DNR, DNI, DNH: Understanding Medical Orders for Life-Sustaining Treatment

Medical emergencies create intense, time-sensitive situations where healthcare teams must make split-second decisions about life-sustaining treatments. For families caring for aging loved ones, understanding medical orders like DNR (Do Not Resuscitate), DNI (Do Not Intubate), and DNH (Do Not Hospitalize) becomes crucial for ensuring their preferences are honored during critical moments.

These medical orders translate your loved one's values and wishes into specific instructions that emergency responders and healthcare providers can follow immediately, without lengthy discussions or family consultations during crisis situations.

Top 3 Key Takeaways

1. These orders are actual medical directives written by physicians based on your loved one's preferences, not just family requests

   
   

2. Each order addresses specific interventions - they can be used independently or together depending on your loved one's wishes

   
   

3. Proper documentation and communication ensure orders are followed across different healthcare settings and emergency situations

   
   

DNR: Do Not Resuscitate Orders

A DNR order instructs medical teams not to perform cardiopulmonary resuscitation (CPR) if your loved one's heart stops beating or they stop breathing. This includes chest compressions, electric shock treatments, insertion of breathing tubes, and medications designed to restart the heart.

Why someone might choose DNR: CPR can be traumatic and often unsuccessful, especially for frail older adults. Studies show that fewer than 15% of people over 70 who receive CPR in hospitals survive to discharge, and many who do survive suffer significant complications like broken ribs, brain damage, or prolonged hospitalization.

What DNR doesn't mean: This order doesn't affect other medical treatments. Your loved one can still receive pain medication, antibiotics, oxygen therapy, IV fluids, and other comfort measures. DNR specifically addresses only resuscitation efforts when the heart or breathing stops.

When DNR takes effect: The order becomes active immediately upon signing and remains in effect until your loved one or their healthcare proxy revokes it. Emergency medical services, hospitals, and nursing homes must honor valid DNR orders.

DNI: Do Not Intubate Orders

DNI orders prevent healthcare providers from inserting a breathing tube (endotracheal tube) down your loved one's throat and connecting them to a mechanical ventilator. This intervention is typically used when someone cannot breathe adequately on their own.

Intubation considerations: The procedure involves sedation, insertion of a plastic tube through the mouth into the windpipe, and connection to a machine that breathes for the patient. While sometimes life-saving, intubation can be uncomfortable and may require ongoing sedation to prevent the patient from fighting the ventilator.

Alternative breathing support: DNI orders don't prevent all breathing assistance. Healthcare providers can still use non-invasive options like oxygen masks, nasal oxygen, or BiPAP (bilevel positive airway pressure) machines that don't require inserting tubes into the throat.

Recovery implications: For aging adults with serious illnesses, intubation often leads to prolonged ICU stays, and many patients never regain the ability to breathe independently. DNI orders reflect preferences to avoid potentially futile interventions that might prolong suffering.

DNH: Do Not Hospitalize Orders

DNH orders direct healthcare providers to avoid hospital transfers and instead provide care in the current setting, whether that's home, assisted living, or a nursing home. These orders prioritize comfort and familiar surroundings over aggressive medical interventions.

Appropriate situations: DNH orders work best for people with advanced illnesses where hospitalization is unlikely to improve their condition or quality of life. They're particularly valuable for individuals with dementia, terminal cancer, or multiple chronic conditions.

Treatment flexibility: DNH doesn't mean "do nothing." Healthcare providers can still treat infections with oral antibiotics, manage pain, provide IV fluids, and address other medical needs in the current care setting.

Emergency exceptions: Most DNH orders include provisions for specific situations where hospitalization might be appropriate, such as treatable fractures or severe pain that requires hospital-level management.

How These Orders Work Together

Many families choose combinations of these orders based on their loved one's values and medical situation. Someone might have DNR and DNI orders but allow hospitalization for treatable conditions. Others might choose all three orders to ensure they remain in familiar surroundings with comfort-focused care.

POLST forms (Physician Orders for Life-Sustaining Treatment) often include these orders together on a single, standardized document that travels with your loved one across different healthcare settings. These bright-colored forms provide immediate guidance to emergency responders.

Coordination with advance directives: These medical orders should align with preferences expressed in living wills and discussions with healthcare proxies. They represent the practical implementation of broader end-of-life wishes.

The Decision-Making Process

Physician involvement is essential because these are medical orders, not just family preferences. Your loved one's doctor must write and sign these orders based on medical assessment and discussion of the patient's condition and wishes.

Family discussions should happen before medical crises arise. Talk with your loved one about their values, fears about medical interventions, and preferences for end-of-life care. These conversations inform decisions about which orders might be appropriate.

Ongoing evaluation allows for changes as your loved one's condition or preferences evolve. Orders can be modified or revoked at any time if circumstances change or your loved one reconsiders their choices.

Practical Implementation

Documentation requirements vary by state, but most require specific forms signed by a physician. Some states use standardized POLST forms, while others have their own DNR order formats.

Emergency medical services must honor properly documented orders, but they need to see the actual paperwork. Keep original documents accessible and ensure copies are available in multiple locations.

Healthcare facility transfers require communication about existing orders. When your loved one moves between hospitals, nursing homes, or other care settings, ensure staff are aware of these orders immediately upon arrival.

Family notification helps prevent confusion during emergencies. Make sure key family members understand which orders exist and what they mean, reducing conflict during stressful situations.

Common Concerns and Misconceptions

"Giving up" feelings sometimes arise when families consider these orders. Healthcare providers can help reframe these decisions as ensuring your loved one receives care that aligns with their values rather than abandoning treatment.

Reversibility questions concern families who worry about making permanent decisions. All these orders can be changed or revoked if your loved one's condition improves or their preferences change.

Pain management fears lead some families to avoid these orders, worrying their loved one won't receive adequate comfort care. These orders don't prevent pain medication or other comfort measures—they specifically address only the designated interventions.

Getting Professional Guidance

Healthcare provider discussions help families understand the medical implications of different choices. Physicians can explain what each intervention involves and discuss realistic outcomes based on your loved one's specific health conditions.

Social workers and patient advocates often facilitate these conversations, especially in hospital or nursing home settings. They can help families navigate complex emotions and practical considerations.

Hospice and palliative care teams specialize in comfort-focused care and can provide valuable guidance about end-of-life planning, including appropriate use of these medical orders.

Moving Forward with Clarity

Understanding DNR, DNI, and DNH orders empowers families to make informed decisions that honor their loved one's values and preferences. These orders provide clear guidance during medical emergencies when emotions run high and time is limited.

Start conversations with your loved one and their healthcare team about end-of-life preferences before crisis situations arise. Work together to create appropriate medical orders that reflect their wishes and ensure those orders are properly documented and communicated to all relevant healthcare providers.

Having these discussions and documents in place gives families confidence that they're advocating effectively for their loved one's preferences, even during the most challenging medical situations.