Overview

Advance directives are legal documents a competent adult completes to communicate healthcare wishes for a time when they can no longer speak for themselves. A living will is a CLIENT document stating which treatments are wanted or refused, but it activates ONLY when the client is terminally ill or permanently unconscious. A durable power of attorney for healthcare (DPOA-HC / healthcare proxy) names a SURROGATE decision-maker whose authority activates only when the client loses capacity — and it covers any medical situation, not just end-of-life. A DNR and POLST/MOLST are PROVIDER ORDERS: a DNR addresses CPR only, and a POLST converts wishes into portable orders (CPR status, level of intervention, artificial nutrition) that are immediately actionable by EMS and travel across care settings.

Interpretation

Two rules decide nearly every NCLEX item: a competent client's CURRENT wishes always override any prior directive or family objection, and a DNR limits CPR only — it never means 'do not treat.'

Advance directive document types

Living WillDPOA-HC / ProxyPOLST / DNR

What it isClient's written treatment wishesNamed surrogate decision-makerProvider-signed medical orders

When it actsTerminal or permanently unconsciousWhen client lacks capacityImmediately, any setting

ScopeTreatments wanted or refusedAny medical decisionCPR status and interventions

Actionable by EMSNoNoYes, travels with client

Living Will

What it is: Client's written treatment wishes
When it acts: Terminal or permanently unconscious
Scope: Treatments wanted or refused
Actionable by EMS: No

DPOA-HC / Proxy

What it is: Named surrogate decision-maker
When it acts: When client lacks capacity
Scope: Any medical decision
Actionable by EMS: No

POLST / DNR

What it is: Provider-signed medical orders
When it acts: Immediately, any setting
Scope: CPR status and interventions
Actionable by EMS: Yes, travels with client

During — Monitoring

Monitor

Verify directive is completed and on the chart

Confirm DNR is signed by a provider

Document directive status and surrogate contact attempts

Default to full code when no order is documented

Translate living will into actionable provider orders

Patient Teaching

Directive can be revoked verbally at any time while competent

Written revocation is not required

Proxy decides only when client cannot

Nurse facilitates choices, does not recommend specific treatments

Keep the directive accessible for emergencies

Report Nowescalate immediately

Arresting client with no code-status order on chart

Initiate CPR; default is full code

Competent client verbally revokes a DNR

Notify provider immediately to update code status

Family demands care that conflicts with valid directive

Escalate to provider and ethics consult

Ambiguous or contradictory code-status documentation

Clinical Pearl

No provider order, no DNR — a family saying 'don't resuscitate' is not a signed order, so you start CPR; and DNR limits CPR only, never 'do not treat.'

Advance Directives, DNR, POLST

Overview

Interpretation

During — Monitoring

Patient Teaching

A client arrives unconscious with no advance directive on file — the family disagrees about resuscitation. Knowing the legal hierarchy of these documents prevents you from being caught in the middle.

Key Distinctions

Clinical Pearl

Ready to practice this topic?