Intensive Care Medicine

, Volume 46, Issue 1, pp 36–45 | Cite as

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

  • Michael E. WilsonEmail author
  • 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



To assess the rates and variability of do-not-intubate orders in patients with acute respiratory failure.


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.


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.


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.


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



This project received no funding.

Compliance with ethical standards

Conflicts of interest

The authors have no conflicts of interest to disclose.

Supplementary material

134_2019_5828_MOESM1_ESM.docx (1 mb)
Supplementary material 1 (DOCX 1028 kb)


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Michael E. Wilson
    • 1
    • 2
    • 3
    Email author
  • Aniket Mittal
    • 1
  • Bibek Karki
    • 1
  • Claudia C. Dobler
    • 2
    • 4
    • 5
  • Abdul Wahab
    • 1
  • J. Randall Curtis
    • 6
    • 7
  • Patricia J. Erwin
    • 8
  • Abdul M. Majzoub
    • 2
    • 4
  • Victor M. Montori
    • 3
    • 9
  • Ognjen Gajic
    • 1
  • M. Hassan Murad
    • 2
    • 4
    • 9
  1. 1.Division of Pulmonary and Critical Care MedicineMayo ClinicRochesterUSA
  2. 2.Robert D. and Patricia E. Kern Center for the Science of Health Care DeliveryMayo ClinicRochesterUSA
  3. 3.Knowledge and Evaluation Research UnitMayo ClinicRochesterUSA
  4. 4.Evidence-Based Practice CenterMayo ClinicRochesterUSA
  5. 5.Institute for Evidence-Based HealthcareBond University and Gold Coast University HospitalGold CoastAustralia
  6. 6.Division of Pulmonary and Critical Care Medicine, Harborview Medical CenterUniversity of WashingtonSeattleUSA
  7. 7.Cambia Palliative Care Center of ExcellenceUniversity of WashingtonSeattleUSA
  8. 8.Medical LibraryMayo ClinicRochesterUSA
  9. 9.Department of MedicineMayo ClinicRochesterUSA

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