Can a Patient Have DNR Without DNI?
Yes, a patient can absolutely have a Do Not Resuscitate (DNR) order without a Do Not Intubate (DNI) order—these are separate medical decisions that should be documented independently. 1
Why DNR and DNI Are Distinct Orders
DNR and DNI address different clinical scenarios and should never be automatically combined:
- DNR specifically means: No chest compressions or defibrillation will be performed if the patient experiences cardiac arrest 1
- DNI specifically means: No endotracheal intubation will be performed, which applies to multiple situations beyond cardiac arrest (respiratory failure, airway protection, surgical procedures) 1, 2
- Some patients may choose to accept defibrillation and chest compressions but not intubation and mechanical ventilation 1—this is a valid and ethically appropriate choice
The Problem with Combined "DNR/DNI" Orders
Combining these orders into a single "DNR/DNI" designation is problematic and not evidence-based:
- In one academic trauma center study, 61.9% of patients with DNR orders had their code status written as "DNR/DNI" in progress notes 3
- Of these "DNR/DNI" patients, 26% had no documentation of informed refusal of intubation for non-arrest situations 3
- This conflation could result in 16.1% of patients being inappropriately denied intubation without informed refusal, and 16.4% being inappropriately intubated despite documented refusal 3
- Patients and healthcare providers frequently misunderstand these terms—52% of patients/families and 35-39% of healthcare providers could not correctly distinguish DNR from DNI definitions 4
Proper Documentation Requirements
When writing DNR orders without DNI, you must:
- Write explicit, separate orders for each limitation 1—oral orders are never acceptable 1
- Document specific interventions to be withheld and those that remain permitted 2
- Include the rationale for the DNR order and document discussions with the patient, surrogate, and family 1
- Clarify that DNR does not automatically preclude intubation, mechanical ventilation, vasopressors, oxygen, IV fluids, antibiotics, or other interventions unless specifically included in the order 1
What DNR Alone Means in Practice
A patient with DNR but no DNI order should receive:
- Full respiratory support including intubation and mechanical ventilation for respiratory failure, airway protection, or other non-arrest indications 1
- All appropriate medical interventions: vasopressors, oxygen support, electrolyte replacement, IV fluids, pain management, antibiotics 1
- No chest compressions or defibrillation if cardiac arrest occurs 1
Critical Pitfall to Avoid
Never assume that a DNR order includes DNI. 3 The limitation-of-treatment order must provide explicit instructions for specific emergency interventions that may arise, including mechanical ventilation 1. If intubation is to be withheld, this requires a separate, informed discussion and documentation of the patient's wishes regarding intubation for non-arrest scenarios 3.
When to Review These Orders
- Periodically as per local protocol, particularly if the patient's condition changes 1, 5
- Before surgery by the anesthesiologist, attending surgeon, and patient or surrogate to determine applicability in the operating suite 1, 2
- DNR/DNI status can be suspended for procedures when appropriate after discussion with the patient 1, 5