Advance Directives: Living Wills, DNR Orders, and End-of-Life Planning

No one wants to think about the day when they cannot speak for themselves. But that day comes for many people, often suddenly and without warning. A stroke, a severe infection, a traumatic injury, or advanced dementia can leave a person unable to communicate their wishes about medical treatment. Without clear written instructions, family members are left guessing, doctors are left without direction, and the result is often treatment that the person would not have wanted.

Advance directives are legal documents that allow a person to state their healthcare wishes in advance and designate someone to make medical decisions on their behalf. They are not about giving up. They are about maintaining control over your own care, even when you can no longer advocate for yourself.

What Are Advance Directives?

Advance directives is an umbrella term for legal documents that communicate a person’s healthcare preferences in the event they become unable to make or communicate decisions. The main types include:

• Living will
• Healthcare power of attorney (healthcare proxy)
• Do Not Resuscitate (DNR) order
• Do Not Intubate (DNI) order
• POLST/MOLST form (Physician Orders for Life-Sustaining Treatment)

Each serves a different purpose, and most people benefit from having more than one.

Living Wills

What a Living Will Does

A living will is a written statement of a person’s preferences regarding specific medical treatments in certain circumstances. It typically addresses situations where the person is:

• Terminally ill with no reasonable expectation of recovery
• Permanently unconscious (persistent vegetative state)
• Suffering from an advanced progressive illness such as late-stage dementia

Decisions a Living Will Can Address

A well-drafted living will provides guidance on:

Life-sustaining treatments:

• Mechanical ventilation (breathing machines)
• Cardiopulmonary resuscitation (CPR)
• Artificial nutrition and hydration (feeding tubes, IV fluids)
• Dialysis
• Blood transfusions
• Antibiotics for life-threatening infections

Pain and comfort care:

• Desire for maximum pain relief even if it may hasten death
• Preference for palliative care or hospice
• Wishes about sedation in cases of intractable suffering

Other medical decisions:

• Organ and tissue donation preferences
• Preferences about hospitalization versus treatment at home or in a care facility
• Wishes regarding experimental treatments

Limitations of Living Wills

Living wills cannot anticipate every medical scenario. Their effectiveness depends on how specifically they are written and whether the current situation matches the conditions described. This is why a living will works best in combination with a healthcare power of attorney, which gives a trusted person the flexibility to make decisions that the document does not specifically address.

Healthcare Power of Attorney

A healthcare power of attorney (also called a healthcare proxy, medical power of attorney, or healthcare surrogate designation) names a specific person to make medical decisions when the patient cannot.

This document is covered in depth in our power of attorney guide, but its relationship to advance directives deserves emphasis here.

How It Works with a Living Will

The living will states the patient’s wishes. The healthcare POA names the person responsible for ensuring those wishes are followed and for making decisions about situations the living will does not cover.

Example: A living will might state “I do not want to be kept on a ventilator if I am in a persistent vegetative state.” But what if the person has a treatable pneumonia and needs short-term ventilator support with a good chance of recovery? The living will does not address this scenario, but the healthcare agent can make the appropriate decision based on their knowledge of the patient’s values.

Choosing a Healthcare Agent

Your healthcare agent should be someone who:

• Understands your values and wishes about medical care
• Can handle the emotional weight of making life-and-death decisions
• Will advocate for your wishes even when pressured by family or providers
• Is accessible and available when needed
• Is not the same person as your primary physician (most states prohibit this)

Have a detailed conversation with your chosen agent about your wishes. The more they understand about your values, the better they can represent you.

Do Not Resuscitate (DNR) Orders

What a DNR Means

A DNR order instructs healthcare providers not to perform cardiopulmonary resuscitation (CPR) if a person’s heart stops beating or they stop breathing. Without a DNR, the default medical protocol is to attempt resuscitation.

