Close this search box.

Do Not Resuscitate / Do Not Hospitalize / Do Not Intubate (DNR/DNH/DNI)

Print Article

A client asked last week whether he had properly signed his own DNR and DNI orders. We asked if he meant a “do not resuscitate” and “do not intubate” order. He confirmed that was what he thought he had signed. It made us think we need to look at the advance directive issue and update some of our earlier posts on the subject.

Do Not Resuscitate (DNR)

Lots of clients want to execute a “Do Not Resuscitate” order for themselves. But that involves a fundamental misunderstanding of what DNR orders are, who creates them and how they are used.

First of all, a Do Not Resuscitate order is not something you sign for yourself. It is a medical order, signed by your doctor and directed to the other treatment staff, not to begin cardiopulmonary resuscitation if you experience cardiac arrest or stop breathing. You can request that your physician enter such an order, but  you can’t order it yourself. The confusion on this point is widespread: one online source muddies the water by asserting that “A do-not-resuscitate (DNR) order is a legal document signed by you and your provider.” Nope. You might sign a consent (assuming you are competent to do so). Or your health care agent might do so (if you are not). But the DNR order is a doctor’s order.

And note that the Do Not Resuscitate order directs withholding of CPR, use of electronic defibrillators (including AEDs), and potentially to a breathing tube. But is not the “plug” that most people say they would want  to have “pulled.” Even a properly executed and effective DNR order would not, by itself, result in removal of a feeding tube — or even removal of an artificial breathing machine once it is in place.

So what is the anxious client to do?

Medical providers will often react to an emergency with an emergency response. Artificial breathing can often become the end-point of a succession of actions attempting to save a patient’s life in the heat of the medical moment. You should appoint a health care agent. Give them the power to refuse consent, and to authorize removal of the breathing apparatus if it is instituted.

It is critically important that you name an agent who will assert your wishes. It is also important that you fully convey those wishes to your agent. Frank, thorough discussions with your agent and the rest of your family — AND your medical providers — is the surest way to accomplish refusal of cardiopulmonary resuscitation. If you think some family members will object, they are the ones you most need to talk with in advance.

Arizona does permit a form that sounds a little like a DNR order. It is the “pre-hospital medical care directive,” and is almost always called “the orange form.” It is unique to Arizona, though other states have something superficially similar called the POLST paradigm. The orange form (which you do sign yourself) directs paramedics and emergency room physicians not to begin CPR or advanced resuscitation techniques. But it doesn’t say anything about your treatment after the ambulance and the emergency room.

Would a “Do Not Intubate” order help?

You could include a “do not intubate” (DNI) instruction in your health care power of attorney and/or living will. Intubation can include both assisted breathing (endotracheal intubation) and tube-feeding. You could express your wishes that neither be used — assuming that is your wish. And tubes are the “machines” that most people imagine when they say they want machines turned off.

A DNI instruction (not really an order) can be powerful. Your health care agent can use it to argue for removal of tube-feeding and/or artificial breathing. They can also use it to resist the implementation of those technological treatments.

You can be as precise (or imprecise) as you wish. You can indicate your preference in favor of one kind of intubation and opposition to the other. Or you can even authorize your agent to give either (or both) a trial period. Or you can leave the decisions up to your agent without guidance — though that’s not our favorite approach.

“Do Not Resuscitate” can mean that you don’t want chest compressions or endotracheal intubation. Do not intubate, written on your chart in the nursing home or hospital, might prevent endotracheal intubation or tube feeding.

What is a “Do Not Hospitalize” instruction?

You could include a “do not hospitalize” (DNH) instruction in your advance directives. If you are at home, or in assisted living or even a skilled nursing facility, they probably can’t intubate you without transferring you to the hospital. So staying out of the hospital can be an effective technique.

Will a DNH instruction guarantee that you won’t be hospitalized or intubated? No. But your odds definitely go up. And they go up even more if your health care agent is active, protective and assertive. And if they know what you want (or, more to the point, don’t want).

What did we tell our client?

Armed with that background, we could explain to our client that he had signed what he needed. His health care power of attorney authorized his agent to withhold intubation and even hospitalization. And, while he couldn’t sign his own Do Not Resuscitate order, he had given his agent authority to consent. What else did he need to do? Talk with his physician and his agent, and make sure his family knew his wishes. That’s all he needed. It was also all he could do.

One Response

  1. Great information. I have been to classes on this before and never had the information explained so clearly. Thank ou

Stay up to date

Subscribe to our Newsletter to get our takes on some of the situations families, seniors, and individuals with disabilities find themselves in. These posts help guide you in the decision making process and point out helpful tips and nuances to take advantage of. Enter your email below to have our entries sent directly to your inbox!

Robert B. Fleming


Robert Fleming is a Fellow of both the American College of Trust and Estate Counsel and the National Academy of Elder Law Attorneys. He has been certified as a Specialist in Estate and Trust Law by the State Bar of Arizona‘s Board of Legal Specialization, and he is also a Certified Elder Law Attorney by the National Elder Law Foundation. Robert has a long history of involvement in local, state and national organizations. He is most proud of his instrumental involvement in the Special Needs Alliance, the premier national organization for lawyers dealing with special needs trusts and planning.

Robert has two adult children, two young grandchildren and a wife of over fifty years. He is devoted to all of them. He is also very fond of Rosalind Franklin (his office companion corgi), and his homebound cat Muninn. He just likes people, their pets and their stories.

Elizabeth N.R. Friman


Elizabeth Noble Rollings Friman is a principal and licensed fiduciary at Fleming & Curti, PLC. Elizabeth enjoys estate planning and helping families navigate trust and probate administrations. She is passionate about the fiduciary work that she performs as a trustee, personal representative, guardian, and conservator. Elizabeth works with CPAs, financial professionals, case managers, and medical providers to tailor solutions to complex family challenges. Elizabeth is often called upon to serve as a neutral party so that families can avoid protracted legal conflict. Elizabeth relies on the expertise of her team at Fleming & Curti, and as the Firm approaches its third decade, she is proud of the culture of care and consideration that the Firm embodies. Finding workable solutions to sensitive and complex family challenges is something that Elizabeth and the Fleming & Curti team do well.

Amy F. Matheson


Amy Farrell Matheson has worked as an attorney at Fleming & Curti since 2006. A member of the Southern Arizona Estate Planning Council, she is primarily responsible for estate planning and probate matters.

Amy graduated from Wellesley College with a double major in political science and English. She is an honors graduate of Suffolk University Law School and has been admitted to practice in Arizona, Massachusetts, New York, and the District of Columbia.

Prior to joining Fleming & Curti, Amy worked for American Public Television in Boston, and with the international trade group at White & Case, LLP, in Washington, D.C.

Amy’s husband, Tom, is an astronomer at NOIRLab and the Head of Time Domain Services, whose main project is ANTARES. Sadly, this does not involve actual time travel. Amy’s twin daughters are high school students; Finn, her Irish Red and White Setter, remains a puppy at heart.

Famous people's wills

Matthew M. Mansour


Matthew is a law clerk who recently earned his law degree from the University of Arizona James E. Rogers College of Law. His undergraduate degree is in psychology from the University of California, Santa Barbara. Matthew has had a passion for advocacy in the Tucson community since his time as a law student representative in the Workers’ Rights Clinic. He also has worked in both the Pima County Attorney’s Office and the Pima County Public Defender’s Office. He enjoys playing basketball, caring for his cat, and listening to audiobooks narrated by the authors.