Advance Directives, DNR, POLST

A patient 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.

Advance directives are legal documents completed by a competent adult that communicate healthcare wishes when the patient can no longer speak for themselves. The three main types tested on NCLEX are the living will, durable power of attorney for healthcare (DPOA-HC), and Do Not Resuscitate (DNR) orders. A living will specifies which treatments the patient does or does not want (ventilators, tube feeding, CPR) but only activates when the patient is terminally ill or permanently unconscious. A DPOA-HC designates a specific person — the healthcare proxy — to make decisions when the patient lacks capacity; it covers any medical situation, not just end-of-life. A DNR is a provider order, not a patient document — it must be signed by a provider to be actionable. POLST (Physician/Provider Orders for Life-Sustaining Treatment) converts a patient's wishes into portable medical orders covering CPR status, level of intervention, and artificial nutrition. Unlike a living will, POLST is immediately actionable by EMS and transfers across care settings. The nurse's role is to verify that documents are completed, on the chart, and accessible — not to witness the signing in all states (check facility policy). Nurses advocate by ensuring the patient understands the documents and that the healthcare team honors them. A patient can revoke or change any advance directive at any time while competent, verbally or in writing.

Key Distinctions

Don't confuse a living will (patient document, activated only in terminal/permanent unconscious state) with a POLST (provider order, immediately actionable in any setting). Students mix up DPOA-HC with general power of attorney — general POA covers finances, not healthcare decisions. A DNR requires a provider order; a family's verbal request alone does not constitute a valid DNR.

Clinical Pearl

No provider order, no DNR. A family saying 'don't resuscitate' is not the same as a signed DNR — without the order, you initiate CPR.