What CPR Actually Involves

Many people have unrealistic expectations about CPR based on television portrayals. In reality:

• CPR involves forceful chest compressions that frequently break ribs, especially in elderly patients
• It may include electric shocks (defibrillation), insertion of a breathing tube, and cardiac medications
• For elderly patients with serious underlying conditions, CPR has a survival-to-discharge rate of approximately 10-20 percent
• Among survivors, many experience significant neurological impairment
• The success rate drops substantially for patients with advanced chronic illness

Understanding these realities helps families make informed decisions rather than emotional ones.

Types of DNR Orders

In-hospital DNR: Applies within a healthcare facility. The attending physician writes the order in the patient’s medical chart.

Out-of-hospital DNR (also called a prehospital DNR): Applies in the community, including the patient’s home and during transport. Emergency medical technicians and paramedics are trained to attempt resuscitation unless they see a valid out-of-hospital DNR. This form must be readily accessible, often posted on the refrigerator or kept in a visible location.

Important Clarifications

• A DNR only applies to cardiac or respiratory arrest. It does not affect any other medical treatment.
• A person with a DNR still receives all other appropriate medical care, including antibiotics, pain management, oxygen, and hospital admission.
• A DNR can be revoked by the patient at any time by simply stating that they want to be resuscitated.

Do Not Intubate (DNI) Orders

A DNI order specifies that the patient does not want to be placed on a mechanical ventilator (breathing machine). A person can have:

• A DNR without a DNI (no CPR but yes to ventilator if needed)
• A DNI without a DNR (yes to CPR but no ventilator)
• Both DNR and DNI
• Neither

These are separate decisions that should be discussed with the patient’s physician based on their specific medical situation and personal values.

POLST/MOLST Forms

What POLST Is

POLST stands for Physician Orders for Life-Sustaining Treatment (called MOLST, MOST, POST, or COLST in some states). Unlike advance directives, which are legal documents created by the patient, a POLST is a medical order signed by a physician that translates a patient’s wishes into actionable clinical instructions.

How POLST Differs from Advance Directives

Feature	Advance Directives	POLST
Who creates it	The patient	The physician, based on patient conversation
Legal status	Legal document	Medical order
When it takes effect	When the patient loses capacity	Immediately upon signing
Who it is for	Any competent adult	Patients with serious illness or frailty
Where it applies	All settings	All settings, including EMS
Format	Varies	Standardized, brightly colored form
Scope	Broad preferences	Specific clinical orders

What a POLST Covers

A POLST form typically addresses:

• Section A: CPR (attempt resuscitation vs. do not attempt)
• Section B: Medical interventions (full treatment vs. selective treatment vs. comfort-focused treatment)
• Section C: Artificially administered nutrition (long-term feeding tubes)
• Section D: Signature of physician and patient or surrogate

Who Should Have a POLST

POLST is not for healthy adults. It is designed for people who:

• Have a serious illness that is expected to be life-limiting
• Are frail with advanced age
• Would not be surprised if they died within the next one to two years
• Have specific treatment preferences that differ from full default medical care

How to Create Advance Directives

Step 1: Reflect on Your Values

Before filling out any forms, think carefully about:

• What does quality of life mean to you?
• What conditions would make life not worth living from your perspective?
• How do you feel about being kept alive by machines?
• Is length of life or quality of life more important to you?
• Do you have religious or spiritual beliefs that affect your medical care preferences?
• Are there specific treatments you would definitely want or definitely not want?

Step 2: Have Conversations

Talk with:

• Your healthcare agent about your wishes and values
• Your physician about your medical conditions and likely scenarios
• Your family members so they understand your decisions
• Your spiritual advisor if faith plays a role in your healthcare decisions

These conversations are more important than the documents themselves. A well-informed healthcare agent with a deep understanding of your values can make better decisions than a form that cannot anticipate every situation.

Step 3: Complete the Documents

Options for completing advance directives:

1. Attorney-drafted documents: Most comprehensive and tailored to your situation. Recommended as part of broader estate planning.
2. State-specific statutory forms: Many states provide free advance directive forms on their health department websites.
3. Five Wishes: A widely accepted document (valid in most states) written in everyday language. Available at fivewishes.org.
4. Hospital-provided forms: Many hospitals offer advance directive forms and social workers who can help complete them.

