Understanding End-of-Life Orders: The DNR, the POLST and the Living Will

Blog

Julia Parker, RN

Very few people really prepare themselves or their loved ones for end-of-life decisions. Medically, several documents need to be readied to clarify your final wishes. Do yourselves, your family and your medical providers a huge favor and complete these.Are you a “DNR?” A DNR order means Do Not Resuscitate. Resuscitation is that dramatic event on TV shows when a patient stops breathing and his heart stops beating. Everyone in scrubs rushes in and pumps his chest, gives him IV drugs and puts a mask with a balloon (a bag-valve mask) over his face and pumps air into his lungs. This is the absolute end of life. This order is valid only if and when your heart stops. A DNR order does not mean that the medical team won’t treat you or fix your broken femur. A lot of care goes on before the DNR can be invoked.A DNR order can be part of a more complex document called a POLST – Physician’s Orders for Life Sustaining Treatment. Different states have variations on the POLST and may go by a slightly different name. People often have multiple copies of a POLST, and some put them on the refrigerator for the paramedics to see if they are called to their homes. A POLST includes a DNR order (or a full resuscitation order if you prefer), but it also has other details including. Do you want aggressive treatment before your heart stops? Do you want IVs? Do you want artificial nutrition and hydration? Or, do you want to only have “Comfort Measures.” Comfort measures mean that the medical team will treat you only to keep you comfortable. So, you might not get IV antibiotics if you get pneumonia, but they might give you oxygen, or medicine to decrease pain and anxiety. An example of how to use this is that most people on Hospice have a DNR with comfort measures only on their POLST. Both a DNR order and a POLST have to be completed in-person, and a doctor or nurse practitioner has to sign them with you.Living wills can be longer and can provide information on how you want to be treated if you cannot speak for yourself. They are designed to include who you want to make decisions if you cannot, whether you want a feeding tube, what to do if you are in a coma and for what length of time. A living will is not a doctor’s order, and does not have to be signed by a doctor. They do not include a DNR. They are usually quite long and full of legal verbiage making them very difficult to invoke in an emergency.All of these documents can be changed or revoked if you change your mind about your care, and are alert and able to do this. Just be sure to destroy old copies and tell your loved ones what your wishes are. If you have questions, you can ask your doctor, nurse or hospital social worker.