Can a patient have a Do Not Intubate (DNI) order without a Do Not Resuscitate (DNR) order?

Can a Patient Have DNI Without DNR?

Yes, a patient can absolutely have a Do Not Intubate (DNI) order without a Do Not Resuscitate (DNR) order—these are separate medical decisions that must be documented independently and explicitly. 1

Understanding the Distinction

DNR and DNI orders address fundamentally different clinical interventions:

• DNR specifically prohibits chest compressions and defibrillation if cardiac arrest occurs 1
• DNI specifically prohibits endotracheal intubation, which applies to multiple situations beyond cardiac arrest including respiratory failure, airway protection, and surgical procedures 1

Some patients may choose to accept defibrillation and chest compressions but refuse intubation and mechanical ventilation—this is a valid and ethically appropriate choice. 1

Clinical Implications of DNI Without DNR

When a patient has DNI but no DNR order, the following care parameters apply:

Interventions That Should Be Provided:

• Full resuscitative efforts including chest compressions and defibrillation if cardiac arrest occurs 1
• All appropriate medical interventions: vasopressors, oxygen support, electrolyte replacement, IV fluids, pain management, and antibiotics 1
• Non-invasive respiratory support (BiPAP, high-flow nasal cannula) for respiratory distress 1

Interventions That Should Be Withheld:

• Endotracheal intubation for any indication (respiratory failure, airway protection, surgical procedures) 1

Documentation Requirements

When writing DNI orders without DNR, explicit separate orders for each limitation must be written—oral orders are never acceptable. 1

Essential documentation must include:

• Clear statement of patient's capacity at time of decision-making 1
• Date of DNI order implementation 1
• Specific interventions to be withheld (endotracheal intubation) 1
• Explicit clarification that DNI does not automatically preclude chest compressions, defibrillation, vasopressors, or other interventions 1
• Record of discussion with patient and/or surrogate decision-maker, including patient's values, goals, and preferences 1

Critical Pitfalls to Avoid

Avoid Early DNR/DNI Orders in Acute Illness

Aggressive full care should be provided early after ICU admission, and new DNR orders should be postponed until at least the second full day of hospitalization for most critically ill patients, particularly those with conditions like intracerebral hemorrhage where early prognostication is unreliable. 2, 3

Early DNR orders (within the first 24-48 hours) have been identified as independent predictors of mortality because they proxy for overall lack of aggressiveness of care rather than just withholding CPR 3. Current outcome prediction models fail to account for the influence of withdrawal of support and early DNR orders, creating bias in prognostication 2, 3.

Avoid Assuming DNI Limits Other Care

A common and dangerous misconception is that DNI status limits other treatments. DNI status does not limit the use of vasopressors, oxygen support, electrolyte replacement, IV fluids, pain management, or antibiotics. 1, 3

Review Orders Regularly

DNI orders without DNR should be reviewed periodically as per local protocol, particularly if the patient's condition changes 1. These orders should be reviewed before surgery by the anesthesiologist, attending surgeon, and patient or surrogate to determine applicability in the operating suite 1.

Consider Suspension for Procedures

DNI status can be suspended for procedures when appropriate after discussion with the patient. 1, 3 This is particularly relevant for procedures where intubation may be needed for airway protection but the underlying cause is readily reversible 4.

The Rationale Behind Separate Orders

The separation of DNI and DNR orders reflects patient autonomy and the recognition that different interventions carry different burdens and benefits. A patient may reasonably conclude that:

• The burden of prolonged mechanical ventilation outweighs potential benefits
• But the brief intervention of chest compressions and defibrillation for a reversible cardiac arrest is acceptable

This nuanced approach to end-of-life care honors patient preferences more accurately than blanket "full code" or "DNR/DNI" designations 1.