Step 4: Execute Properly

Requirements vary by state but generally include:

• Signature of the person creating the directive
• Witness signatures (usually two witnesses)
• Notarization (required in some states)
• Witnesses must typically be adults who are not named as the healthcare agent, not the attending physician, and not employees of a facility where the person is a patient

Step 5: Store and Distribute

• Keep the original in an accessible location (not a safe deposit box)
• Give copies to your healthcare agent, backup agent, primary care physician, specialists, and any care facilities
• Upload to your state’s advance directive registry if one exists
• Carry a wallet card indicating that you have an advance directive and where it is located
• If entering a hospital or care facility, ensure copies are in your medical record

Communicating Your Wishes

Creating the documents is only half the job. Communicating your wishes ensures they are followed.

Conversations to Have

With your healthcare agent:

• Walk them through every section of your living will
• Discuss scenarios that your documents do not specifically address
• Explain the values behind your decisions, not just the decisions themselves
• Ask if they are truly willing and able to honor your wishes even under family pressure

With your family:

• Explain your decisions and the reasoning behind them
• Listen to their concerns and feelings without necessarily changing your decisions
• Make clear that these are your choices and that your healthcare agent has the authority to enforce them
• Reduce the chance of family conflict during a crisis by having this conversation now

With your physician:

• Discuss your advance directives at a routine appointment, not during a medical emergency
• Ask your doctor whether your directives are medically clear and actionable
• Request that your advance directive be added to your medical record
• Discuss whether a POLST form is appropriate for your situation

Updating Advance Directives

Advance directives are not one-time documents. Review and potentially update them:

• Every five years at minimum
• After any major health diagnosis
• After a hospitalization or serious medical event
• After a major life change (marriage, divorce, death of a spouse or named agent)
• If you move to a different state (your directives should comply with your new state’s laws)
• If your values or preferences change for any reason

To update, create new documents following the same process and distribute them to replace all existing copies.

State Laws and Facility Requirements

State Variations

Advance directive laws differ significantly across states:

• Terminology and form requirements vary
• Some states have specific statutory forms that are recommended or required
• Witness and notarization requirements differ
• Some states have advance directive registries
• Recognition of out-of-state directives varies

Care Facility Requirements

Under federal law, Medicare and Medicaid-certified facilities must:

• Ask patients upon admission whether they have advance directives
• Document the existence of advance directives in the medical record
• Ensure that staff follow advance directives as permitted by state law
• Provide written information about advance directive rights
• Not discriminate based on whether a patient has advance directives

When moving a parent to assisted living or any care facility, bring copies of all advance directives and ensure they are part of the admission paperwork.

Common Misconceptions

“Advance directives are only for old people.” Any adult can become incapacitated. Young adults should have at least a healthcare power of attorney.

“My family knows what I want.” Families frequently disagree about what their loved one would have wanted. Written documentation prevents conflict and provides legal clarity.

“A DNR means they won’t treat me.” A DNR only applies to CPR. You will still receive all other appropriate medical care.

“Once I sign, I can’t change my mind.” You can revoke or modify advance directives at any time while you are competent.

“My doctor can override my advance directive.” In most states, providers must follow valid advance directives or transfer the patient to a provider who will.

Conclusion

Advance directives are among the most compassionate things you can do for your family. By clearly stating your wishes and naming someone you trust to advocate for them, you spare your loved ones the anguish of guessing what you would have wanted during the most difficult moments of their lives.

Complete these documents while you are healthy and able. Talk to your family, your healthcare agent, and your doctor. Store the documents where they can be found when they are needed. And revisit them periodically to make sure they still reflect your values.

Planning for end-of-life care is not morbid. It is an act of love, responsibility, and self-determination.

Related Reading

• End-of-Life Planning Guide
• Talking to Parents About Care
• Elder Abuse Prevention
• State Regulations Guide
• Senior Care Planning Timeline