Should noninvasive ventilation be used with the do-not-intubate patient?

Most of the large quantity of data on noninvasive ventilation (NIV) in acute respiratory failure is from patients who want all possible treatments and life-support. Few data are available on NIV in patients who have elected specific limits on life support and treatments (eg, patients with do-not-intubate [DNI] orders) and patients who are near the end of life and will receive comfort measures only (CMO). The most critical issue regarding NIV in DNI and CMO patients is informed consent. The patient must be informed of the risks and potential benefits of NIV, and must consent to NIV. We have few data on patients' attitudes about NIV at end of life. Data from cancer patients at end of life suggest that they want to maintain control over care decisions and may want treatment that delays death long enough that they can put their affairs in order. If informed consent and control of care decisions are assured, then NIV can be appropriate in DNI and CMO patients to reverse an acute respiratory failure that is not necessarily life-terminating, or to improve patient comfort, or to delay death.