Do Not Resuscitate and Do Not Intubate orders
Do Not Resuscitate (DNR) and Do Not Intubate (DNI) orders are medical documents that tell doctors and emergency medics not to try to bring a person back to life if their heart has stopped beating or they have stopped breathing. This article defines both orders, explains why there is some confusion about the two orders, and says how doctors and paramedics can tell if a person has a DNR and/or DNI order.
What are Do Not Resuscitate and Do Not Intubate orders?
Do Not Resuscitate (DNR) and Do Not Intubate (DNI) orders are medical documents, requested by a patient and signed by a doctor, that instruct other doctors and emergency medics not to try to bring a person back to life using certain techniques, if their heart has stopped beating or they have stopped breathing.
Individuals can request a DNR and/or DNI order from their doctor, who must sign it for it to be valid. A person may also be asked to fill out a DNR and/or DNI form when they are admitted to a hospital or hospice. If they already have a DNR or DNI of their own, they can provide it to the staff on admission.
Do Not Resuscitate order
A DNR order tells doctors and medics not to try to restart a person’s heart using cardiopulmonary resuscitation (CPR) if the person’s heart has stopped beating on its own or they stop breathing.
The term “CPR” sometimes just means chest compressions (done by hand or a mechanical chest compressor) and mouth-to-mouth breathing. When professional medical personnel with access to life-support equipment talk about CPR, though, they usually also mean techniques such as electric shock, artificial ventilation, and intravenous medication (that is, delivered into the veins using a needle).
There are two kinds of DNR orders:
- In-hospital DNR. This applies to people who are in a medical facility such as a hospital or nursing home. It tells the facility’s medical personnel not to give the person CPR. It is very important to know that “do not resuscitate” does not mean “do not treat.” A person with a DNR order will continue to receive all other appropriate efforts to revive them, unless they have given other instructions in an advance directive or to their medical proxy.
- Out-of-hospital DNR (known as OOH-DNR). This applies to people who are not in a medical facility, such as those who are still living at home. If a person collapses and 911 is called, the OOH-DNR tells emergency responders not to give the person CPR. It also gives them the legal ability to withhold this treatment. As with an in-hospital DNR, they can and will provide other kinds of treatment.
Hospices covered by Medicare do not ask patients to sign a DNR form, since the people are there to receive end-of-life care, not to be cured.1 However, some independent hospices may require patients to sign a DNR.
Do Not Intubate order
A DNI order tells doctors and medics not to use breathing tubes to keep a person alive when they have stopped breathing or are no longer able to breathe on their own.
The term “breathing tubes” includes temporary tubes put down the airways and longer-term tubes attached to a ventilator. It does not include ways of helping a person breathe without using tubes, such as by putting a breathing mask over the face.
Does a DNR order include a DNI order?
Usually, no. However, it can be confusing, and some states do use the term “DNR” to also mean “DNI.”
The reason for the confusion is that the term “cardiopulmonary resuscitation” refers to both the heart and the lungs. “Cardio” means “heart,” and “pulmonary” means “lungs.” Since CPR can involve a ventilator, which means the person will have breathing tubes put down their airways, the DNR order can cross into the territory of the DNI order.
Generally speaking, though, a person isn’t thinking about cardiac arrest when they ask for a DNI order. They are asking not to be put on a ventilator or other kinds of artificial breathing machines if they are permanently unable to breathe on their own.
All that said, a person can always tell the doctor that they want a DNR order but not a DNI order, or the other way around. If they have only a DNR order, they may still be placed on a ventilator if they are unable to breathe on their own. This could happen, for instance, if they have pneumonia or COVID-19.
If they have a DNI order but not a DNR order, doctors and medics will attempt CPR, but not use any tubes to help restart the breathing.
How does a doctor or medic know if a person has a DNR/DNI order?
The person with the DNR/DNI order should tell all the medical people who are involved with them that they have this order. They should also tell their family members and any other caregivers who might end up being involved if they have a medical emergency.
The OOH-DNR order is usually done on a brightly colored piece of paper. The person should put the order in a prominent place, such as on the fridge or by a land-line phone, if one exists. These are the places that emergency medics will look first.
In addition, most states require a person with a DNR and/or DNI order to wear a brightly colored or engraved bracelet or necklace saying that they have the order. These items tell emergency medics that a DNR or DNI order exists, so that they do not attempt aggressive measures to keep the person alive or bring them back to life. If the medic can’t find the DNR, they will assume there isn’t one and do everything they can to revive the person.
Overview of health care documents
Portable medical orders (POLST)
External supporting content
1Does Hospice Require You to Sign a DNR? VITAS Healthcare.