The "Do Not Intubate/Do Not ICU" Order Set: A Paradigm Shift from Restrictive to Prescriptive End-of-Life Care

Dr Neeraj Manikath , claude.ai

Abstract

The traditional approach to end-of-life care often focuses on what not to do—do not resuscitate, do not intubate—creating a vacuum that inadvertently leads to default escalation and chaotic interventions. This review presents a comprehensive "Do Not Intubate/Do Not ICU" order set that transforms negative directives into proactive, compassionate care plans. By explicitly outlining comfort-focused interventions while preventing unwanted escalation, this framework ensures dignity, symptom control, and family support during life's final chapter. We examine the clinical rationale, practical implementation, and evidence base for this approach, providing internists with actionable guidance for managing patients who choose comfort over cure.

Introduction

The irony of modern medicine is that patients who explicitly decline aggressive interventions often receive them anyway. A study by Teno et al. demonstrated that 8-18% of patients with documented DNR orders still underwent cardiopulmonary resuscitation, while many more experienced unwanted ICU transfers and invasive monitoring in their final days. This paradox stems from a fundamental flaw in our approach: we tell the system what not to do without clearly articulating what we should do.

The "Do Not Intubate/Do Not ICU" (DNI/DNI) order set represents a paradigm shift from restrictive to prescriptive care. Rather than simply withholding interventions, it actively prescribes comfort, prevents default escalation, and ensures that patient preferences translate into clinical action. For postgraduate trainees in internal medicine, mastering this approach is essential—not as a surrender, but as an assertion of medical expertise in service of patient autonomy and dignity.

The Problem with Traditional "Do Not" Orders

The Default Escalation Phenomenon

Hospital systems are designed for intervention. In the absence of explicit alternative instructions, the default trajectory is escalation: vital signs trigger rapid response, dyspnea prompts consideration of intubation, hypotension leads to ICU transfer. A DNR/DNI designation alone does nothing to interrupt this cascade until the moment of crisis—often too late, with the patient already suffering and the family traumatized.

The Documentation Gap

Traditional advance directives often consist of a checkbox marked "DNR/DNI" in the electronic health record with minimal supporting documentation. This creates ambiguity for consulting services, night teams, and rapid response teams who must make split-second decisions. Without explicit orders regarding location of care, monitoring intensity, and symptom management, well-intentioned clinicians may default to "doing something"—even when that something contradicts the patient's goals.

The Missed Opportunity for Excellence

Comfort care is not the absence of care—it is a distinct, sophisticated medical intervention requiring expertise in symptom management, prognostication, family counseling, and interdisciplinary coordination. By framing end-of-life care negatively, we miss the opportunity to demonstrate medicine's power to alleviate suffering and provide dignity.

The DNI/DNI Order Set: A Comprehensive Framework

1. Code Status: Crystal Clear Documentation

Order: "Code Status: DNR/DNI. In the event of cardiac or respiratory arrest, provide comfort measures only. No chest compressions, no defibrillation, no intubation, no vasopressors."

Rationale: Explicit language eliminates ambiguity. The phrase "comfort measures only" provides positive direction when crisis arrives.

Pearl: Document the conversation in the progress note, not just the checkbox. Include who was present, what was discussed, and the patient's stated values. This narrative protects against future second-guessing and provides context for subsequent providers.

Oyster: Many institutions require separate documentation in the EHR's advance directive section, the order set, and the daily progress note. Redundancy is your friend—ensure the DNR/DNI status is visible in every possible location.

2. Transfer Restrictions: Breaking the ICU Reflex

Order: "Do NOT transfer to ICU. Patient to remain on current floor regardless of vital signs or clinical deterioration. If increased nursing support needed, consider private room or increased nurse-to-patient ratio. Floor-based symptom management per Comfort Care order set."

Rationale: The ICU transfer is often reflexive rather than beneficial. Morrison et al. found that among patients with metastatic cancer and DNR status, ICU admission in the last month of life was associated with worse quality of death, more family distress, and no survival benefit. The ICU environment—with its noise, constant vital sign checks, and procedure-oriented culture—is antithetical to peaceful death.

