DNR Orders and Living Wills: What Every Patient Should Know

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Advance care planning is a fundamental right and an act of personal control that ensures your medical treatment matches your values when you cannot speak for yourself.

This guide explains the key differences between legal documents like living wills and health care powers of attorney, and medical orders such as do-not-resuscitate (DNR) and physician orders for life-sustaining treatment (POLST).

Understanding Advance Directives

Advance directives are legal documents created before a medical crisis to guide healthcare decisions. The Patient Self-Determination Act requires hospitals, nursing homes, and other healthcare facilities participating in Medicare and Medicaid to inform patients of their right to create advance directives upon admission.

A comprehensive advance directive typically includes two parts: the living will, which provides written instructions, and the health care power of attorney, which appoints someone to make decisions. Together, these components establish both your wishes and your advocate.

Living Wills: Your Written Medical Instructions

A living will is a legal document that specifies which medical treatments you want or don’t want if you become unable to communicate your wishes. It typically applies when you have a terminal illness or are in permanent unconsciousness, such as an irreversible coma or persistent vegetative state.

Living wills can address several types of medical decisions:

Life-sustaining treatments include procedures that artificially prolong the dying process. You can specify your wishes about cardiopulmonary resuscitation (CPR), mechanical ventilators for breathing assistance, and dialysis when kidneys fail. Instructions can also cover implantable devices like pacemakers and defibrillators and whether they should be deactivated near the end of life.

Artificial nutrition and hydration represents one of the most emotionally charged decisions. This involves receiving food and water through a tube or intravenously when you cannot eat or drink normally. Most advance directive forms provide a separate section for this choice, allowing you to accept or refuse this intervention independently of other life-sustaining treatments.

Palliative and comfort care addresses a common misconception that refusing life-sustaining treatment means refusing all medical care. A living will should explicitly state your desire for comfort-focused care, ensuring you receive medication for pain, nausea, and other symptoms to maintain comfort and dignity even if you decline aggressive treatments.

Other personal wishes can include organ and tissue donation instructions, religious or spiritual beliefs, and statements about personal values, such as defining what constitutes an acceptable quality of life.

A living will doesn’t take effect immediately upon signing. Its instructions typically activate only after two physicians certify in writing that you cannot make or communicate healthcare decisions and have a qualifying medical condition as defined by state law, such as terminal illness or permanent vegetative state.

Health Care Power of Attorney: Appointing Your Medical Advocate

A health care power of attorney (HPOA), also called a health care proxy, durable power of attorney for health care, or health care surrogate, is a legal document where you appoint someone to make medical decisions on your behalf if you become unable to do so.

The authority granted to a healthcare agent is typically broad. Unless you place specific limitations in the document, the agent can make almost any medical decision, from consenting to routine procedures to making profound end-of-life choices.

This flexibility makes the HPOA more versatile than a living will alone because it applies to all medical situations where you’re unable to decide, not just end-of-life scenarios. For instance, an agent could make decisions if you’re temporarily unconscious after a car accident, a situation where a living will wouldn’t apply.

Selecting an agent requires careful consideration. Choose someone you trust deeply, who understands your values and wishes, and has the strength to advocate for those wishes even when family members or medical staff disagree. Name at least one alternate agent in case your primary choice is unavailable or unwilling to serve.

Like a living will, an HPOA becomes effective only when an attending physician determines you’ve lost the capacity to make or communicate healthcare decisions. This loss of capacity can be temporary or permanent.

Combined Advance Directives

Many states now promote single, streamlined advance directive forms that combine living wills and health care powers of attorney. This integrated approach prevents confusion and potential conflicts that might arise when an agent’s decision contradicts a statement in the living will.

These combined forms often allow you to specify the level of authority your agent has. You might choose whether the instructions in the living will portion are “binding” on the agent or serve as “guidelines,” giving the agent flexibility to interpret your wishes in unforeseen circumstances.

Medical Orders for Emergency Situations

While advance directives are legal documents for future planning, medical orders give direct, actionable instructions that are critical in emergencies. Healthcare providers create these orders.

Do-Not-Resuscitate Orders: Specific Commands for Cardiac Arrest

A do-not-resuscitate (DNR) order is a medical order written by a physician or other qualified healthcare provider. It explicitly instructs all medical personnel, including emergency responders, not to perform cardiopulmonary resuscitation (CPR) if your heart stops beating or you stop breathing.

Understanding what CPR involves helps explain why someone might choose a DNR. CPR typically includes forceful and repeated chest compressions that can break ribs, electric shocks to the chest (defibrillation) to restart the heart, insertion of a breathing tube into the throat (intubation), and injection of powerful cardiac drugs. For individuals who are already frail or have terminal illness, CPR’s chances of success are often low, and the process can be painful and invasive.

