What Are DNR and DNI Orders?

It’s difficult to think about the choices you have for medical care at the end of your life. And there can be a lot of important decisions to make. Do you prefer to die at home or in the hospital? Do you want to do everything possible to prolong your life, or do you prefer to minimize treatments and procedures that might cause pain? 

As hard as it is, thinking about how you want to live your final days has many advantages. And one of the most important decisions everyone needs to make is whether or not they want to be revived if they’re dying. 

“Resuscitation” is the medical term for the treatments or actions that healthcare providers perform to save your life. Although resuscitation can improve chances of survival, what we see on popular television shows distorts our understanding of survival. Far fewer people survive resuscitation than most people believe, especially people with underlying chronic illness. And it’s important to consider the drawbacks to resuscitation. 

DNR (do not resuscitate) and DNI (do not intubate) orders tell medical providers not to attempt CPR or resuscitation measures. Below we discuss what this means and the reasons why people put these orders in place.

What is a DNR order?

DNR stands for “do not resuscitate.” If your heart stops beating (cardiac arrest), a DNR order means you do not want any lifesaving measures. 

Many people think that CPR (cardiopulmonary resuscitation) is the main lifesaving measure used in resuscitation. But there are actually multiple treatments and procedures. 

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The main components of lifesaving resuscitation include:

• Chest compressions: This is what most people call CPR. It’s a technique that uses repeated, forceful compressions of the chest to keep the blood pumping through the body when the heart is not working. 

• Defibrillation: This treatment uses electricity to try and restart the heartbeat. This electric shock can be delivered through handheld paddles or pads that stick to the chest. 

• Intravenous (IV) medications: Providers use many medications during resuscitation. Some of them are powerful medications, like epinephrine, that aim to get the heart beating again. But this is just one of many IV medications that someone may get when receiving chest compressions.

• Supporting breathing: The heart gets most of the attention during a cardiac arrest. But during resuscitation, it’s important to keep oxygen flowing in and carbon dioxide flowing out. Placing a mask and inflatable bag over someone’s mouth can accomplish this. It can also be done with intubation, a procedure we’ll explain more below.

A DNR order is a legal document signed by you (or someone you elect to make decisions for you) and your healthcare provider. It tells all medical providers that you do not want the above treatments if your heart stops beating. 

But it’s important to understand that a DNR order is not a “do-not-treat” order for when you’re very sick or dying. It only comes into play when someone has a cardiac arrest. 

What is a DNI order?

DNI stands for “do not intubate.” Intubation is the process of placing a breathing tube into your airway. It’s a small plastic tube that sits in your windpipe (trachea). The breathing tube can then connect to a ventilator, which many people call a “life support machine.” It’s a machine that delivers oxygen to your lungs, takes carbon dioxide out, and breathes for you. Someone places a DNI order when they elect not to be intubated and put on a ventilator. 

You may be wondering why there’s a separate order for intubation when it’s included in the lifesaving treatments that are also part of a DNR. We’ll explain.

Can you have DNI orders without DNR orders, and vice versa?

Most often a DNR order also includes a DNI order. This is because restarting someone’s heart requires supporting their breathing, too. 

But DNI orders can be separate from DNR orders. When someone starts to have difficulty breathing, the heart may continue beating for a period of time. If someone stops breathing completely, the heart cannot last that long. But if someone is still breathing — just not well — the heart can actually hold out for a longer period of time. 

The DNI order exists separately so someone can communicate whether or not they want to be put on a ventilator if they are having severe breathing difficulty — even when their heart is still beating. In other words, it saves them from being intubated outside of a cardiac arrest.

When and why do people use DNR or DNI orders?

There are many reasons why people may choose to have DNR or DNI orders. In general, people and their families think about this when they’re in the end stages of an illness. This is because when someone is very sick, CPR and intubation are much less likely to save their life. And even if it does, that person is unlikely to ever be disconnected from the life support machines that are keeping them alive. 

But every person and situation are a little different. And you don’t have to wait for the end stages of an illness to start thinking about these decisions. Some examples of why someone may choose a DNR or DNI order are:

• Terminal disease: Even if someone with a terminal disease, like cancer, is not in the hospital or actively sick, they still may decline resuscitation when it comes to that point.

• Advanced chronic illness: Many people with chronic conditions, like heart disease or COPD, know it’s more likely that their heart will stop beating or they may stop breathing well. And they want to be proactive about stating their wishes for the end of their life. 

• Personal preference: Someone does not have to have a terminal illness to elect this for themselves. For example, older adults may choose this when they reach an advanced age, even if they’re very healthy. And some people may choose this for religious reasons.

How do you establish DNR or DNI orders?

There are a few ways you or your healthcare advocate can establish DNR and DNI orders. It’s always helpful to start with a conversation with your provider about your wishes and the risks and benefits of these orders. 

If you decide you would like a DNR or DNI order when you’re not currently in need of hospitalization, your options include:

• Physician order for life-sustaining treatment (POLST): This is a medical document that details your wishes. A healthcare provider files it. The document can travel with you between facilities (like from a nursing facility to a hospital). 

• Advanced directive: This is a legal document that explains any wishes you have for your medical care in the event you cannot speak for yourself — like if you’re in a coma.

• Living will: This is a specific type of advanced directive in which you clarify the medical treatments, procedures, and medications you do or don’t want to receive to keep you alive. If you can’t speak for yourself, your providers can refer to healthcare instructions in your living will.

• Durable power of attorney for healthcare (DPA): Whether or not you have a document that explains your wishes, it can be helpful to appoint someone to make decisions for you if you are unable to. They can communicate your preferences and enact the DNR/DNI orders.

If you haven’t established any of the above orders and you’re hospitalized (for any reason), it’s never too late to have a conversation with your provider in the hospital about your wishes. Your hospital provider can add a DNR or DNI order to your medical record. 

Can you reverse DNR or DNI orders?

Yes. You can reverse or change DNR and DNI orders. If you think you want to change your mind about your preferences, have a conversation with your loved ones and your healthcare team. Your loved ones can help advocate for your wishes if you’re not able to speak for yourself. And your provider can help answer the questions and concerns you have. They can also assist with making sure the orders are changed in your medical record. 

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Written by:

Nicole Andonian, MD

Nicole Andonian, MD, is a private practice anesthesiologist in Orange County, California. Her focus is in general anesthesia, regional anesthesia, and acute pain management.

Edited by:

Katie E. Golden, MD

Katie E. Golden, MD, is a board-certified emergency medicine physician and a medical editor at GoodRx.

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