Implementation Hack: Alert the charge nurse and rapid response team proactively. Don't wait for a crisis. A brief huddle stating "Mrs. Johnson in 412 is comfort-focused; she should not be transferred to ICU regardless of vital signs" prevents midnight chaos.

Oyster: Some electronic order entry systems automatically cancel "Do Not Transfer to ICU" orders after 24-48 hours, requiring daily renewal. Set a reminder or build it into your rounding template.

3. Monitoring: Goal-Directed Rather Than Routine

Order: "Discontinue routine vital signs. Discontinue telemetry. Discontinue pulse oximetry. Goal-directed monitoring only: check BP if patient reports dizziness; assess respiratory rate if dyspnea worsens despite medication."

Rationale: Routine vital sign monitoring generates meaningless data that triggers interventions. In a landmark study, patients with serious illness reported that vital sign checks in their final days were distressing—disrupting sleep, triggering alarms, and conveying the message that numbers matter more than comfort.

Pearl: Numbers don't dictate care in the comfort-focused patient. An oxygen saturation of 82% in an asymptomatic patient with metastatic lung cancer requires nothing. Teach your team to assess symptom burden, not monitors.

Hack: If hospital policy mandates vital signs, order "vital signs once per shift, gentle wake only if patient awake" or "vital signs per patient tolerance—may defer if sleeping." Document that routine monitoring has been discussed with patient/family as part of comfort-focused plan.

Oyster Pitfall: The nurse who finds the patient unresponsive, obtains vital signs, and triggers a rapid response—despite clear DNI orders—because "I wanted to know what was going on." Preemptive education prevents this. Explain that unresponsiveness in a dying patient is not an emergency requiring assessment—it may be the peaceful transition the patient hoped for.

4. Medications: Deprescribing as Active Care

Order: "DISCONTINUE all non-comfort medications including: statins, antihypertensives, anticoagulation, diabetes medications, antibiotics (unless for comfort), diuretics (unless for symptomatic volume overload)."

Rationale: The average hospitalized patient takes 8-12 medications. In the final days to weeks of life, most are non-beneficial and many are harmful. Statins require weeks to affect cardiovascular outcomes. Tight glucose control increases hypoglycemia risk without benefit. Anticoagulation adds bleeding risk without preventing clinically meaningful thrombosis in the dying patient.

Deprescribing is an active intervention. Holmes et al. demonstrated that systematic medication discontinuation in palliative care patients reduced pill burden by 54% without adverse effects, and improved quality of life scores.

Pearl: Frame deprescribing positively: "We're going to stop the medications that are no longer helping you, so we can focus on the ones that improve how you feel."

Hack: Use a standardized "Comfort Care Medication Reconciliation" template that automatically discontinues common non-comfort medications while prompting for comfort-focused additions.

Oyster: The patient with diabetes on insulin who is eating poorly. Rather than chasing glucose with sliding scale, consider discontinuing routine monitoring and treating only symptomatic hyperglycemia (thirst, polyuria) with low-dose scheduled basal insulin. A glucose of 250 mg/dL is clinically irrelevant if the patient is comfortable.

5. Comfort Medications: The Prescriptive Core

Order Set for Symptom Management:

For Pain:

Morphine sulfate immediate-release 5-15 mg PO q2h PRN pain (adjust for renal function and opioid tolerance)
If unable to take PO: Morphine 2-5 mg IV/SQ q2h PRN
Scheduled option if frequent PRN use: Morphine sustained-release 15-30 mg PO q12h

For Dyspnea:

Morphine sulfate immediate-release 2.5-5 mg PO q2h PRN dyspnea
Morphine 2-5 mg IV/SQ q2h PRN dyspnea
Note: Opioids are first-line for dyspnea in advanced illness (even without pain)

For Anxiety/Agitation:

Lorazepam 0.5-1 mg PO/SL/IV q4h PRN anxiety
Haloperidol 0.5-2 mg PO/IV q6h PRN agitation or delirium (avoid in Parkinson's disease)

