Do Not Intubate the Patient
The nurse should honor the patient's signed DNI order and not proceed with endotracheal intubation, regardless of the son's request, as patient autonomy is paramount and the documented DNI order represents the patient's legally binding decision about refusing invasive mechanical ventilation. 1, 2, 3
Ethical and Legal Framework
The patient's autonomy takes absolute precedence over family preferences in this situation. 1, 2, 3 The DNI order is the patient's decision—not a family decision—and must be honored even when family members disagree. 1 Ventilation therapy should be withheld if not desired by the patient, even when the medical team or family believes it could extend life. 1, 2, 3
The correct answer is D: Do not intubate because the patient signed the order.
Appropriate Alternative Management
Non-Invasive Ventilation as Primary Intervention
Offer NIV immediately as the primary intervention for this deteriorating patient with progressive pulmonary fibrosis and a DNI order. 1, 2, 3 NIV can relieve dyspnea symptoms while respecting the patient's wishes and avoiding intubation. 1, 2 The critical distinction is that NIV should be used to relieve dyspnea symptoms, not to unnecessarily prolong a dying process. 1, 3
- NIV has shown a 49% survival rate in DNI-status patients when used as active treatment in the emergency setting. 4
- However, NIV did not provide significant symptom relief in more than half of patients who received it solely for comfort at end-of-life. 4
- In patients with progressive pulmonary fibrosis who deteriorate despite NIV, continue comfort-focused care without escalating to intubation. 1
Concurrent Palliative Care Measures
Administer opioids for dyspnea prophylaxis, sometimes combined with benzodiazepines for anxiety reduction. 1, 2, 3 Ensure immediate palliative care consultation, as clinicians delivering ventilatory support should have ready access to palliative medicine. 1, 3
Focus on symptom relief as the primary goal with regular monitoring of symptom burden. 1 If symptom control is not achieved with NIV and medications, targeted sedation may be appropriate to reduce dyspnea and anxiety. 1
Critical Communication with the Son
Document transparent, empathic communication with the son about the care plan that respects the patient's DNI order. 1, 2, 3 Explain that while his concern is understandable, the patient's documented wishes take precedence over family preferences. 1
Clarify that DNI status does not mean "do nothing"—aggressive symptom management and NIV are still appropriate. 1 DNI status does not limit the use of other treatments such as oxygen support, medications, and non-invasive respiratory support. 5, 2
Inform the son about possible physical reactions and what to expect during the clinical course. 1 Ensure senior medical staff are involved in decision-making, particularly when differences in opinion exist between medical staff and patient representatives. 5, 1, 2
Common Pitfalls to Avoid
Do not frame this as a "family decision." While family input is valuable, the DNI order is the patient's decision. 1, 3 Without explicit clarification of the patient's goals of care, potentially beneficial care may be withheld, but conversely, unwanted interventions must not be imposed. 6
Avoid assuming that DNI means withholding all aggressive care. Residents and nurses often incorrectly assume that patients who refuse intubation would prefer not to receive other interventions. 6 Other treatments such as oxygen support, medications, and NIV remain appropriate. 1, 2
Do not equate "prolonging life" with benefit. Quality of life and patient autonomy take precedence over duration of survival. 1, 3 Clinicians consistently underestimate survival ("prognostic pessimism" bias), but this does not justify overriding a DNI order. 1, 2
Monitoring and Reassessment
Regular assessment of the medical indication should be carried out during NIV therapy. 1 If the patient fails to improve or rapidly deteriorates despite NIV and palliative measures, continue comfort-focused care without escalating to intubation. 1