A do not intubate order, usually shortened to DNI, is a medical order telling the care team not to place a breathing tube into a person’s windpipe or connect them to a mechanical ventilator if their breathing fails. It is a specific and limited instruction. It is not an instruction to stop treating someone, and it does not switch off other forms of help with breathing. A person with a DNI can still receive oxygen, mask-based breathing support, nebulizers, antibiotics, fluids, and full comfort care. This guide explains what intubation involves, how a DNI relates to a DNR, who writes the order, how it can be changed, and why forms and names differ by state.
What a do not intubate order actually means
DNI stands for do not intubate. When a clinician writes this order in someone’s chart, they are recording one decision: if this person’s breathing fails, do not put a tube down their throat and do not connect them to a ventilator.
The order is narrow on purpose. It covers one procedure and the machine that follows from it. It says nothing about pain medicine, antibiotics, oxygen, dialysis, surgery, hospital admission, or whether someone gets visitors. Those are separate questions, decided separately. A frequent and understandable fear among families is that a DNI is shorthand for giving up. It is not. In practice it is a request that one particular intervention not be used, made by a person who has thought about what that intervention would mean for them.
A DNI reflects one person’s values, weighed against their own medical situation. Some people with serious lung disease decide they do not want a breathing tube because they have seen what recovery looks like, or because they judge that the burden outweighs what they hope to gain. Other people in similar circumstances decide the opposite, because for them even a difficult chance is worth taking. Both decisions are legitimate. Neither is the correct one in the abstract, and neither says anything about a person’s courage or their will to live.
What intubation involves in plain terms
Understanding a DNI is easier once you know what is being declined. Intubation, more formally endotracheal intubation, means a clinician passes a flexible tube through the mouth (occasionally the nose), between the vocal cords, and into the trachea, the windpipe. A small balloon near the tip is inflated to hold the tube in place. The tube is then connected to a ventilator, a machine that pushes air and oxygen into the lungs.
In an emergency the placement itself takes under a minute, and medicines are given so the person is asleep and does not feel it. While the tube is in place, a person cannot speak, because the tube sits between the vocal cords, and cannot eat or drink, so nutrition is given through a vein or a separate feeding tube. Most people are sedated for at least part of the time. Cleveland Clinic’s patient explainer on intubation walks through the procedure step by step, including how the tube is removed when it is no longer needed.
Intubation saves lives every day, and it is performed millions of times a year in the United States, mostly for surgery. It also carries real burdens: sore throat, injury to teeth or vocal cords, infections, and, when a tube is needed for more than a few days, a possible tracheostomy, a surgical opening in the neck. Outcomes after emergency intubation vary a great deal depending on why it was needed, a person’s age, and their health beforehand. General figures cannot tell any individual what would happen to them, which is why a conversation with your own clinician about your own situation is far more useful than any number found online.
What a DNI does and does not mean
The single most common misunderstanding about this order is scope. The table below sets out what a DNI withholds and what continues unchanged.
| A DNI means | A DNI does not mean |
|---|---|
| No breathing tube placed into the windpipe | No oxygen; oxygen through nasal prongs or a mask continues |
| No invasive mechanical ventilation through a tube | No mask-based breathing support; BiPAP or CPAP may still be offered where it fits the person’s goals |
| One named procedure is declined in advance | Do not treat; antibiotics, fluids, nebulizers and other medicines continue as usual |
| An order the care team must follow | No hospital, no ICU, no surgery; those remain separate decisions |
| A decision recorded while the person can express it | Permanent; it can be revisited and reversed at any time |
| A choice about one intervention | Less care or lower priority; comfort care is always provided in full |
DNI and DNR: separate decisions, often discussed together
DNI and DNR are frequently spoken about in the same breath, which is exactly why they get confused. They address different emergencies.
A DNI applies when breathing fails while the heart is still beating. A DNR applies when the heart stops: it instructs the team not to perform CPR, meaning chest compressions and the associated resuscitation efforts. Because CPR in a hospital normally includes intubation as part of the attempt, the two decisions overlap in practice, and clinicians usually explain both at once. When people weigh a DNI, care teams generally raise the companion decision, a do not resuscitate order.
They remain separate choices, and you can hold any combination of them. A person may have a DNI and no DNR: they would accept chest compressions if their heart stopped, but not a breathing tube for respiratory failure. A person may have a DNR and no DNI: they would accept a breathing tube for a treatable pneumonia, but not CPR if their heart stopped. A person may have both, or neither. Having neither is called full code, and it is simply the default if no other order exists.
