physical reactions to respiratory distress and accompany them accordingly 2
The correct answer is D (do not intubate) with implementation of Answer A (palliative care), which may include Answer C (non-invasive ventilation) if appropriate for symptom relief rather than life prolongation.