POLST vs. DNR vs. advance directive What each one does, and which your family actually needs

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An advance directive is a legal planning document completed in advance by any adult; it activates only when capacity is lost. A POLST is a physician medical order for seriously ill patients that emergency responders can act on immediately. A DNR is a specific order about CPR only, and is often one part of a POLST.

Most families encounter all three terms for the first time in a crisis -- standing in a hospital hallway, or while a social worker hands over a stack of forms. The names sound interchangeable. They are not. Each document has a different legal weight, a different audience, and a different moment when it applies. Getting them mixed up leads to situations where a patient's actual wishes are not followed, or where a document that should be protecting someone is sitting in a drawer at home when the ambulance arrives.

The three documents, explained

Advance Directive

An advance directive is a legal planning document -- not a medical order. Any adult with decision-making capacity can complete one, regardless of whether they are healthy or ill. It does two things: it records the person's general preferences about medical treatment (the living will component), and it names a healthcare proxy who can make decisions on their behalf if they cannot speak for themselves.

The key feature of an advance directive is when it activates: only when the person loses decision-making capacity. Until that point, the document sits in the background. The person remains fully in charge of their own care. Physicians typically require a formal finding of incapacity (usually certified by two doctors) before the directive takes effect.

Because it is a legal document, requirements vary by state. Most states require either two witnesses or notarization. Free state-specific forms are available through CaringInfo.org, a program of the National Hospice and Palliative Care Organization.

An advance directive is the right starting point for most adults planning ahead, including those who are currently healthy. For a deeper look at what the document contains and how to get one, see our guide on what an advance directive is and why your parent needs one.

POLST (Physician Orders for Life-Sustaining Treatment)

A POLST is a physician medical order, not a planning document. It is completed collaboratively between a patient (or their surrogate) and a physician, nurse practitioner, or physician assistant. Because it is a medical order signed by a clinician, emergency responders can act on it immediately without waiting for a physician to interpret a general preferences document.

POLST is designed for people who are seriously ill -- typically those with a life expectancy of one year or less, advanced frailty, or a serious progressive condition. It is not intended for healthy adults planning ahead. Where an advance directive expresses wishes broadly, a POLST translates those wishes into specific, immediately enforceable orders.

A POLST typically addresses:

• CPR preference -- attempt resuscitation or do not attempt
• Level of medical intervention -- full treatment, limited interventions, or comfort-focused care only
• Artificial nutrition -- whether to use a feeding tube if the person cannot eat
• Hospitalization preference -- whether to transfer to a hospital or remain in place for comfort care

A critical feature: the POLST travels with the patient. It should be posted somewhere accessible at home (often on the refrigerator, per EMS convention), and it goes with the patient to any care setting. This portability is the whole point -- the orders follow the person, not the institution.

State-by-state name variations

The form goes by different names depending on the state. All refer to the same type of document:

• POLST -- used in most states, including California, Oregon, Washington, Colorado, and many others
• MOLST (Medical Orders for Life-Sustaining Treatment) -- New York, Maryland
• MOST (Medical Orders for Scope of Treatment) -- North Carolina and some others
• POST (Physician Orders for Scope of Treatment) -- Tennessee, West Virginia

The National POLST organization maintains a current state-by-state map and form links at polst.org. If a parent has one form from one state and moves to another, the new state's physician should review and reissue it in the local format.

DNR (Do Not Resuscitate)

A DNR is a specific physician order that instructs emergency responders and medical staff not to perform CPR if the person's heart or breathing stops. It addresses one thing and one thing only: the decision about resuscitation.

A DNR is a subset of what a POLST covers. When a physician completes a POLST with a patient, the CPR section of that form serves as the DNR order. A standalone DNR is also possible -- a patient can request one without completing a full POLST.

A DNR does not mean "do not treat." It does not affect pain management, antibiotics, surgery for injuries, or any other form of care. It applies only to the act of CPR itself. Families sometimes misunderstand a DNR as meaning their loved one will receive no care -- that is not accurate.

Like a POLST, a DNR must be signed by a physician to be honored by emergency responders in most states. A statement in an advance directive that says "I do not want CPR" is a general wish -- it becomes an enforceable order only when a physician issues the actual DNR.

Side-by-side comparison

When each document is appropriate

Advance directive: for any adult planning ahead

An advance directive is appropriate for any adult who wants to ensure their medical wishes are documented before a crisis. This includes healthy adults in their 40s and 50s, not just older adults. It is particularly urgent for anyone with a recent serious diagnosis, early-stage dementia, or a family history of sudden illness -- because the window to complete it while they still have full capacity can close faster than expected.

Most estate planning attorneys include advance directive preparation alongside wills and trusts. Hospitals increasingly offer advance directive assistance as part of routine admission paperwork.

POLST: for the seriously ill

A POLST becomes relevant when a person has a serious, progressive illness with a limited life expectancy -- typically under a year -- or when a person is in advanced frailty. It is the document that translates an advance directive's general wishes into specific, enforceable medical orders that travel with the patient.

Physicians, nurse practitioners, and physician assistants initiate the POLST conversation. If your parent has a diagnosis that fits, the conversation with their doctor about completing a POLST is one of the most important steps a family can take. For a broader look at how all these documents fit into end-of-life planning, the End of Life guide covers the full landscape including hospice and palliative care.

DNR: for those who have made a specific decision about CPR

A standalone DNR order is appropriate when a patient -- or their surrogate -- has made a clear decision that they do not want CPR attempted if their heart or breathing stops. This can apply in a hospital, nursing facility, or at home. In a home setting, the DNR (or the CPR section of a POLST) needs to be accessible to EMS -- not buried in a filing cabinet.

In practice, most DNR decisions for seriously ill patients are captured within a POLST form rather than as standalone orders.

What happens when documents conflict

Conflicts happen more often than families expect. A parent might have an advance directive from 10 years ago that says "no heroic measures" but a more recent POLST that requests full intervention because their wishes changed after a recovery. Or a family member may have updated a POLST without informing the healthcare proxy named in the advance directive.

When documents conflict, two general rules apply:

• Physician orders take precedence over general directives in an emergency. Emergency responders follow the POLST or DNR because it is an immediately enforceable order. They cannot pause to interpret a general advance directive document in the field.
• More recent documents generally supersede older ones. If a POLST was completed after an advance directive, the POLST reflects more current wishes and typically governs in a conflict.

The best way to prevent conflict is to review all documents together -- ideally with the treating physician -- whenever health status changes significantly. Confirm that the advance directive, any POLST, and the healthcare proxy all reflect consistent wishes and that the proxy has current copies of everything.

Where to get each document

• Advance directive: Free state-specific forms at CaringInfo.org. Can also be obtained through a hospital's patient advocate, a palliative care team, or an estate planning attorney.
• POLST / MOLST / MOST / POST: Must be completed with and signed by a licensed physician, nurse practitioner, or physician assistant. The treating doctor or palliative care team initiates this process.
• DNR: Issued by a physician. In a hospital or nursing facility, request it through the care team. For a home DNR, the primary care physician or specialist can issue it -- in many states, it must be on a specific state-approved form to be honored by EMS.