A licensed clinician (physician or permitted advanced practice provider) authorized under state law and institutional policy must sign the DNIO; some facilities require co-signature or attending affirmation for validity.

Can a DNIO be electronic?

Yes. Electronic signatures are valid under the federal ESIGN Act (15 U.S.C. ch. 96) and UETA in most states if intent, consent, attribution, and retention are met; follow facility authentication and HIPAA requirements.

Are witnesses or notarization required?

Requirements vary by state and facility. Some jurisdictions or institutions require a witness or notary for certain advance directives; confirm local rules before relying on a notarized requirement.

What if family disagrees during an emergency?

Clinicians should follow the valid DNIO in the chart; if the order’s validity is disputed, document the conflict, continue legal and ethics consultations per policy, and provide care consistent with immediate safety and the order when authoritative.

How do DNIO and POLST relate?

POLST/MOLST forms are portable medical orders that may include a DNIO directive; ensure DNIO language aligns with any POLST to avoid conflicting instructions during transfers.

How to update or revoke a DNIO?

The clinician should document the revocation in the EHR, obtain and sign a new order reflecting current preferences, and notify the care team so the previous directive is clearly superseded.

Electronic Signature
Templates
Other
Do Not Intubate Order

Do Not Intubate Order

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

What a Do Not Intubate Order Is and When It Applies

A Do Not Intubate Order (DNI or DNIO) is a clinician-issued medical order directing that a patient should not receive endotracheal intubation for respiratory failure or cardiopulmonary arrest. It is distinct from an advance directive in that a licensed clinician documents and signs the order in the medical record, reflecting current clinical assessment and patient preferences. DNIOs are used across hospitals, long-term care, and emergency settings to align treatment with a patient’s goals of care, reduce unwanted invasive interventions, and provide clear guidance to responding teams.

Why a Clear Do Not Intubate Order Matters

A properly completed Do Not Intubate Order ensures patient preferences are honored, reduces clinical confusion during emergencies, and documents the medical rationale for withholding intubation.

Who Typically Completes and Relies on a Do Not Intubate Order

Maintain copies in the electronic health record and at the bedside so all responding clinicians can find and follow the order.

Attending Physician — Signs and documents clinical justification and orders in the patient chart; responsible for clinical accuracy.
Advanced Practice Provider — May complete and co-sign where state law and institutional policy allow; ensures order availability.
Nursing and Respiratory Staff — Use the order during acute events to guide airway management and document adherence.

Stepwise Process to Complete a Do Not Intubate Order

Follow a consistent sequence to confirm capacity, document consent or surrogate input, and finalize the clinician order so it is actionable during emergencies.

01

Confirm Identity: Verify patient identity using two identifiers from the chart or ID band.
02

Assess Decision-Making: Document capacity; if lacking, identify authorized surrogate per facility policy.
03

Discuss Goals: Explain implications of DNIO and alternatives; record patient or surrogate preferences.
04

Document Order: Clinician completes, signs, and places order in EHR and bedside chart.

How a Do Not Intubate Order Is Activated in Clinical Workflow

A DNIO must be visible and linked to other advance care documents so first-responders and admitting teams act consistently with the order.

Prepare the Order: Complete form fields and include clinical rationale.
Clinician Signs: Sign electronically or on paper per institutional policy.
Record in EHR: Place order in active orders and flag in problem list.
Notify Care Team: Inform nursing, respiratory therapy, and on-call staff of the directive.

Essential Data Elements to Include on the Do Not Intubate Order

Patient ID: Full legal name

Date of Birth: MM/DD/YYYY

Medical Record: MRN or identifier

Order Statement: Clear DNIO directive

Clinician Details: Name and license

Signature Info: Signed and dated

Core Components Every Professional Do Not Intubate Order Should Contain

A complete DNIO combines patient identifiers, a clear clinical directive, supporting rationale, signatory authority, and visibility instructions so it functions as an unambiguous medical order.

Directive Statement

A concise, affirmative sentence specifying 'Do Not Intubate' for respiratory failure or arrest, written so any responding clinician can understand and act on it immediately.

Clinical Rationale

Brief clinical explanation for the order (e.g., advanced illness, low likelihood of benefit) to inform clinicians and document medical decision-making.

Scope and Limitations

Specify whether the order applies only to intubation or to additional airway interventions like mechanical ventilation or resuscitation.

Signatures and Authentication

Clinician signature with license number and date; include witness or notary if required by facility or state law.

Visibility and Flags

Instructions to place the DNIO in the EHR orders, bedside chart, and transfer paperwork so it is visible during handoffs and emergencies.

How to Configure an Electronic DNIO Workflow

Design electronic workflows to capture required fields, enforce authentication, and ensure order visibility across systems.

