Do-not-intubate orders in patients with acute respiratory failure: a systematic review and meta-analysis

Michael E. Wilson, Aniket Mittal, Bibek Karki, Claudia C. Dobler, Abdul Wahab, J. Randall Curtis, Patricia J. Erwin, Abdul M. Majzoub, Victor M. Montori, Ognjen Gajic, M. Hassan Murad

Research output: Contribution to journalArticle


Purpose: To assess the rates and variability of do-not-intubate orders in patients with acute respiratory failure. Methods: We conducted a systematic review of observational studies that enrolled adult patients with acute respiratory failure requiring noninvasive ventilation or high-flow nasal cannula oxygen from inception to 2019. Results: Twenty-six studies evaluating 10,755 patients were included. The overall pooled rate of do-not-intubate orders was 27%. The pooled rate of do-not-intubate orders in studies from North America was 14% (range 9–22%), from Europe was 28% (range 13–58%), and from Asia was 38% (range 9–83%), p = 0.001. Do-not-intubate rates were higher in studies with higher patient age and in studies where do-not-intubate decisions were made without reported patient/family input. There were no significant differences in do-not-intubate orders according to illness severity, observed mortality, malignancy comorbidity, or methodological quality. Rates of do-not-intubate orders increased over time from 9% in 2000–2004 to 32% in 2015–2019. Only 12 studies (46%) reported information about do-not-intubate decision-making processes. Only 4 studies (15%) also reported rates of do-not-resuscitate. Conclusions: One in four patients with acute respiratory failure (who receive noninvasive ventilation or high-flow nasal cannula oxygen) has a do-not-intubate order. The rate of do-not-intubate orders has increased over time. There is high inter-study variability in do-not-intubate rates—even when accounting for age and illness severity. There is high variability in patient/family involvement in do-not-intubate decision making processes. Few studies reported differences in rates of do-not-resuscitate and do-not-intubate—even though recovery is very different for acute respiratory failure and cardiac arrest.

Original languageEnglish (US)
JournalIntensive Care Medicine
StateAccepted/In press - Jan 1 2019



  • Acute respiratory failure
  • Critical care
  • Do-not-intubate
  • Intensive care units
  • Noninvasive ventilation
  • Palliative care

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine

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