Respect the Patient's DNI Order
You must honor the patient's documented Do Not Intubate (DNI) order and not proceed with intubation, regardless of the team's belief that it might prolong life. 1
Ethical and Legal Foundation
Patient autonomy is paramount — the DNI order represents the patient's documented preference regarding invasive mechanical ventilation and must be honored, even when the medical team believes intubation 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
Ventilation therapy should be discontinued or withheld if it is not desired by the patient, even when clinicians believe it could prolong survival. 1
Why Consulting Family is Not the Primary Action
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, not the family's. 1
The DNI order stands unless there is clear evidence it no longer reflects the patient's wishes. 1
Alternative Management Strategy for This COPD Patient
Non-invasive ventilation (NIV) should be offered as the primary intervention for this deteriorating COPD patient with a DNI order:
NIV can be used to relieve dyspnea symptoms while respecting the patient's wishes, as it does not violate the DNI order. 1, 2
In COPD patients with acute hypercapnic respiratory failure, NIV should be started using the same criteria as in acute exacerbations of COPD. 2
NIV has demonstrated reasonable outcomes in DNI patients with COPD — hospital mortality was 34% in COPD patients with DNI orders receiving NIV, which was significantly better than other diagnoses in the DNI group. 3
NIV should be used to relieve symptoms, not to unnecessarily prolong a dying process. 1
Symptom Management Priorities
Administer opioids for dyspnea prophylaxis, sometimes combined with benzodiazepines for anxiety reduction. 1
Ensure palliative care consultation is obtained, as clinicians delivering ventilatory support should have ready access to palliative medicine. 1
Common Pitfalls to Avoid
Avoid "prognostic pessimism" bias — clinicians consistently underestimate survival, 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
Remember that DNI status does not limit the use of other treatments such as vasopressors, oxygen support, or electrolyte replacement. 2
Documentation Requirements
Document transparent, empathic communication with the team and family about the care plan that respects the patient's DNI order. 1
Ensure senior staff involvement in decision-making, particularly when differences in opinion exist between medical staff and patient representatives. 2
Answer: A. Respect the patient's DNI order