Formal advance directive, DNR and the POLST: what you need to know

January 23, 2016

With the widespread success of Dr. Atul Gwande’s book, “Being Mortal”, which spent most of the past year on the New York Times Health Best Sellers list, more and more people are beginning the conversation about the type of care they would want or not want at the end of life.

While this is a very personal subject for many, everyone should discuss their wishes about end-of-life care with the people most important to them because no one knows when that information might be needed (e.g., in case of accident or sudden cardiac arrest if the individual can not speak for him/herself.) There are online tools for facilitating this: The Conversation Project is an organization that has gained popularity in the last couple of years and has wonderful resources available, like a Starter Kit, to help people begin the discussion.

Terms surrounding end-of-life decision-making:

  1. Formal advance directive is a type of legal document that allows you to spell out your decisions about end-of-life care ahead of time. They give you a way to tell your wishes to family, friends and healthcare professionals – and to avoid confusion later on.
  2. Do not resuscitate (DNR) or no code, is a legal order written either in the hospital or on a legal form to withhold cardiopulmonary resuscitation (CPR) or advanced cardiac life support (ACLS), in respect of the wishes of a patient in case their heart were to stop or they were to stop breathing.
  3. Physician Order for Life-Sustaining Treatment (POLST) is a medical order for those with serious illness or frailty. A POLST form is completed with your healthcare professional to direct the kinds of treatment you want in a medical crisis. As a seriously ill or frail patient, POLST orders help give you more control over the treatments you do or do not want to receive in a medical crisis. The form works even if you later lose the ability to speak for yourself.

What are the pros and cons of each?

Completing a formal advance directive is a natural outgrowth of the conversation process and is strongly recommended as having your wishes clearly documented can relieve your loved ones of the burden of making difficult decisions about your care. Advance directives can be completed by an individual with or without consultation with an attorney; they do not require the participation of a health care professional. States have their own advanced directive forms that are easily accessed online or the forms can be obtained from hospitals or outpatient medical offices.

Oregon's POLST form

Oregon’s POLST form

Most healthcare professionals would recommend DNR for people who have advanced life-limiting illnesses since CPR is very likely to be unsuccessful – or even if it is successful in restoring a heartbeat, the person would be left with severe disability.

Not every state has POLSTs but all hospitals and similar facilities (nursing homes) recognize DNR orders. POLST allows people to specify that they do not want to have CPR, but, in addition, allows them to specify that they want full treatment (CPR and hospitalization) or limited treatment (hospitalization but no CPR).

POLST and DNR orders differ from formal advance directives in that they are the outcome of discussions with health care providers; literally they are orders that must be signed by a physician, physician assistant or a nurse practitioner. No one can have a DNR or POLST without the involvement of one of these health care professionals. POLST covers outpatient care and DNR is for inpatient care.

“Having the conversation with Mom was much, much easier than I expected. As it turned out, she was relieved to have a say in how she wanted her end-of-life care to be handled. The hard part, as her daughter, was bringing up such an awful subject but I’m so glad we got around to talking about it. If I had known how much peace of mind it would give her, I would have brought it up months earlier.” ~ M. Baker

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