How should DNR and DNI orders be managed, and what role does patient autonomy play?

• A. Respect patient wishes; ensure orders are current and accessible; involve patient or surrogate; review and update as goals evolve; clarify limits of resuscitation.
• B. DNR means no care of any kind; DNI means do not attempt any further management.
• C. DNR orders never change.
• D. DNI overrides patient wishes.

Answer: (A)

Respecting patient autonomy while providing care that matches their goals is the central idea. DNR and DNI orders specify what should be avoided during a life-threatening event, but they do not mean all care should stop. The emphasis is on keeping the orders current, accessible to all members of the care team, and grounded in the patient’s or a legally authorized surrogate’s informed preferences.

Involve the patient or surrogate in the decision, and regularly review and update the orders as goals or prognosis evolve. When capacity is lacking, use advance directives or surrogate decision-makers and honor substituted judgment or the patient’s best interests. This dynamic, ongoing process ensures the care plan reflects what the patient values most.

It’s important to recognize what these orders do not imply: they do not mean no care at all. A DNR means do not perform CPR if the patient’s heart stops, but other treatments, comfort measures, and symptom management can still be provided. A DNI means do not place an endotracheal tube, but other medical treatments and supportive care can continue if aligned with the patient’s wishes. DNI and DNR should never override patient wishes; autonomy guides what is included or excluded, with goals revisited as circumstances change.