A DNR order is not a “do not treat” order. It applies only to resuscitation. A person with a DNR order can and should continue receiving all other appropriate medical treatments, including antibiotics for infections, dialysis for kidney failure, transfusions, surgery, and pain medication.

DNR orders come in two forms:

In-hospital DNR orders are written by a doctor and placed in a patient’s medical chart during a hospital or nursing home stay. They remain valid for the duration of that stay.

Out-of-hospital DNR (or prehospital DNR) orders use specific, state-authorized forms designed for Emergency Medical Services (EMS) personnel to honor in the community—at home, in public, or during transport. These forms are often printed on brightly colored paper for easy identification and may be accompanied by medical alert bracelets or necklaces.

Some healthcare systems use alternative terminology like DNAR (Do Not Attempt Resuscitation) and AND (Allow Natural Death) to emphasize preventing suffering and respecting natural life course rather than focusing on procedure refusal.

POLST: Comprehensive Medical Orders for Serious Illness

Physician Orders for Life-Sustaining Treatment (POLST) represents a more recent and comprehensive type of medical order. Depending on the state, this document may be called MOLST (Medical Orders for Life-Sustaining Treatment), POST (Physician Orders for Scope of Treatment), or COLST (Clinician Orders for Life-Sustaining Treatment). All serve the same function.

A POLST is a standardized medical order form, often printed on brightly colored paper like pink or green for high visibility in patient records.

POLST isn’t intended for all adults. It’s specifically designed for individuals with serious, advanced, or terminal illness, or those in advanced frailty. A common guideline suggests POLST is appropriate for someone whose physician wouldn’t be surprised if they died within the next year or two.

The scope of POLST is significantly broader than a traditional DNR. It translates general wishes expressed in advance directives into specific, actionable medical orders that can be followed in emergencies.

A POLST form typically includes sections for:

Cardiopulmonary resuscitation (CPR) with a clear choice to either “Attempt Resuscitation” or “Do Not Attempt Resuscitation (Allow Natural Death).”

Level of medical intervention allows for more nuance than a simple DNR. Patients can choose among options like “Full Treatment” (including intensive care), “Selective Treatment” (providing care like IV fluids and antibiotics but avoiding intubation or ICU), or “Comfort-Focused Treatment” (prioritizing pain and symptom management while allowing natural death).

Use of breathing machines provides specific choices about mechanical ventilation.

Medically administered nutrition gives instructions on long-term feeding tubes.

Other treatments may include options for antibiotic use or requests to avoid hospital transfer unless necessary for comfort.

A defining feature of POLST is its portability and immediate actionability. The form travels with patients across all healthcare settings—from home to hospital to nursing facility and back—ensuring consistent communication of their wishes. Because it’s a valid medical order signed by a healthcare provider, EMS personnel can and must honor it in emergencies.

Key Differences Between Documents

Understanding the precise function of each end-of-life planning document is essential for making informed choices. These tools aren’t mutually exclusive; many people benefit from a combination of documents for the most comprehensive protection.

Document Comparison

Why Living Wills Aren’t DNR Orders

One of the most dangerous misconceptions in end-of-life planning is equating a living will with a DNR order. They are fundamentally different, and understanding this difference is crucial for ensuring your wishes are followed in a crisis.

A living will is a legal document that expresses future wishes to your family and healthcare team. A DNR is an immediate medical order directed at all healthcare providers, including first responders.

The conflict arises in emergency situations outside hospitals. When paramedics arrive at a scene, their legal and professional duty is to do everything possible to save a life. They must initiate CPR unless presented with a valid, physician-signed medical order to the contrary.

EMS personnel don’t have the time, training, or legal authority to locate, read, interpret, and verify the validity of a complex legal document like a living will during a life-or-death emergency. Therefore, even if you have a perfectly valid living will clearly stating you don’t want CPR, paramedics will still perform CPR. The only way to prevent this is to have a specific out-of-hospital DNR order or POLST form that’s immediately visible and recognizable to them.

Advance Directives vs. POLST: Planning vs. Current Orders

The distinction between comprehensive advance directives (living will and HPOA) and POLST forms lies in their intended audience and purpose. They complement each other rather than replace one another.

Every competent adult, regardless of current health status, should have an advance directive. Unexpected accidents or illnesses can happen at any age, and having a directive ensures your wishes are known and you have a designated advocate.

A POLST, in contrast, is exclusively for individuals already facing serious, life-limiting illness, advanced frailty, or terminal diagnosis. It’s not a planning tool for hypothetical futures; it’s a set of actionable medical orders based on your current health condition and prognosis.

Creating a POLST involves detailed conversation between patient and doctor about what to expect as illness progresses and what treatments align with goals of care. The POLST then converts broad preferences outlined in advance directives into concrete, physician-signed orders that all healthcare providers, including EMS, can follow.

