In a competent 74-year-old patient with pulmonary fibrosis who has a signed Do‑Not‑Intubate (DNI) order and presents with respiratory distress, should the provider honor the DNI and provide comfort measures only despite a relative requesting intubation?

Honor the DNI Order and Provide Comfort Measures Only (Answer A)

The provider must honor the patient's signed DNI order and provide comfort-focused care only, regardless of the family's wishes, as the competent patient's documented autonomous decision takes legal and ethical precedence over family preferences.

Legal and Ethical Foundation

The patient's autonomy is the paramount principle in this scenario. When a competent adult patient has documented their treatment preferences through a DNI order, this directive must be respected even when family members disagree 1. The patient's right to refuse life-sustaining treatment, including intubation, is legally protected and ethically fundamental 2.

A critical distinction must be made: DNI orders specifically prohibit endotracheal intubation, which means option C (proceed with intubation) directly violates the patient's documented wishes and is both legally and ethically impermissible 3, 4.

Why Not the Other Options?

Option B (Stop Respiratory Support) is Incorrect

• Stopping all respiratory support abruptly would cause unnecessary suffering 1
• DNI does not mean "withdraw all care"—it specifically limits intubation 3, 5
• Supplemental oxygen and other comfort measures should continue if they relieve dyspnea 1

Option C (Intubation) is Unacceptable

• This directly violates the signed DNI order 3, 4
• Family members cannot override a competent patient's documented wishes 2
• Proceeding would constitute battery and violate informed consent principles 6

Option D (NIV) Requires Careful Consideration

• NIV can be used in DNI patients only if it aligns with comfort goals 1, 2, 5
• However, in a patient with pulmonary fibrosis and multiple respiratory failure episodes, NIV may prolong suffering rather than provide comfort 1
• NIV should not be used to circumvent the patient's DNI wishes when the underlying condition is non-reversible 1, 2

The Correct Approach: Comfort Measures Only

Immediate Symptom Management

• Treat dyspnea aggressively with opioids: Start with bolus dosing followed by continuous infusion 1
• Add benzodiazepines for anxiety/agitation once dyspnea is addressed with opioids 1
• Titrate medications to symptoms with no dose ceiling 1

Specific Pharmacologic Recommendations

• For opioid-naive patients: morphine 2-5 mg IV bolus, then continuous infusion 1
• For benzodiazepines: midazolam 2 mg IV bolus, followed by 1 mg/hour infusion 1
• Double infusion rates if patient requires 2 bolus doses within an hour 1

Discontinue Non-Comfort Interventions

• Stop all non-comfort medications, blood work, and monitoring 1
• Discontinue vasopressors, antibiotics, IV fluids not needed for comfort 1
• Supplemental oxygen should only be provided if it improves comfort, not to target specific saturation goals 1

Addressing the Family's Concerns

Communication Strategy

• Acknowledge the family's distress and desire to help their loved one 1
• Explain that honoring the patient's wishes is the way to help them 1, 2
• Emphasize that comfort measures are active, aggressive treatment—not "giving up" 1
• Clarify that the patient made this decision when competent and it must be respected 2, 6

Legal Protection

• Document the patient's DNI order clearly in the medical record 1
• Document the family's request and your explanation of why it cannot be honored 1
• The provider is legally protected when honoring valid advance directives 3, 6

Common Pitfalls to Avoid

• Do not allow family pressure to override patient autonomy 2, 6
• Do not use NIV as a "compromise" if it merely prolongs dying rather than providing comfort 1, 2
• Do not undertitrate comfort medications out of fear of hastening death—symptom relief is the goal 1
• Do not delay palliative interventions while negotiating with family 1

Documentation Requirements

Document the following in the medical record 1:

• The patient's signed DNI order and when it was executed
• The family's request for intubation
• Your explanation to the family about honoring the patient's wishes
• The comfort measures initiated and the rationale (symptom management)
• Ongoing assessment of the patient's comfort level

In summary, the provider must choose option A—comfort measures only—as this is the only approach that respects the patient's documented autonomous decision while providing aggressive symptom management to ensure dignity and comfort at end of life 1, 2.