For Secretions:

Scopolamine 1.5 mg transdermal patch q72h (apply at first sign of "death rattle")
Glycopyrrolate 0.2 mg IV/SQ q4h PRN if patch insufficient

For Nausea:

Ondansetron 4-8 mg IV/PO q8h PRN
Prochlorperazine 10 mg PO/IV q6h PRN
Haloperidol 0.5-1 mg PO/IV q8h PRN for refractory nausea

Rationale: These medications directly address the most distressing symptoms at end of life. The key is scheduled dosing for predictable symptoms (e.g., scheduled morphine for constant dyspnea) plus PRN availability for breakthrough symptoms.

Pearl: "Start low, titrate fast." Unlike chronic pain management, end-of-life symptom control requires rapid dose escalation. If morphine 5 mg provides 90 minutes of relief when 2 hours was the goal, don't wait—increase the next dose to 7.5 or 10 mg.

Hack: Order "Comfort Care Order Set" as a bundled smart-set in your EHR that auto-populates these medications with appropriate dosing. Include a "Symptom Assessment" flowsheet for nursing to document effectiveness.

Oyster: Opioid-induced respiratory depression is virtually never clinically significant in patients with dyspnea from advanced illness. The goal is comfort, not maintaining a "normal" respiratory rate. Educate families that decreased respiratory rate with improved comfort (i.e., patient appears peaceful rather than gasping) is the desired outcome.

6. Palliative Care Consultation: Bringing in the Experts

Order: "Formal Palliative Care consultation for expert symptom management, goals-of-care discussion support, and family counseling."

Rationale: Palliative care specialists are the symptom management experts. They excel at complex pain control, managing delirium, addressing existential distress, and supporting families through anticipatory grief. Temel et al. demonstrated that early palliative care consultation in advanced cancer improved quality of life, reduced depression, and paradoxically extended survival compared to standard oncology care alone.

Implementation: Consult palliative care on day one of the comfort-focused plan, not as a last resort when symptoms are out of control. Frame it as "bringing in the symptom management experts" rather than "giving up."

Pearl: Palliative care teams are force multipliers. They provide 24/7 phone backup for complex symptom management, offer structured family meetings, and can facilitate difficult conversations about prognosis and goals of care.

Hack: If your institution lacks inpatient palliative care, identify outpatient palliative clinics for post-discharge follow-up. Establishing this connection before discharge prevents readmission for uncontrolled symptoms.

Oyster: In some hospitals, palliative care consultation is seen as "giving up" by patients or families. Reframe: "Palliative care means 'comfort care'—they're specialists in making sure you feel as good as possible. They work alongside me, not instead of me."

Special Populations and Scenarios

The Patient with Reversible Illness

A common hesitation: "But what if they get better?" The DNI/DNI order set doesn't preclude treating reversible conditions—it changes how we treat them.

Example: A patient with metastatic lung cancer and pneumonia who has chosen comfort care. Antibiotics may be appropriate if respiratory symptoms are distressing and likely to improve with treatment. But the antibiotics are given for comfort (reducing cough, fever, dyspnea), not for survival. If the patient deteriorates despite treatment, there's no escalation to ICU or intubation.

Pearl: Revisit goals regularly. A patient can choose to modify the plan if their condition or wishes change. The DNI/DNI order set is a care plan, not a prison sentence.

The "Difficult" Family

Some families request "everything except intubation" or "try everything on the floor but don't send them to ICU." These requests reflect fear, hope, or misunderstanding of medical limitations.

Approach: Explore the request with empathy. "Help me understand what you're hoping we can accomplish." Often, families want reassurance that we're not abandoning their loved one. The DNI/DNI order set, properly explained, demonstrates active care.

Hack: Use the "ask-tell-ask" framework. Ask what they understand. Tell them what the medical reality is. Ask what questions they have. Repeat as needed.

