Allow Natural Death and Do Not Resuscitate Orders
Allow Natural Death (AND) and Do Not Resuscitate (DNR) orders are written by a physician. Often referred to simply as DNRs, they instruct healthcare providers not to attempt to revive you if your heart stops. This option is sometimes selected by people who, for medical reasons, would not benefit from cardiopulmonary resuscitation (CPR). Discuss with your doctor whether such an order is appropriate for you. Some states allow you to include DNR instructions as part of your advance directive. If yours does not, you will need a separate document.
DNR instructions in your advance directive may not apply if you receive emergency care, such as in the event of a sudden collapse. If you do not want resuscitation attempted under any circumstance, you need a form that is separate from your advance directive, sometimes called an “out-of-hospital DNR.”
Out-of-Hospital DNR Orders
Out-of-hospital DNRs are written by a physician, usually only for terminally ill, or extremely elderly and frail people who do not want to be revived and only want comfort care. They apply in the event of a medical event anywhere outside of a healthcare facility. If your doctor approves your request for an out-of-hospital DNR, you will be told how to properly display the document, and you may need to wear a bracelet or necklace indicating that you have such an order. Some states require a specific colored-paper copy of your order to be posted on a refrigerator or other conspicuous place in your home.
Out-of-hospital DNRs can be difficult to enforce. Emergency personnel rarely withhold resuscitation, and they are not required to search for out-of-hospital DNR documentation in an emergency. To reject all emergency efforts, you will need to instruct family and neighbors, far ahead of time, not to call 911 if they find you without signs of breathing or heartbeat.
To learn more about what you need to do to ensure that paramedics comply with your out-of-hospital DNR, you can call your local ambulance service or fire department.
Physician/Medical Orders for Life-Sustaining Treatment (POLST OR MOLST)
Most often called POLST, but sometimes MOLST, physician or medical orders for life-sustaining treatment are written by a physician. They are a means to translate your advance directive into physician orders to be followed by all medical personnel. Your physician may use the POLST form to write orders that reflect the types of life-sustaining treatment, such as CPR or tube-feeding, that you do or do not want given your medical situation.
POLST orders are not for everyone. Only patients with an illness or frailty serious enough that a healthcare professional would not be surprised if they died within one year should have them. For these patients, their current health status indicates the need for standing medical orders. For healthier patients, an advance directive is a more appropriate tool for making future care wishes known.
Currently, only about half of all states have POLST forms available, and the forms have a range of different titles. There is a dedicated website, Polst.org, you can visit to learn more. Or you can speak with your physician about whether or not your state uses a version of POLST.
In the Toolkit: You can add My Particular Wishes (page 21) and Dementia Provision (page 23) forms to your advance directive to provide more detail about your preferences regarding specific interventions. Download the Toolkit.
Advance Directive Addendum: My Particular Wishes for Therapies That Could Sustain Life
You can include more detail about your wishes regarding specific life-sustaining interventions in your advance directive by completing this Compassion & Choices’ form, included in the toolkit. It lists a range of treatments, including the life-support interventions described above. For each listed treatment you can check that you consent to the treatment, consent to a trial period or refuse it. You can also use the form as a basis for discussion.
Advance Directive Addendum: Dementia Provision
Most advance directives take effect when a person is unable to make healthcare decisions and is either permanently unconscious or terminally ill. Usually advance directives do not include provisions that address when a person is not dying, but has lost decision-making capacity and the ability to self-feed due to severe dementia. You can add a dementia provision to your advance directive to advise physicians and family of your specific wishes about artificial nutrition and hydration, including spoon-feeding. We have provided one in the toolkit. Be aware that not all memory care or long-term care facilities will honor such a directive, so you’ll want to explore the issue before you are admitted. To lessen the chance your preferences will be challenged, you may also consider videotaping a statement explaining why you have completed a dementia directive, and making clear that you have made your decision without pressure or coercion.