What should a nurse do for an elderly woman with progressive pulmonary fibrosis and a signed do not intubate (DNI) order who deteriorates and develops respiratory distress, when her son requests intubation?

Honor the DNI Order and Provide Non-Invasive Support with Palliative Care

The nurse should not intubate the patient because the signed DNI order must be honored, and instead should initiate non-invasive ventilation (NIV) with concurrent palliative care measures to relieve respiratory distress. 1, 2

Ethical and Legal Framework

Patient autonomy is paramount in this situation. The patient was conscious and alert when she signed the DNI consent, making this a valid advance directive that represents her documented preference regarding invasive mechanical ventilation. 1, 2 This decision must be respected even when family members disagree, as the DNI order is the patient's decision, not a family decision. 2

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. 3, 2

Immediate Management Strategy

Non-Invasive Ventilation as Primary Intervention

• Offer NIV as the primary intervention for this deteriorating patient with progressive pulmonary fibrosis and a DNI order. 1, 2
• NIV can relieve dyspnea symptoms while respecting the patient's wishes and avoiding intubation. 3, 1
• The critical distinction is that NIV should be used to relieve dyspnea symptoms, not to unnecessarily prolong a dying process. 3, 2
• NIV should be supervised by experienced clinicians who understand its role in palliative care. 3

Concurrent Palliative Care Measures

• Administer opioids for dyspnea prophylaxis, sometimes combined with benzodiazepines for anxiety reduction. 3, 1, 2
• Ensure palliative care consultation is obtained immediately, as clinicians delivering ventilatory support should have ready access to palliative medicine. 1, 2
• Focus on symptom relief as the primary goal, with regular monitoring of symptom burden. 3

Critical Communication Requirements

With the Family (Son)

• Document transparent, empathic communication with the family about the care plan that respects the patient's DNI order. 3, 1, 2
• Explain that while the son's concern for his mother is understandable, the patient's documented wishes take precedence over family preferences. 2
• Clarify that DNI status does not mean "do nothing" - aggressive symptom management and NIV are still appropriate. 1
• Inform family members about possible physical reactions and what to expect during the clinical course. 3

With the Healthcare Team

• Ensure senior medical staff are involved in decision-making, particularly when differences in opinion exist between medical staff and patient representatives. 1
• Communication should be transparent, empathic and authentic, both within the team and with the family. 3

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. 2
• Avoid "prognostic pessimism" bias: Clinicians consistently underestimate survival, but this does not justify overriding a DNI order. 1, 2
• Do not equate "prolonging life" with benefit: Quality of life and patient autonomy take precedence over duration of survival. 2
• Do not assume that DNI means withholding all aggressive care - other treatments such as oxygen support, medications, and NIV remain appropriate. 1

Monitoring and Reassessment

• Regular assessment of the medical indication should be carried out during NIV therapy. 3
• If symptom control is not achieved with NIV and medications, targeted sedation may be appropriate to reduce symptoms of dyspnea and anxiety. 3
• If the patient fails to improve or rapidly deteriorates despite NIV and palliative measures, continue comfort-focused care without escalating to intubation. 3, 2

The correct answer is A (Palliative care) combined with option C (Non-invasive ventilation), but never option B (Endotracheal intubation). The most appropriate response is D - do not intubate because the patient signed the order - while simultaneously providing aggressive symptom management through NIV and palliative interventions. 1, 2