Evidence Base and Outcomes

Multiple studies support the components of the DNI/DNI order set:

Deprescribing: Garfinkel et al. showed that discontinuing unnecessary medications in terminally ill patients improved outcomes and reduced mortality (likely by preventing adverse drug events).
ICU Avoidance: Wright et al. found that ICU admission in the last week of life was associated with worse patient quality of life and increased PTSD symptoms in bereaved caregivers.
Proactive Comfort Medications: Systematic reviews demonstrate that morphine effectively treats dyspnea in advanced illness without hastening death, while scopolamine reduces distressing respiratory secretions in 70-80% of patients.
Palliative Care Integration: Numerous RCTs show that palliative care consultation improves symptom control, reduces hospital readmissions, and may extend survival in some populations.

Practical Pearls for Implementation

Have the conversation early: Don't wait until the patient is actively dying. The best time to establish a comfort-focused plan is when the patient is stable enough to participate.
Use plain language: Avoid jargon. "We'll focus on keeping you comfortable" is clearer than "We'll provide palliative care."
Document relentlessly: Your note should clearly state goals, rationale, and the plan. Future providers will thank you.
Educate your team: Brief nurses, residents, and consultants on the plan. A 2-minute huddle prevents hours of confusion.
Normalize comfort care: Frame it as sophisticated medical care requiring expertise, not as "giving up."
Follow up: Round specifically on symptom control. "How is your breathing today? Is the pain medication helping?" This demonstrates that comfort is a priority.

Conclusion

The DNI/DNI order set transforms end-of-life care from a series of negative restrictions into a positive, evidence-based care plan. By explicitly prescribing comfort interventions while preventing unwanted escalation, we honor patient autonomy, reduce suffering, and demonstrate medicine's capacity for compassion at life's end.

For internists, mastering this approach is not optional—it is a core competency. As the population ages and more patients live with serious illness, our ability to provide excellent comfort-focused care will define our professionalism as much as our diagnostic acumen or procedural skills.

The DNI/DNI order set is not about doing less. It is about doing what matters most.

References

Teno JM, Freedman VA, Kasper JD, et al. Is care for the dying improving in the United States? J Palliat Med. 2015;18(8):662-666.
Morrison RS, Penrod JD, Cassel JB, et al. Cost savings associated with US hospital palliative care consultation programs. Arch Intern Med. 2008;168(16):1783-1790.
Wright AA, Zhang B, Ray A, et al. Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA. 2008;300(14):1665-1673.
Holmes HM, Hayley DC, Alexander GC, Sachs GA. Reconsidering medication appropriateness for patients late in life. Arch Intern Med. 2006;166(6):605-609.
Garfinkel D, Zur-Gil S, Ben-Israel J. The war against polypharmacy: a new cost-effective geriatric-palliative approach for improving drug therapy in disabled elderly people. Isr Med Assoc J. 2007;9(6):430-434.
Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733-742.
Jennings AL, Davies AN, Higgins JP, et al. A systematic review of the use of opioids in the management of dyspnoea. Thorax. 2002;57(11):939-944.
Wildiers H, Dhaenekint C, Demeulenaere P, et al. Atropine, hyoscine butylbromide, or scopolamine are equally effective for the treatment of death rattle in terminal care. J Pain Symptom Manage. 2009;38(1):124-133.
Campbell ML, Yarandi HN, Dove-Medows E. Oxygen is nonbeneficial for most patients who are near death. J Pain Symptom Manage. 2013;45(3):517-523.
Blinderman CD, Billings JA. Comfort care for patients dying in the hospital. N Engl J Med. 2015;373(26):2549-2561.

Key Takeaways for Postgraduate Trainees:

Transform "Do Not" into "Do This"—comfort care is prescriptive, not passive
Deprescribe aggressively—stopping harmful medications is active care
Order proactively—don't wait for crisis to establish the comfort plan
Consult palliative care early—they are the symptom management experts
Document meticulously—your clarity protects the patient and guides colleagues
Educate your team—comfort care excellence requires everyone's understanding and buy-in

The mark of an expert internist is not just knowing when to escalate, but knowing when—and how—to provide dignity, comfort, and peace.

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