Field	Configuration
Patient Identifiers	Auto-populate from EHR
Clinician Authentication	MFA or SSO required
Audit Trail	Record IP, timestamp, actions
Storage	Save to EHR and secure archive

Digital Signing and Integration Considerations

Electronic DNIO workflows should meet clinical authentication and privacy standards before deployment.

Authentication: MFA, SSO supported
Integrations: EHR and cloud connectors
Compliance: HIPAA BAA available

Timing and Review Expectations for Do Not Intubate Orders

DNIOs should be dated, reviewed regularly, and re-evaluated when clinical status or patient preferences change.

Effective Immediately:

Order takes effect at documented date/time.

Periodic Review:

Reassess with significant condition changes or transfer.

On Transfer:

Include DNIO in transfer paperwork and handoff notes.

Discharge Planning:

Document outpatient follow-up and advance directives.

Expiration:

Specify if order is time-limited or ongoing.

Key Risks and Consequences of an Incorrect or Missing DNIO

Unwanted Treatment: Patient receives intubation contrary to wishes

Legal Exposure: Civil liability for failing to follow valid order

Care Delays: Confusion leads to slower emergency response

Conflict with Documents: Order inconsistent with advance directive

Invalid Authorization: Signed by unauthorized clinician

Privacy Breach: PHI mishandled during distribution

Practical Tips to Ensure Accurate and Reliable DNIOs

Applying consistent best practices reduces risk, ensures legal compliance, and improves adherence during crises.

Use Standardized Forms and Templates

Adopt institutionally approved DNIO templates that include required fields, clinician license details, and cross-references to POLST or living will to avoid ambiguity and inconsistent wording.

Document Capacity and Consent Clearly

Record who participated in the discussion, whether the patient had capacity, or which surrogate provided consent to create a clear record for future review or disputes.

Ensure Immediate EHR Visibility

Flag the DNIO in the problem list and orders, and add a bedside indicator where permitted so emergency responders can find and follow the directive quickly.

Review at Key Transitions

Reassess and re-document the DNIO when the patient transfers, is discharged, or has a major change in clinical status to keep the directive current and valid.

Sample Use Cases Showing How Do Not Intubate Orders Work in Practice

Two brief case examples show common workflows and outcomes when a DNIO is used correctly.

Hospital Palliative Care

An elderly patient with advanced pulmonary fibrosis opts to avoid invasive ventilation to prioritize comfort

Team documents capacity and surrogate input
The DNIO is placed in the EHR, flagged on the problem list, and respected during an acute respiratory event, avoiding intubation consistent with goals.

Skilled Nursing Facility

A resident’s family confirms preference for no intubation after decline in baseline function

Physician completes a facility DNIO and links it to the resident’s POLST
On transfer to hospital, the order accompanied records and guided ED clinicians to provide non-invasive supportive care aligned with the resident’s wishes.

eSignature Options for Digitizing Do Not Intubate Orders

Select an eSignature vendor that supports HIPAA workflows, audit trails, and EHR integrations; the table compares starting prices and a few relevant features.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Check vendor	Check vendor	Check vendor	Check vendor
Bulk Send	Yes (Business Premium)	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No
Envelope Cap	No cap	100 envelopes/user/year	Varies	Varies	Varies

Frequently Asked Questions About Do Not Intubate Orders

Answers to common questions that arise when creating, signing, or relying on a DNIO in U.S. clinical settings.

Need help? Contact support

Who may sign a DNIO?
A licensed clinician (physician or permitted advanced practice provider) authorized under state law and institutional policy must sign the DNIO; some facilities require co-signature or attending affirmation for validity.
Can a DNIO be electronic?
Yes. Electronic signatures are valid under the federal ESIGN Act (15 U.S.C. ch. 96) and UETA in most states if intent, consent, attribution, and retention are met; follow facility authentication and HIPAA requirements.
Are witnesses or notarization required?
Requirements vary by state and facility. Some jurisdictions or institutions require a witness or notary for certain advance directives; confirm local rules before relying on a notarized requirement.
What if family disagrees during an emergency?
Clinicians should follow the valid DNIO in the chart; if the order’s validity is disputed, document the conflict, continue legal and ethics consultations per policy, and provide care consistent with immediate safety and the order when authoritative.
How do DNIO and POLST relate?
POLST/MOLST forms are portable medical orders that may include a DNIO directive; ensure DNIO language aligns with any POLST to avoid conflicting instructions during transfers.
How to update or revoke a DNIO?
The clinician should document the revocation in the EHR, obtain and sign a new order reflecting current preferences, and notify the care team so the previous directive is clearly superseded.

Explore Templates

Letter Requesting Meeting to Discuss Estate Closure Sample Letter Attorney Letter Regarding Notice of Deposition Sample Letter for Foreclosed Home Letter Regarding Motion to Sell Property of Estate Letter Regarding Settlement Agreement

be ready to get more

Join over 28 million airSlate SignNow users

Sign Now