Creating Your Advance Care Documents

Understanding these documents is the first step; creating them is the next. The process for creating legal advance directives differs from obtaining medical orders like DNR or POLST. This distinction reveals a fundamental aspect of healthcare planning: advance directives represent proactive, citizen-led legal processes, while medical orders involve reactive, physician-gated medical processes.

How to Create Advance Directives

Creating an advance directive is an act of self-advocacy that starts with you. While a doctor’s input is highly recommended, the legal power to create the document rests with you.

Step 1: Reflect and decide. Consider your personal values. What makes life meaningful to you? What are your fears about end of life? Think about specific scenarios: under what conditions would you want to stop life-sustaining treatment? What’s more important to you, length of life or quality of life?

Step 2: Talk to your doctor. Schedule a conversation about advance care planning. This is a covered benefit for Medicare recipients as part of the annual wellness visit. Discuss your current health, your prognosis if you have chronic conditions, and potential medical decisions that might arise. This conversation helps you understand your options from a medical perspective.

Step 3: Find your state’s forms. Laws governing advance directives vary significantly by state, so use forms valid where you live. You don’t need to create documents from scratch. Several reputable national organizations provide free, state-specific advance directive forms you can download and print.

Reliable sources include:

• The National Hospice and Palliative Care Organization’s CaringInfo program
• AARP advance directive resources
• The American Bar Association estate planning resources

Step 4: Complete the form and appoint your agent. Fill out the form clearly and thoughtfully. When appointing your healthcare agent and at least one alternate, choose people you trust completely to honor your wishes and who have agreed to take on this important role.

Step 5: Sign and finalize correctly. To be legally valid, your advance directive must be signed and finalized according to your state’s specific laws. This typically requires signing the document in the presence of two qualified witnesses or a notary public. States have strict rules about who can serve as witnesses; for example, your appointed agent, your doctor, and individuals who stand to inherit from you are often disqualified from being witnesses.

Step 6: Distribute and store copies. A completed advance directive is useless if no one knows it exists or cannot find it in an emergency. Give copies to your primary care physician, your healthcare agent, your alternate agents, and close family members. Keep the original document in a place that’s safe but easily accessible. A bank safe deposit box is often a poor choice, as it may be inaccessible on weekends or holidays when the document is needed. Carry a wallet card stating that you have an advance directive and listing your agent’s contact information.

How to Obtain DNR or POLST Orders

Unlike advance directives, DNR or POLST orders are medical orders. You cannot simply download a form and sign it to make it valid. The process must be initiated and completed in partnership with a healthcare provider, who ensures the order is medically appropriate.

The physician’s central role: Conversation with a physician (or in some states, a nurse practitioner or physician assistant) is the mandatory first step. You must discuss your health condition, prognosis, and goals of care to determine if a DNR or POLST is right for you at this time.

The process:

• After thorough discussion, the healthcare provider completes the official state-authorized DNR or POLST form with you, ensuring it accurately reflects your choices
• The form must be signed by both the healthcare provider and patient (or their legal surrogate if incapacitated) to become a valid medical order
• The original order is placed in your official medical record
• If you have an out-of-hospital DNR or POLST, you receive a copy of the form (often on designated bright-colored paper) to keep in a prominent, visible location at home, such as on the refrigerator door, where emergency responders are trained to look
• You may be advised to obtain and wear a medical alert bracelet or necklace indicating your status

This physician-gated process highlights a key difference in the balance of power. The advance directive is pure expression of individual autonomy. The DNR or POLST represents negotiated space where that autonomy meets medical reality, resulting in shared decision-making based on current, known medical conditions.

The Importance of Conversation

Legal documents and medical orders are essential tools, but they don’t substitute for human conversation. The most well-written advance directive can fail if the people meant to enforce it—your family and healthcare agent—don’t truly understand your values and wishes.

Having early, honest, and ongoing conversations about your preferences is perhaps the most critical part of advance care planning. These discussions achieve several vital goals:

They reduce the burden on loved ones. Making life-or-death decisions for someone else creates immense emotional and psychological weight. Knowing they’re following your clearly expressed wishes can alleviate guilt and stress during a crisis.

They prevent family conflict. When a patient’s wishes are unknown, family members may disagree on the best course of action, leading to painful disputes at the worst possible time.

They ensure better care. Studies show that patients who have had end-of-life conversations are more likely to receive care that aligns with their goals and to die in their preferred setting (such as at home rather than in an ICU).

When talking with your loved ones and healthcare agent, go beyond the documents. Discuss the “why” behind your choices. What are your biggest fears? What makes life meaningful for you? Under what specific circumstances would you find life no longer worth living? Who do you want to be with you? The more your agent understands your perspective, the more confident they can be in advocating for you.

Legal Realities and Common Questions

The landscape of advance care planning is governed by state laws and healthcare system protocols. Understanding these realities and having answers to common questions helps you navigate the process more effectively.

