POLST vs advance directive vs DNR: what each one does

These three names often get used as if they meant the same thing. They don't. One is a legal document you sign while you are well. The other two are medical orders that a clinician signs with you.

Knowing the difference saves a lot of worry. This post explains each one, who it is for, and when it comes into the picture. It is part of our guide to estate planning documents, which shows how all the pieces fit together.

The short answer, side by side

What is an advance directive?

An advance directive is a legal document that speaks for you if you can't communicate. The National Institute on Aging names the two most common kinds: a living will and a durable power of attorney for health care (National Institute on Aging).

In Washington, the living will is called a health care directive. Any adult may sign one about life-sustaining treatment in a terminal condition or a permanent unconscious condition (RCW 70.122.030). It is notarized or signed before two qualified witnesses.

Your doctor doesn't need to sign it. You can make one at the kitchen table, decades before you need it. Our full post on what an advance directive is includes a checklist of what to put in yours.

What is a POLST form?

POLST stands for Portable Orders for Life-Sustaining Treatment in Washington. It turns your treatment wishes into medical orders that emergency crews and hospitals can act on right away.

The Washington State Department of Health describes it as a physician order form meant to go with you from one care setting to another (Washington State Department of Health). It covers resuscitation, medical interventions, antibiotics and artificial feeding.

Who should have one

The Washington State Medical Association says a POLST is designed for people who are seriously ill or in very poor health, regardless of age. Healthy adults are pointed to an advance directive instead (WSMA).

WSMA encourages clinicians to consider a POLST for a patient they would not be surprised to see die within one to two years (WSMA). Completing one is voluntary.

What the Washington form looks like

Here is what WSMA describes (WSMA):

• Section A, resuscitation. Whether you want CPR if your heart stops, or do not attempt resuscitation (DNAR).
• Section B, level of treatment. For example, full treatment, or a more limited approach.
• Side 2, nutrition. Your wishes about medically assisted nutrition, such as a feeding tube.
• Signatures. A physician, physician assistant or advanced registered nurse practitioner signs, along with you or your legal medical decision-maker. Your own signature is preferred when possible.
• Paper. It is printed on bright green paper so it stands out in a medical record. It is still honored on any color, and copies, faxes and digital images are valid.

Where to keep it

At home, WSMA says to keep the POLST in a prominent place. In a care facility, it goes first in your record and near you (WSMA).

WSMA also notes that pocket cards, bracelets and necklaces are not enough on their own for Washington medics to act on. Washington has no state POLST registry, so the paper form matters (WSMA).

Other states use other names

POLST programs differ by state. The national POLST organization notes that state programs may be called MOLST, POST, MOST or LST (National POLST). WSMA says Washington medics will try to honor other states' forms, and Oregon accepts Washington's (WSMA).

What is a DNR order?

A DNR is a "do not resuscitate" order. The National Institute on Aging describes it as part of your medical chart. It tells hospital or nursing facility staff not to attempt CPR or other life-support measures if your heartbeat and breathing stop (National Institute on Aging).

You may also hear "DNAR" (do not attempt resuscitation) or "AND" (allow natural death). NIA also describes an out-of-hospital DNR, which tells emergency crews your wishes when you are not in a hospital.

Without a DNR order, staff will try to restart your heart and breathing. NIA notes that even if a living will says you don't want CPR, a DNR order in your hospital file helps avoid confusion.

How DNR and POLST overlap

In Washington, the CPR choice is Section A of the POLST form. WSMA explains that you can choose DNAR in Section A and still choose full treatment in Section B (WSMA).

The reverse needs care. WSMA says choosing CPR usually means choosing full treatment too, because CPR often leads to a breathing tube and intensive care.

If hospice is part of the picture, our post on hospice and your wishes explains who speaks for you at that stage.

Does a POLST replace an advance directive?

No. WSMA says a POLST complements an advance directive and is not meant to replace it. You still need an advance directive to appoint a health care decision-maker (WSMA).

That is the key difference. A POLST records orders for specific treatments. It can't sit with your doctor and talk through a situation the form didn't foresee.

Only a person can do that. That is the job of your medical power of attorney. If you're still deciding who that should be, our post on choosing a medical power of attorney offers nine questions to ask.

Which do you need right now?

Here is a typical case, a composite. Carol is 63 and healthy. She signs a health care directive and names her friend Ruth as medical power of attorney, with a backup behind Ruth.

Ten years later, Carol's heart failure worsens. Her doctor raises a POLST. They fill it out together, and the green form goes somewhere easy to spot at home. Ruth, still named, has both documents and knows what Carol wants.

What it costs and how to start

A POLST is filled out during a visit with your clinician. An advance directive can often be made for little or nothing; NIA notes that many states offer free forms (National Institute on Aging).

Medicare Part B covers voluntary advance care planning as part of the yearly Wellness visit (Medicare.gov). That visit is a natural time to raise these questions.

If you're putting a full plan together, how to get power of attorney walks through the steps. For the price side, see how much a will costs.

Common questions

Is a POLST the same as a DNR?

No. A DNR is about CPR only. A POLST covers CPR and also your level of treatment and your wishes about tube feeding. In Washington, the CPR choice, including do not attempt resuscitation, sits in Section A of the POLST form.

Who can sign a POLST form?

In Washington, a physician, physician assistant or advanced registered nurse practitioner signs it with the patient. If the patient can't sign, their legal medical decision-maker can sign instead. WSMA says the patient's own signature is preferred when possible.

Do I need a POLST if I'm healthy?

Usually not. WSMA says the POLST is designed for people who are seriously ill or in very poor health. Healthy adults are better served by an advance directive that records wishes and names a decision-maker.

Is a copy of a POLST valid?

In Washington, yes. WSMA says photocopies, faxes and digital images of the form are valid, and it is honored on any color of paper. Keep the original in a prominent place at home.

Does a living will count as a DNR?

Not on its own. A living will records your wishes, but emergency crews and hospital staff act on medical orders. Even if your living will says you don't want CPR, NIA notes that a DNR order in your hospital file helps avoid confusion.

Sources

• POLST (Washington State Medical Association)
• Portable Orders for Life-Sustaining Treatment (Washington State Department of Health)
• About POLST (National POLST)
• Advance Care Planning: Advance Directives for Health Care (National Institute on Aging)
• Advance care planning (Medicare.gov)
• RCW 70.122.030: Health care directive (Washington State Legislature)