Do not intubate order, is the misunderstanding finally over?

Sir,

We read with great pleasure the article by Arabi et al. “Shifting paradigm: From no code and do-not-resuscitate to goals of care policies.”[1] The authors highlight that the policies dealing with the limitations of medical treatment in patients with compromised medical conditions, as defined by no code or do-not-resuscitate status, are concerned by a number of inconsistencies. These include the understanding and implementation of the concept, the decision-making, the communication to patients and their relatives, and the management, that is influenced by the false belief that no code or do-not-resuscitate orders always state that the patient is approaching the end of life. The author claims that the new approach of goals of care, that is aimed at discussing the decision about resuscitation within the global plan of care and is supported by increasing literature,[2] should be regularly used in patients in critical conditions. Indeed, 10 years ago we reported that in a group of elderly patients (mean age was 81 years) with acute hypercapnic respiratory failure who received a do-not-intubate order, 87% were successfully treated with noninvasive mechanical ventilation (NIMV).[3] Further, a 3 years follow-up of the patients continuing NIMV at home showed overall mortality of 46.2% after 3 years, i.e., the majority of patients had a long-term survival despite the do-not-intubate order.[4] At present, we know from a meta-analysis on 27 studies evaluating 2,020 patients with do-not-intubate orders that the pooled survival was 56%, being 68% for COPD and for pulmonary edema, 41% for pneumonia, and 37% for patients with malignancy.[5] A large proportion of patients who were treated by NIMV survived at 1 year, but scant data on quality of life in survivors were available. According to authors, quality of life in survivors, as well as quality of death in nonsurvivors, are crucial issues that warrant to be investigated. As mentioned by Arabi et al., a shift is ongoing from hurried surrender to mindful interventions when dealing with elderly patients in critical medical conditions. This is likely to result in clear advantages from the individual and societal perspective and in improvement in health-care quality.

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