State Laws and Variations

There’s no single federal law standardizing advance directives, DNRs, or POLSTs across the country. Instead, these documents are governed by individual state laws, which can vary significantly.

These variations affect:

Required forms: Some states have mandatory statutory forms, while others are more flexible.

Witness and notary requirements: The number of witnesses, their qualifications, and whether a notary can be used instead differs from state to state.

Portability: While most states have reciprocity laws recognizing advance directives legally created in other states, it’s always best practice to complete forms for your current state of residence to avoid potential confusion or delays in honoring them. Medical orders like out-of-hospital DNRs are often not portable across state lines; you may need to obtain a new one if you move or travel frequently.

Pregnancy clauses: Many states have laws that can automatically invalidate or suspend a woman’s advance directive to withhold or withdraw life-sustaining treatment if she’s pregnant, particularly if the fetus is considered viable.

Given these complexities, use the state-specific resources and forms provided earlier. For individuals with complex family situations or health conditions, consulting with a local attorney specializing in elder law or estate planning provides valuable guidance.

What Happens Without Advance Directives

If you become unable to make medical decisions without having an advance directive, you don’t simply lose your rights. Instead, decision-making authority falls to a surrogate, as determined by a legal hierarchy established in your state’s law.

This hierarchy of next-of-kin typically proceeds in the following order:

1. A court-appointed guardian (if one exists)
2. A spouse or domestic partner
3. An adult child
4. A parent
5. An adult sibling
6. Another adult relative or close friend who knows your wishes

The problem with this default plan is twofold. First, the person designated by the state may have no idea what your wishes truly are. Second, other family members may disagree with the designated surrogate’s decision. This can lead to immense emotional distress, guilt, and sometimes contentious and costly court battles to determine your “best interest.”

Decisions made under the “best interest” standard may not reflect what you would have actually chosen for yourself. Therefore, advance care planning should be viewed as the most effective way to opt out of this uncertain default system. It’s a gift to your loved ones, protecting them from the burden of making these agonizing decisions without guidance and ensuring your personal values—not a court’s or stranger’s interpretation—guide your final chapter.

Frequently Asked Questions

Aren’t these documents just for older or terminally ill people?

No. While the need may seem more immediate for older adults or those with serious illness, unexpected accidents or medical emergencies can happen to any competent adult at any age. All adults over 18 should have advance directives.

If I have a living will that says no life support, will I still get pain medication?

Yes, absolutely. A decision to refuse life-sustaining treatment is separate from the goal of providing comfort care. Your medical team has a duty to manage pain and other symptoms to keep you comfortable, and a living will doesn’t interfere with that. You can use your directive to explicitly state your desire for robust pain management.

Can I change my mind?

Yes. As long as you’re competent (able to make your own decisions), you can change or revoke your advance directive or medical order at any time. To do so, destroy all copies of your old documents and create new ones, following all proper signing and witnessing procedures. Distribute new copies to your doctor, agent, and family to avoid confusion.

Can my family override my DNR or living will?

Generally, no. A legally valid advance directive or medical order is the highest expression of your wishes. These documents are created to ensure your choices are respected, even if your family disagrees. If you’ve clearly stated your wishes and appointed an agent to enforce them, your family cannot legally override that decision.

Do I need a lawyer to create an advance directive?

No, a lawyer isn’t required to create a legally valid advance directive. State-specific forms are widely available for free. The most important thing is to carefully follow your state’s rules for signing and witnessing the document. However, if your personal situation is complex or you have legal questions, consulting an attorney is always a good option.

Can I use my advance directive to request all possible treatments to keep me alive?

Yes. An advance directive is a tool for expressing your personal wishes, whatever they may be. You can use it to direct your healthcare team to provide aggressive, life-sustaining treatment in all situations, just as you can use it to refuse such treatment.

What’s the difference between a health care power of attorney and a financial power of attorney?

They are two completely separate legal documents. A health care power of attorney grants someone authority to make medical decisions on your behalf. A financial power of attorney grants someone authority to manage your financial affairs (such as paying bills and managing investments). You can choose the same person or different people as agents for each role.

What’s the difference between a “living will” and a regular “will”?

These documents serve entirely different purposes. A living will (an advance directive) deals with your medical care decisions while you’re still alive but unable to speak for yourself. A last will and testament directs the distribution of your money and property after you’ve died.

What does DNR mean in other contexts?

The acronym “DNR” can have other meanings in different contexts, which sometimes causes confusion in online searches. For many state governments, “DNR” stands for the Department of Natural Resources, an agency dealing with state parks, wildlife, and environmental conservation. This is completely unrelated to the medical do-not-resuscitate order.

Our articles make government information more accessible. Please consult a qualified professional for financial, legal, or health advice specific to your circumstances.