What is a DNI? Does Jewish Law Ever Believe a DNI is Appropriate?

 Many conditions can cause a person to have difficulty breathing.  Examples include:

• Heart attack
• Overdose of medication
• Lung failure
• Hypothermia

People may also need to protect their airways when they are under anesthesia or are suffering from some underlying illness that endangers their breathing.

In these situations, it’s critical to intubate the patient. This means we place a tube in their throat that is connected to a ventilator. Intubation is a form of artificial respiration. It’s not a perfect replacement for the way in which we naturally breathe. Normally, our diaphragm expands and contracts to draw air in and push it out, like a balloon.   With a ventilator, we are pushing or forcing air in.  That process, along with the physical discomfort of the tube down one’s throat, can be uncomfortable. 

Normally, the discomfort of intubation is greatly outweighed by the benefit it provides. Our goal is for the intubation to be a bridge to get the patient through an acute event and then restore normal breathing.  The expectation is that the patient will usually be on the ventilator for a short time.

However, after about two weeks, having the intubation tube in a patient’s throat can become problematic, leading to:

1. Higher risks of infection in the lungs. 
2. Breakdown of the throat tissue which can cause permanent damage, especially to the vocal cords.

If the patient still requires help with breathing, they would undergo a tracheotomy procedure.  A tracheotomy procedure entails: 

• Making a hole in the patient’s neck to open a direct airway through the trachea, otherwise known as the windpipe.
• The hole is created below the vocal cords to protect them from damage.
• Inserting a tube to allow a person to breathe without the use of their nose or mouth.

There are times, however, when intubation may not be appropriate.

Intubation can be a very beneficial intervention when used to enable a patient to survive a difficult period. It’s a bridge to a healthier destination. Even when it becomes permanent, it might enable some people to interact meaningfully with others. But for permanently unconscious, bed-bound patients, it can become a bridge to nowhere. 

For this reason, we do not encourage intubation for such patients when there are very little to no prospects to ever take them off the ventilator. Do not intubate if there is no hope to extubate.  Especially with terminal patients who are declining and suffering, it’s best not to prolong their dying.  Withholding aggressive interventions can allow the patient to die naturally with appropriate comfort measures.

In this circumstance and other cases with terminally ill patients, Jewish law may permit a plan of care known as a DNI, “Do Not Intubate.”  This instructs physicians and other health care professionals not to put the patient on a ventilator in the first place.  Instead, our focus is on keeping the patient comfortable, with minimal suffering and maximum amount of loving care.   

Many times, a DNI is not appropriate, and one should never feel coerced to agree to one. Patients and their families have the right to request continued intervention. However, there are circumstances where it is appropriate to passively allow nature to take its course. 

Before agreeing to a DNI, we recommend a group conversation with the patient (when possible), their proxy and close family members, the primary healthcare provider, and one’s rabbi. Ematai’s hotline is always available for consultation. 

Where is a DNI recorded? Understanding a POLST form

A DNI* directive is frequently recorded on a POLST form.  A “POLST” (Physician Orders for Life-Sustaining Treatment)* is a form containing medical orders that a physician, nurse practitioner or physician assistant initiates and completes for a patient likely being in the final year of their life. Usually printed on bright pink paper, a POLST consists of general instructions regarding types of treatment you are to receive based on your healthcare provider’s best medical judgment as well as your goals and preferences. Unlike other medical orders, however, in addition to the healthcare provider signing these orders, you or your proxy are asked to sign the POLST as well, as further indication that these orders would be fitting for you as you approach the end of your life. 

A POLST thus touches upon the gravest of halakhic questions and intervention dilemmas. Once completed, a POLST will guide decision-making for your care, whether you are in a hospital, rehabilitation center, nursing home, or your home.  Given the serious implications of these documents, one should talk to your physician, proxy, and rabbi about whether a POLST makes sense for you.

*Different areas use slightly different acronyms to refer to the same set of provider orders, such as: MOLST (Medical Orders for Life-Sustaining Treatment), POST (Physician Orders for Scope of Treatment), MOST (Medical Orders for Scope of Treatment), or TROPP (Transportable Physician Orders for Patient Preferences).