Do-Not-Resuscitate Orders and Advance Directives

Advance directives let people record, in advance, their wishes about future medical care or name a surrogate to decide for them; do-not-resuscitate (DNR) orders are clinician orders that translate a decision to forgo cardiopulmonary resuscitation into an actionable instruction. In the prehospital setting these documents must be recognized, validated, and honored quickly, often during an active resuscitation, which makes their portability and clarity critical.

Definition

A do-not-resuscitate order is a clinician's order to withhold cardiopulmonary resuscitation in the event of cardiac or respiratory arrest; an advance directive is a document by which a person with capacity states future treatment preferences or appoints a health-care surrogate to make decisions if they later lose capacity.

Scope

The topic distinguishes the main instruments — living wills, durable powers of attorney for health care, traditional DNR orders, and portable medical-order forms such as POLST/MOLST — and examines how out-of-hospital DNR programs make a patient's wishes enforceable by field crews. It treats these as legal-ethical instruments and decision frameworks, not as protocols for withholding or providing any specific intervention.

Core questions

• How do advance directives differ from actionable medical orders like DNR or POLST?
• What makes an out-of-hospital DNR valid and recognizable to field crews?
• Who may speak for a patient who has lost decision-making capacity?
• What is the scope of a DNR — and what care still continues under one?
• How are conflicts between documents, families, and clinical reality resolved?

Key concepts

• Living will
• Durable power of attorney for health care / health-care proxy
• Do-not-resuscitate (DNR/DNAR) order
• Portable medical orders (POLST/MOLST)
• Out-of-hospital DNR programs
• Substituted judgment and best-interest standards
• Scope of resuscitation vs. comfort care

Mechanisms

Advance directives express preferences but are not themselves orders; a clinician must translate them into actionable instructions. DNR orders, and portable order forms such as POLST/MOLST, close that gap by recording physician (or authorized clinician) orders that travel with the patient across care settings and can be acted on immediately by EMS. Out-of-hospital DNR programs add jurisdiction-specific tokens — bracelets, forms, or registry entries — so that a field crew can quickly verify a valid order and limit resuscitation accordingly. When no valid order exists and the patient lacks capacity, decision-making shifts to a named surrogate or default decision-maker applying substituted judgment (the patient's known wishes) or, failing that, the patient's best interests.

Clinical relevance

These instruments determine whether and how resuscitation is attempted, making their recognition a core prehospital competency with direct ethical and legal stakes. This entry explains how the documents function and relate to one another so learners understand the framework; it does not direct when to start, withhold, or stop resuscitation, which is governed by jurisdictional law, valid orders, and medical direction.

Evidence & guidelines

Out-of-hospital DNR programs emerged from professional and community efforts in the late twentieth century (e.g., early community DNR experience described by Stell, 1990) and were reinforced by statutory frameworks such as the U.S. Patient Self-Determination Act, which advance directives operationalize (Murphy, 1992). The NAEMSP bioethics statement (1993) addresses honoring such directives in the field, and the POLST paradigm (Hickman et al., 2005) reflects the move toward portable, actionable orders that better realize the original intent of advance directives.

History

Advance-care planning gained legal force in the late twentieth century through right-to-die jurisprudence and statutes such as the Patient Self-Determination Act, which required institutions to inform patients of their rights. Because living wills proved hard to act on in emergencies, the POLST/MOLST paradigm and out-of-hospital DNR programs were developed so that a patient's resuscitation wishes could be honored by prehospital crews at the moment of crisis.

Debates

Why do advance directives so often fail to guide care?

Directives are frequently unavailable, vague, or not translated into actionable orders when an emergency occurs, which motivated the portable-order (POLST) movement and ongoing debate about how best to capture and honor patient wishes.

Key figures

• Susan E. Hickman
• Bernard J. Hammes
• Susan W. Tolle

Seminal works

• murphy-1992
• hickman-2005

Frequently asked questions

Does a DNR order mean no treatment at all?

No. A DNR order specifically directs that cardiopulmonary resuscitation be withheld in the event of arrest; it does not by itself stop other care such as comfort measures, oxygen, or treatment of reversible problems, the scope of which depends on the order and applicable policy.

What is the difference between an advance directive and a POLST form?

An advance directive states a person's future wishes or names a surrogate, while a POLST/MOLST form is a set of actionable clinician orders meant to travel with the patient and be followed immediately, including by prehospital crews.