How DNI compares with advance directives and POLST
A related source of confusion is the difference between an order and a document expressing your wishes. A DNI is a clinician’s order, written in the medical record, that other clinicians act on immediately. An advance directive is a legal document you write yourself, and someone has to read and interpret it before it changes anything. POLST forms sit in between: they are portable medical orders, signed by a clinician, that travel with you.
| Document | What it is | Who creates it | When it applies |
|---|---|---|---|
| DNI | Medical order declining a breathing tube and ventilator | A clinician, after talking with you or your decision-maker | Breathing failure, acted on immediately |
| DNR | Medical order declining CPR | A clinician, after talking with you or your decision-maker | Cardiac arrest, acted on immediately |
| Advance directive or living will | Legal document stating your wishes and naming a proxy | You, often with a lawyer or a form from your state | If you cannot speak for yourself; guides later orders |
| POLST or MOLST | Portable medical orders covering CPR, intubation and more | You and a clinician together, both signing | Across settings, including at home with paramedics |
The practical consequence matters. An advance directive stored in a drawer at home cannot direct a paramedic at three in the morning. A DNI in a hospital chart, or a signed POLST on the refrigerator, can. Many people benefit from having both: the directive to explain the reasoning and name a proxy, and orders so the reasoning is actually followed.
Breathing support that remains available with a DNI
This is the part that surprises most families. Declining a breathing tube does not mean declining help with breathing.
Oxygen and non-invasive ventilation
Oxygen through nasal prongs or a face mask continues normally. Beyond that, several forms of support deliver pressurized air without any tube. Non-invasive ventilation, often given as BiPAP, uses a snug-fitting mask that pushes air into the lungs and eases the work of breathing. CPAP delivers a steady pressure that helps keep the small air sacs open. High-flow nasal oxygen delivers warmed, humidified oxygen at high rates through soft prongs in the nose. All of these are compatible with a DNI, and all are routinely offered to people who have one, provided the person finds the mask tolerable and it fits their goals.
These options are not automatic, and they are worth discussing explicitly. Some people accept a DNI precisely because they want to avoid an intensive care unit, and a tight mask for days is not what they had in mind either. Others want everything short of a tube. Making that boundary clear in advance spares everyone guesswork during an emergency.
Medicines, symptom relief and comfort care
Medicines continue: antibiotics for infection, diuretics for fluid overload, steroids and nebulizers for airway disease, and opioids, which are strikingly effective at easing the sensation of breathlessness even when they do not change the underlying lung problem. Comfort care is not a lesser tier of medicine reserved for the end; it is active treatment of symptoms, and it runs alongside everything else.
Because a DNI conversation often begins when someone is already living with shortness of breath, symptom relief is usually the most immediate concern rather than a distant one. Palliative care teams are specialists in exactly this, and involving them does not mean stopping other treatment.
How a DNI order is made, documented and changed
Who decides, and what capacity means
An adult who has decision-making capacity decides for themselves. Capacity means being able to understand the information, weigh it against your own values, and communicate a choice. It is specific to the decision at hand and can fluctuate; someone confused during a fever may recover capacity days later.
When someone cannot decide for themselves, a healthcare proxy named in an advance directive, or a surrogate identified under state law, steps in. Their job is not to say what they would want, but to reconstruct what this person would have chosen, using prior conversations and known values. This is why saying your wishes out loud, to the people who might one day speak for you, matters as much as any form.
Clinicians assessing someone’s condition draw on the same records you can read. A lung exam may document clear to auscultation bilaterally, and the same note may describe a person as showing no acute distress. Teams tracking level of consciousness use the Glasgow Coma Scale, and a bedside check often records a brief orientation assessment. When breathing is the question, clinicians reading a blood gas result also check base excess, which reflects the metabolic side of the body’s acid balance.
A DNI can be reversed at any time
This deserves emphasis, because many people hesitate out of a belief that the decision is final. It is not. A person with capacity can cancel or change a DNI at any moment, for any reason, without justifying it to anyone. A single sentence to a nurse or doctor is enough; the order is rewritten.
Orders are also revisited as circumstances shift. A DNI made during advanced illness may be reconsidered if a new treatment changes the outlook. Many hospitals temporarily suspend a DNI during surgery, because anesthesia normally requires a breathing tube for reasons unrelated to a crisis; this should be discussed and agreed beforehand, not assumed in either direction. Charts sometimes flag an urgent instruction as a STAT order, but a DNI is the opposite kind of entry: a standing instruction meant to be found and read calmly.
Forms and names vary by state
The United States has no single national form. Some states use POLST, others MOLST, POST or MOST. Out-of-hospital DNR forms, bracelets and wallet cards exist so paramedics can honor a decision at home, and the rules for what paramedics may accept differ by state. Witnessing and signature requirements vary, and a form valid in one state may not be recognized in another.
