Your mom has advanced heart failure and has been in the hospital three times this year. After the last stay, she told you, "If my heart stops, I don't want them pounding on my chest." Her living will says so, but the hospice nurse asks whether she has a DNR or a POLST. You're not sure what the difference is, or whether she needs both.
This guide uses MedlinePlus from the National Library of Medicine, the National Institute on Aging (NIA), National POLST and state health department guidance. It explains what each order does, who it's for, how it fits with an advance directive, and practical steps so emergency responders actually see it. It's general information, not medical or legal advice. Your parent's doctor is the right person to talk through the choices.
Why a living will isn't always enough
Advance directives, such as a living will and a health care power of attorney, state your parent's wishes and name someone to speak for them6. But in an emergency, responders follow medical orders. The NIA notes that even with a living will that says no CPR, it helps to have a DNR order in the medical file, because without one, staff will make every effort to restart the heart6.
National POLST describes the same problem: the standard of care in an emergency is for EMS to attempt everything reasonably possible to save a life3. For people who are seriously ill or frail, that can mean CPR, a breathing tube and a rush to intensive care, even when those treatments are painful or unlikely to help4. Medical orders turn wishes into instructions responders can act on. For background, see advance directive vs. living will. A named health care proxy can speak for your parent.
What a DNR order is
A do-not-resuscitate order is a medical order written by a health care provider. It tells providers not to perform CPR if your parent's breathing or heartbeat stops1. CPR can include chest compressions, electric shocks to restart the heart, a breathing tube and medicines1.
A DNR is narrow. It covers CPR only, and it has no instructions for other treatments, such as pain medicine, other medicines or nutrition1. Having a DNR doesn't mean your parent stops getting care. They can still receive antibiotics, treatment for pain and comfort care, and they can still go to the hospital.
The provider writes the order after talking with your parent if possible, or with their health care proxy or family1. In a hospital, it goes in the medical record. For home and other settings outside a hospital, the provider can explain how to get a wallet card, bracelet or other document so emergency responders know your parent's DNR status, and some states have standard forms through the health department1.
What a POLST form is
A POLST form is a portable medical order for people with a serious illness that's getting worse or advanced frailty from aging4. The name originally stood for physician orders for life-sustaining treatment, but nationally it's now just called POLST, and states use other names such as MOLST, POST, MOST and LST3. National POLST keeps a directory of what each state calls its program7.
A POLST form usually covers three decisions2:
- CPR or no CPR. What to do if your parent's heart or breathing stops.
- Level of treatment. Full or intensive treatment, selective treatment, or comfort-focused care. The form also addresses whether your parent wants to go to the hospital or stay where they are3.
- Medically assisted nutrition. No artificial feeding, a trial period, or a long-term feeding tube.
Because it's a medical order, a POLST is completed and signed by a provider after a conversation about your parent's diagnosis, prognosis, options and goals. It isn't a form your parent fills out alone32.
DNR vs. POLST side by side
Here's how the two compare at a glance.
- What it covers. A DNR covers CPR only1. A POLST covers CPR, level of treatment and nutrition2.
- Who it's for. A DNR can be for anyone who decides they don't want CPR1. A POLST is for people who are seriously ill or frail4.
- Who signs. A health care provider signs both13.
- Can it say yes to treatment? A DNR only says no to CPR. A POLST can also confirm that your parent wants full treatment, including CPR3.
- Where it works. A hospital DNR is in the chart. A POLST is designed to travel with your parent across care settings45.
Many POLST forms include the CPR decision, so in many states a POLST marked "no CPR" serves as the DNR order. New York, for example, says its MOLST form is the only authorized form for documenting both a nonhospital DNR and a nonhospital do-not-intubate order8. Rules differ by state, so ask your parent's provider which form your state uses.
Which one does your parent need?
If your parent is healthy, National POLST says they don't need a POLST, and an advance directive is the preferred planning tool4. New York describes its MOLST as meant for people with serious health conditions who want to avoid or receive life-sustaining treatment, live in or need long-term care, or might die within the next year8.
A POLST may fit if your parent has advanced heart or lung disease, cancer that no longer responds to treatment, or advanced frailty. National POLST's own examples include an older woman who is very frail and spends most of her time in bed and wants a natural death at home4. It also notes a person with early dementia who is otherwise healthy might choose full treatment for now and revisit the form as things change4. See end-of-life signs in the elderly.
A DNR alone may be enough if your parent's only clear wish is to avoid CPR. A DNR may also be part of a hospice care plan1. See what hospice provides and hospice vs. palliative care.
How to start the conversation
These are hard talks. MedlinePlus suggests thinking about the choice while your parent can still decide, learning about their condition and what to expect, and talking with the provider about the pros and cons of CPR1. A few questions can help:
- What matters most to you now? Time at home, comfort, being alert, or trying every treatment.
- What would you want if your heart stopped? This is the CPR question.
- Would you want to go back to the hospital? This is the level-of-treatment question on a POLST3.
- How do you feel about a feeding tube? This is the nutrition question2.
- Who should speak for you if you can't? This is the health care agent.
Bring your parent's health care agent to the appointment if possible. If your parent can't take part, the provider can talk with the agent or surrogate13. See power of attorney for an elderly parent.
Keeping the order where it will be seen
An order only helps if responders find it. National POLST recommends5:
- Keep the original at home. Put it somewhere visible that caregivers know, such as on the refrigerator, beside the bed or in the medicine cabinet.
- Carry a copy. Keep one in a wallet or purse near the ID when your parent leaves home.
- Tell family and caregivers. They can point EMS to the form quickly.
- Know what happens in facilities. In a hospital or nursing home, the form is in the chart, and the original goes with your parent when they move between settings.
- Review it. At least once a year, when health changes, or when your parent moves.
For a DNR outside the hospital, ask about a wallet card or bracelet1. If your parent is moving into a care community, bring copies to the move-in meeting. See assisted living vs. nursing home.
Moving or traveling between states
POLST programs are run state by state, with different names, forms and rules37. If your parent moves to be near you, or spends winters somewhere else, ask a provider in the new state to review the form and, if needed, sign the local version. Use the National POLST state directory to find what the program is called there and whether the state keeps a registry75.
For a DNR, ask the new provider whether the state has its own out-of-hospital form, since standard forms are often issued by state health departments1. When traveling, carry copies of the order and the advance directive, and tell any travel companions where they are.
Changing or canceling an order
Your parent can always change their mind. With a DNR, they can ask for CPR at any time1. A POLST can't be edited because it's a signed medical order, so to change it, your parent tells the provider and signs a new form. To void one, draw a line across it and write VOID in large letters, or destroy it, then tell the provider so the medical record and any state registry are updated5.
Also check that the advance directive and the POLST agree. National POLST advises making sure they support the same goals and don't conflict5.
Common mistakes families make
- Relying only on a living will. Responders follow medical orders6.
- Thinking a DNR means no care. It covers only CPR1.
- Getting a POLST for a healthy parent. An advance directive is the right tool4.
- Keeping the form in a drawer. Responders need to see it5.
- Never reviewing it. Wishes and health change5.
If a facility or doctor won't follow your parent's wishes, MedlinePlus explains that the provider may transfer care to someone who will, and in a hospital or nursing home disputes must be settled so wishes are followed1. A long-term care ombudsman can help in a nursing home or assisted living.
Getting help
Start with your parent's primary care provider, palliative care team or hospice. Hospitals and nursing homes often have social workers who help with these forms. For caregivers carrying this weight, see caregiver burnout.
