Understanding POLST and DNR
POLST, which stands for Physician Orders for Life-Sustaining Treatment, is a crucial document that reflects a patient’s wishes and treatment goals, specifically for those who are seriously ill or have chronic conditions that will likely be one’s cause of death.
DNR stands for Do Not Resuscitate. It is medical order that tells emergency responders not to attempt CPR if a person’s heart or breathing stops.
A POLST form is a medical order that tells healthcare professionals and emergency responders what kind of treatment a seriously ill person wants — or does not want — in a medical emergency.
A POLST may include a DNR, and spells out other treatment preferences such as whether to accept breathing machines, to stay home and not go to the hospital, accept or decline feeding tubes, or whether, as the form states, “Comfort Focused Treatments” are the primary goals of care.
POLST forms are designed to ensure that a person’s wishes are honored across settings, including at home, in a hospital, at a nursing facility, or during emergency transport. Both POLST and DNR forms must be completed with the patient present and signed by a physician, physician assistant (PA), or advanced practice registered nurse (APRN).
Without a POLST or DNR, emergency 911 responders and hospital personnel are required to attempt resuscitation in the case of cardiac or respiratory arrest.
Medical Orders Must Be Easy to Find
Margaret is in her eighties, widowed, and lives alone in a rural part of New Hampshire. She has advanced heart disease and has planned carefully. She completed an advance directive, named a healthcare agent, and later worked with her clinician to complete a POLST and a Do Not Resuscitate (DNR) order. Her wishes were clear: she did not want resuscitation or aggressive life-prolonging treatment, and she hoped to remain at home at the end of her life.
One evening, Margaret develops severe chest pain and shortness of breath. Feeling frightened and unwell, she calls 911. Because she lives in a small rural town, it takes nearly 30 minutes for emergency responders to arrive.
As one EMT begins to assess Margaret, the other looks for medical orders and immediately sees them — a bright pink DNR and a bright yellow POLST — posted under a magnet on the refrigerator.
Margaret is unresponsive. Her breathing is irregular and her pulse is faint. The EMTs review her medical orders. Her wishes were clearly documented in valid medical orders: no CPR and no transport to the hospital.
The EMTs stay with her. They speak gently to her and hold her hands as her breathing slows. Within minutes, Margaret’s heart stops. She dies quietly at home, as she had hoped.
Margaret planned thoughtfully. The emergency responders followed the law — because her medical orders were immediately visible and accessible when they arrived.
Is a DNR right for me or my loved one?
A DNR may be helpful if the risks and harms of attempting resuscitation appear to outweigh benefits for people. This is often represented if one or more of the following feels true:
- A person has a very serious, chronic, or life-limiting illness
- Health has been declining, with repeated hospitalizations or increasing medical needs
- Emergency treatments like CPR are unlikely to be helpful or may cause harm
- The outcome after CPR could be unacceptably limited
- Comfort, quality of life, or avoiding aggressive interventions is now the priority
- There is concern that calling 911 could lead to unwanted resuscitation or aggressive treatment or hospital transfers, even if that is not what the person wants.
- Clear medical orders would reduce stress or conflict for family members
- A clinician has raised questions about if aggressive treatment should be used if the heart or breathing were to stop
When is a POLST right for me or my loved one?
A POLST may be helpful if experienced caregivers would not be surprised if the person were to die within a year or two. A POLST is not recommended for people who are generally healthy or whose medical conditions are stable and/or reversible. In those cases, a Living Will and Durable Power of Attorney for Healthcare (Advance Directives) are often sufficient because the decisions will not be immediate, may change, and will take place over time.
An Advance Directive is strongly recommended for anyone over age 18 because unexpected and emergency events may occur that prevent the person from being able to speak for themselves. For example, parents not named in an advance directive may not be able to gain access to their adult children’s care or have any authority in decisions about their children after a serious injury in many states.
If you’re unsure, a conversation with a healthcare provider who knows your or your loved one’s medical situation can help determine whether a DNR or POLST makes sense now — or later.
POLST and DNR Orders in New Hampshire
New Hampshire, like other states, has its own forms.
- Portable DNR (P-DNR) Order
- A bright pink document recognized statewide
- Must be signed by a physician, physician assistant, or APRN
- Should be prominently displayed on the refrigerator and in a person’s medical chart.
- May also be carried as a wallet card
- May be worn as a medical bracelet
- POLST – Medical Order
- A bright yellow document recognized statewide
- Signed by a physician, physician assistant, or APRN (APRN)
- Should be clearly posted on the refrigerator or prominently in a person’s medical chart where Emergency Medical Services personnel will look for it
- May serve as a DNR if it explicitly states:
“This will constitute a DNR Order, and no separate DNR order will be required.” - Also addresses additional treatment decisions, such as:
- Hospital transfer
- Medically administered (artificial) nutrition
- Other medical interventions, goals or time limits for treatment
- Comfort Focused Treatment as a primary goal
Some people think they only need a DNR. They should be offered the options of a POLST by their provider in order to delineate the boundaries of preferred treatment interventions across a range of medical situations. A health care provider can help determine which form — or combination — is most appropriate.
Important to Understand
A Living Will is not a valid DNR order. A Living Will describes a person’s preferences and provides guidance but does not override EMS protocols. If 911 is called and emergency personnel do not see an actual signed DNR or POLST order, they are legally required to begin resuscitation, even if advance directives exist that describe a desire for no resuscitation.
- Neither the Durable Power of Attorney for Healthcare (DPOAH), or spouse, is able to instruct EMS personnel to withhold resuscitation efforts.
- POLST and Portable DNR forms are invalid unless reviewed and signed by a qualified medical provider.
- The original signed form must be readily available — typically on the refrigerator at home or in the patient’s medical chart in a facility. Otherwise, resuscitative efforts will immediately begin.
- Copies may be shared with healthcare providers and the patient’s healthcare agent or DPOAH.
- Under New Hampshire law, DNR bracelets or necklaces may only be issued to individuals who have a valid DNR order.
This national POLST guide offers step-by-step help in understanding the question and choices in a POLST form. It’s a good way to prepare for conversation with your physician.