What should be done for a patient with Chronic Obstructive Pulmonary Disease (COPD) who has a Do Not Intubate (DNI) order when their condition deteriorates and intubation may prolong their life?

Respect the DNI Order

The patient's DNI order must be honored—intubation should not be performed regardless of the medical team's belief that it might prolong life, as patient autonomy is paramount and documented preferences must be respected. 1, 2, 3

Ethical and Legal Framework

• Patient autonomy takes absolute precedence: The DNI order represents the patient's documented refusal of invasive mechanical ventilation and must be honored even when clinicians believe intubation could extend survival. 1, 2
• Ventilation therapy should be withheld if not desired by the patient, according to the American Thoracic Society, even when the medical team or family believes it could prolong life. 2, 3
• While patients cannot insist on specific treatments being performed, their refusal of interventions like intubation is legally and ethically binding. 1

The Correct Answer is A: Respect His DNI

Option B (consulting the relative) is incorrect because the DNI order is the patient's decision, not a family decision—while family input is valuable for understanding the patient's values, they cannot override a documented DNI order. 1, 2

Options C and D (proceeding with intubation) directly violate medical ethics and potentially constitute battery, as they override the patient's documented autonomous decision. 1, 2

Alternative Management Strategy

Offer Non-Invasive Ventilation (NIV)

• NIV should be offered as the primary intervention for this deteriorating COPD patient with a DNI order, as it can relieve dyspnea symptoms while respecting the patient's wishes and avoiding intubation. 1, 2, 3
• The critical distinction: NIV should be used to relieve dyspnea symptoms, not to unnecessarily prolong a dying process. 2
• In COPD patients with DNI orders who received NIV, observational data show surprisingly high hospital survival rates (>30-60%) with 3-month quality of life equivalent to patients without care limitations. 4

Aggressive Symptom Management

• Administer opioids for dyspnea prophylaxis, sometimes combined with benzodiazepines for anxiety reduction. 1, 2, 3
• Obtain immediate palliative care consultation, as clinicians delivering ventilatory support should have ready access to palliative medicine. 4, 1, 2
• Focus on symptom relief as the primary goal with regular monitoring of symptom burden. 2

Critical Communication Requirements

With the Family

• Document transparent, empathic communication explaining that while their concern is understandable, the patient's documented wishes take precedence over family preferences. 1, 2
• Clarify that DNI does not mean "do nothing"—aggressive symptom management, NIV, oxygen support, vasopressors, and electrolyte replacement remain appropriate. 4, 2, 3
• Inform family members about possible physical reactions and what to expect during the clinical course. 2

With the Healthcare Team

• Ensure senior medical staff are involved in decision-making, particularly when differences in opinion exist. 2, 3
• Communication should be transparent, empathic, and authentic both within the team and with the family. 2

Common Pitfalls to Avoid

• Do not equate "prolonging life" with benefit: Quality of life and patient autonomy take precedence over duration of survival. 1, 2
• Avoid "prognostic pessimism" bias: Clinicians consistently underestimate survival, but this does not justify overriding a DNI order. 1, 2, 3
• Do not assume DNI means withholding all aggressive care: Other treatments such as oxygen support, medications, vasopressors, and NIV remain appropriate. 4, 2, 3
• Residents often incorrectly assume that patients who refuse CPR would prefer not to receive other interventions—without explicit clarification of goals of care, potentially beneficial care may be withheld against the patient's wishes. 5

If NIV Fails

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