The practical takeaway is to confirm what applies where you actually live and receive care. Your clinician, the hospital’s social worker, or your state health department can tell you which form is current. Discussions about breathing support often sit alongside broader conversations about function and independence, including activities of daily living, since what someone hopes to return to shapes what they are willing to go through.
Latest scientific advances
Research from the last few years has focused on two things relevant to anyone weighing a DNI: what breathing support can achieve without a tube, and whether these conversations help or harm the people having them.
A 2024 review examined non-invasive respiratory support in hospitalized older adults with sudden breathing failure. Non-invasive ventilation means a tight-fitting mask that helps push air into the lungs, with no tube. Reviewing studies of people aged 65 and over, the authors found that the short and medium-term benefits, including a lower chance of needing a ventilator and improved survival, were broadly similar to those seen in younger patients once differences in illness severity and other conditions were accounted for. The authors specifically note these approaches as an option for people who are too frail for intubation or who have a DNI order.
What this means for you: a DNI does not leave a person without effective help. It closes one door and leaves several others open. This was a narrative review rather than a pooled statistical analysis, and results depended heavily on the setting, so it describes a general direction rather than a guarantee for any individual (Coppola S, et al., Expert Review of Respiratory Medicine, 2024).
A 2023 study of 1,375 adults hospitalized with COVID-19 at two Midwestern hospitals found that about one in five had a documented DNR or DNI order, or both. Older age was associated with having one. What this means for you: these orders are an ordinary, common part of hospital care rather than something rare or exceptional. If a clinician raises the subject, it is not a signal that they have concluded anything about your prognosis; it is a routine question asked of many patients on admission (Comer AR, et al., Resuscitation Plus, 2023).
A randomized trial published in 2025 addressed the worry that these conversations do harm. Researchers at six Swiss hospitals studied 177 patients, average age 76, comparing a structured checklist-guided conversation about code status with usual care. Two findings stand out. People whose conversation followed the checklist were less likely to want intensive care admission, suggesting that a clearer explanation changed what some people chose. Just as importantly, measured anxiety and depression afterwards were no worse in either group.
What this means for you: in this study, talking carefully about intubation and resuscitation did not leave people more distressed, which is the fear that most often keeps families from starting. Physicians also found the structured conversations less difficult. This was a single trial of modest size in one country, so it points in a reassuring direction rather than settling the matter (Arpagaus A, et al., JAMA Network Open, 2025).
Questions worth bringing to the conversation
If you are thinking about a DNI, for yourself or with someone you love, a few questions tend to open things up:
- Given my specific health, what would intubation most likely be for, and what would recovery realistically look like?
- If I decline a breathing tube, what would you still offer me for breathlessness?
- Would BiPAP or high-flow oxygen be options for me, and would I want them?
- Is a DNI the same as a DNR here, and do I want them handled the same way?
- Which form does my state use, and who needs a copy?
- What happens to this order if I have surgery?
- Who would speak for me if I could not speak for myself, and do they know what I want?
There is no deadline and no right answer. Some people decide quickly; others need several conversations across months. Both are fine.
Glossary
| Term | Definition |
|---|---|
| DNI (do not intubate) | A medical order stating that no breathing tube should be placed and no mechanical ventilator used. It does not limit other treatment. |
| DNR (do not resuscitate) | A medical order stating that CPR should not be attempted if the heart stops. It is a separate decision from a DNI. |
| Intubation | Placing a tube through the mouth or nose into the windpipe to keep the airway open and allow a machine to deliver air. |
| Mechanical ventilator | A machine that moves air and oxygen into and out of the lungs, usually through a breathing tube. |
| Non-invasive ventilation (BiPAP) | Breathing support given through a tight-fitting mask instead of a tube, delivering pressurized air to ease the work of breathing. |
| CPAP | Continuous positive airway pressure; a steady pressure delivered by mask that helps keep the small air sacs in the lungs open. |
| Code status | The shorthand a hospital uses to record which resuscitation measures a person wants, such as full code, DNR, or DNI. |
| Advance directive | A legal document in which you state your treatment wishes and name someone to decide for you if you cannot. |
| POLST or MOLST | Portable medical orders for life-sustaining treatment, signed by you and a clinician, that apply across care settings. Names vary by state. |
| Capacity | The ability to understand information about a decision, weigh it, and communicate a choice. It can change over time. |
| Healthcare proxy | The person you name to make medical decisions on your behalf if you become unable to make them yourself. |
| Comfort care | Active treatment aimed at relieving symptoms such as pain and breathlessness. It continues regardless of a DNI or DNR. |
Frequently asked questions
Can you have a DNI without a DNR?
