Gerontology, Palliative Care & Prevention · Topic 6 of 13

Advance Care Planning & POLST

Palliative & ethics · advance care planning

Advance Care Planning & POLST

An advance directive is the patient's legal voice; a POLST is a signed medical order. Name the surrogate, and remember DNR means only no CPR.

Key numbers

In-hospital CPR: about 1 in 6 survive≈ 15% to discharge

01 · What it isPOLST is a portable medical order

POLST is a portable medical order signed by a health care professional after a goals-of-care conversation, for serious life-limiting illness or advanced frailty; EMS can act on it — an advance directive is not an order.

02 · The ruleSurrogate order: agent, then default hierarchy

Without capacity, the agent named in the durable power of attorney decides; with no agent, state default-surrogate law usually ranks spouse or domestic partner, adult child, parent, sibling, then other relatives or a close friend.

03 · The ruleDNR withholds only CPR

A DNR (DNAR) order withholds only resuscitation; antibiotics, dialysis, ICU care and symptom management are still given or withheld by the patient's goals — never use code status as a proxy for other treatment limits.

The rules

Know these

Surrogates decide by the patient's wishes must knowSurrogates use substituted judgment — what the patient would choose, from known wishes and values; when wishes are unknown, they decide by the patient's best interests, never by their own preferences.

POLST Section A: CPR yes or noPOLST Section A applies when the patient has no pulse and is not breathing: YES CPR (attempt resuscitation, which requires Full Treatments in Section B) or NO CPR (any Section B option).

POLST Section B: full, selective or comfortPOLST Section B applies with a pulse or breathing: Full Treatments (including intensive care), Selective Treatments (avoid ICU; noninvasive ventilation, antibiotics and IV fluids allowed), or Comfort-Focused Treatments (transfer only if comfort cannot be achieved).

POLST is voluntary and can be changedA POLST is always voluntary; a surrogate may agree to one for a patient who lacks capacity, and the patient or surrogate can change or void it at any time.

A capable patient overrides the agentWhile the patient retains decision-making capacity, the patient's own current decision controls — the health care agent and prior documents guide care only after capacity is lost.

Document advance directive status on admissionThe federal Patient Self-Determination Act requires hospitals and long-term care facilities to document prominently in the record whether the patient has an advance directive; obtain a copy and confirm it is current.

No surrogate: guardian, or ethics before DNRAn incapacitated patient with no surrogate needs a court-appointed guardian for ongoing decisions (emergency care proceeds on implied consent); consult the ethics committee before writing a DNR order for such a patient.

What it is

Core idea

Advance directive: living will plus health care proxy must knowAn advance directive is a legal document completed by a capable adult: a living will states treatment preferences; a durable power of attorney for health care names an agent (proxy). It usually activates when capacity is lost.

Diagnosis & monitoring

Work-up

In-hospital CPR: about 1 in 6 surviveSurvival to discharge after in-hospital CPR is roughly 15–25% in most studies (about 1 in 6); it is lower with non-shockable rhythms, metastatic cancer and dialysis, and survivors risk neurologic and functional decline.

Management

Orders

Code status: understanding, goals, then recommendDiscuss code status inside goals of care: ask what the patient understands and expects, explore values, then make a recommendation in plain language using the word "die" — never ask "Do you want everything done?"

Recommend against CPR when goals are comfortWhen the patient and clinician agree that death is approaching and the goal is comfort, CPR is not an appropriate intervention — recommend against it rather than offering it as a menu choice.

Offer a time-limited trial when prognosis is uncertainA time-limited trial uses a therapy (e.g., ventilation, dialysis) for a set period with prespecified markers of improvement; at the end, continue it, or withdraw and focus on comfort if goals are unmet.

Advance directive or POLST?

Commonly confused

What it is	Legal document (living will, health care power of attorney)
Who it is for	Any adult
Who completes it	The patient, while still capable
EMS can follow it	No
Surrogate can create it	No

More detail

Reference

Show 7 reference facts

A living will usually applies only after incapacity plus a specified condition (terminal illness, permanent vegetative state or end-stage disease) is diagnosed, and it cannot compel medically unwarranted care.

If the agent seems to conflict with the living will, the power of attorney usually grants broad discretion, so written instructions guide rather than bind the agent; legal advice may be needed.

When several surrogates share the same priority (e.g., adult children), consensus is preferred; some states allow a majority decision, and persistent disagreement warrants an ethics consultation.

Confirm whether a DNR order stays in effect before surgery or other procedures with a known risk of cardiopulmonary arrest, and document the patient's choice.

POLST is no longer an acronym nationally and goes by state names such as MOLST, POST and MOST; only the state-approved form is valid in each state.

In most states a clinician caring for the patient cannot serve as the patient's health care agent, nor usually witness the patient's living will.

Patient choice is not limitless: clinicians need not provide treatment that is medically or ethically inappropriate, but should seek ethics consultation and help with transfer rather than unilaterally labeling care "futile".

Pearl

The advance directive speaks for the patient; the POLST gives the order; the DNR covers only CPR.

Sources · Merck Manual Professional — Advance Directives (Aug 2025) · Merck Manual Professional — Consent and Surrogate Decision Making (Aug 2025) · Merck Manual Professional — The Dying Patient (May 2026) · National POLST — POLST and Advance Care Planning (for professionals) · National POLST Model Form (2025) · National POLST — For Patients (what POLST is, who it is for) · National POLST — The National POLST Form (state-approved forms only) · AMA Code of Medical Ethics Opinion 5.4 — Orders Not to Attempt Resuscitation (DNAR) · Palliative Care Network of Wisconsin Fast Fact #23 — Discussing DNR Orders, Part 1 (2025) · Palliative Care Network of Wisconsin Fast Fact #179 — CPR Survival in the Hospital Setting (2025) · Palliative Care Network of Wisconsin Fast Fact — Time-Limited Trials for Serious Illness · AMA Code of Medical Ethics Opinion 5.3 — Withholding or Withdrawing Life-Sustaining Treatment · Starter sheet built from the verified AGACNP fact map (facts reviewed 2026-10-15).