Yes. They are separate orders addressing different situations, and you can have either one on its own. A DNI without a DNR means you would not want a breathing tube if your breathing failed, but you would accept CPR if your heart stopped. Some people choose this combination deliberately. Because CPR in a hospital usually involves intubation as part of the attempt, it is worth asking your clinician how the team would handle that overlap in practice, so that everyone understands what you intend. The reverse arrangement, a DNR without a DNI, is also possible and is chosen by people who would accept a breathing tube for a treatable problem such as pneumonia.
Can a DNI order be reversed?
Yes, at any time. If you have decision-making capacity, you can change or cancel a DNI simply by telling a member of your care team, and you do not need to explain why. The order is rewritten in your record. Nothing about a DNI is permanent or binding on your future self. If you cannot speak for yourself, your healthcare proxy or legal surrogate may request a change, working within state law and your previously expressed wishes. Many people revisit the decision as their health or their priorities change, and clinicians expect this rather than being surprised by it.
Does DNI mean no oxygen?
No. Oxygen is not affected by a DNI. You can receive oxygen through nasal prongs or a face mask exactly as anyone else would. A DNI declines the breathing tube and the ventilator that connects to it, not oxygen itself. Mask-based support such as BiPAP or CPAP, and high-flow oxygen through the nose, also remain available and are commonly used for people with a DNI, as long as you find them tolerable and they match your goals. If you want to decline mask-based support too, that is a separate choice you can make and have recorded.
What is the difference between DNR and DNI?
A DNR applies when the heart stops beating and means no CPR, meaning no chest compressions or associated resuscitation efforts. A DNI applies when breathing fails while the heart is still going, and means no breathing tube and no mechanical ventilator. They are often discussed at the same appointment because they belong to the same conversation about what you want in an emergency, but they are decided independently. You can have one, both, or neither.
Who signs a do not intubate order?
A physician or other authorized clinician writes and signs a DNI, which is what makes it an order the care team must follow. It is written only after a conversation with you, or with your healthcare proxy or surrogate if you cannot take part. Your part is the decision; the clinician’s part is recording it correctly so colleagues act on it. On a POLST-type form, both you and a clinician typically sign. Requirements for signatures and witnesses differ from state to state, so ask locally what your form needs to be valid.
Does a DNI mean I will not be admitted to the ICU?
Not by itself. A DNI addresses one procedure, not where you are cared for. People with a DNI are sometimes admitted to intensive care for close monitoring, mask-based breathing support, or treatment of an infection. That said, some people choose a DNI as part of a broader wish to avoid intensive care, and if that is your preference it is worth saying so directly, because it will not be assumed from the DNI alone.
Sources
- National Library of Medicine — Do-not-resuscitate order: MedlinePlus Medical Encyclopedia — MedlinePlus, National Institutes of Health — medlineplus.gov
- Vranick J, Sanghavi DK, Torp KD, Stanton M — Do Not Resuscitate — StatPearls, NCBI Bookshelf, National Library of Medicine, 2022 — ncbi.nlm.nih.gov
- Cleveland Clinic — Intubation: Procedure, Risks and Recovery — Cleveland Clinic Health Library, 2025 — my.clevelandclinic.org
- National Institute on Aging — Advance Care Planning: Advance Directives for Health Care — National Institute on Aging, National Institutes of Health — nia.nih.gov
- Coppola S, Radovanovic D, Pozzi T, et al. — Non-invasive respiratory support in elderly hospitalized patients — Expert Review of Respiratory Medicine, 2024 — doi.org
- Comer AR, Fettig L, Bartlett S, et al. — Code status orders in hospitalized patients with COVID-19 — Resuscitation Plus, 2023 — doi.org
- Arpagaus A, Arpagaus L, Becker C, et al. — Checklist-Guided Code Status Discussions in Patients for Whom Cardiopulmonary Resuscitation Is Considered Futile: An Analysis of a Randomized Clinical Trial — JAMA Network Open, 2025 — doi.org
Further reading
- DNR Meaning: Do Not Resuscitate Guide
- SOB Meaning: Shortness of Breath Guide
- BE Meaning: Base Excess Blood Gas Measure
- ADL Meaning: Activities of Daily Living Guide
- GCS Meaning: Glasgow Coma Scale Guide
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Understanding what is written in your own medical record, lab results included, can make it easier to take part in decisions about your care and to ask the questions that matter to you. Tests that often come up in conversations about breathing include a blood gas, which shows how well the lungs are exchanging oxygen and carbon dioxide, a complete blood count, and kidney function. BloodSense helps you understand what your results say in plain language. It does not diagnose, and it does not replace your doctor or the conversation you have with them.
