DNR, MOLST, and POLST Orders Explained

DNR stands for "Do Not Resuscitate." It is a medical order instructing that if your heart stops or you stop breathing, medical staff should not perform cardiopulmonary resuscitation (CPR)—chest compressions, medications, and defibrillation intended to restart your heart.

Many people misunderstand DNR. They think it means "do not treat" or "let the person die." Not true. A DNR order addresses only one specific scenario: cardiac arrest or respiratory arrest. It says nothing about whether you want antibiotics, IV fluids, pain medication, oxygen, or any other treatment. You can have a DNR order and still receive full medical care for pneumonia, infection, or broken bones.

Another misunderstanding: people fear that having a DNR means staff will ignore them or provide poor care. This is unfounded. Nursing homes are required to provide the same quality care to DNR patients as to non-DNR patients. The only difference is what happens if your heart stops.

Why the confusion? Because conversations about DNR often happen in crisis—when someone is already very ill—and the word "resuscitate" feels scary and final. Clear, calm conversation about what DNR actually means helps.

These three documents all communicate end-of-life wishes, but they serve different purposes and have different legal weight.

An advance directive is a general legal document where you write your healthcare wishes and values. It might say things like, "If I have irreversible dementia and cannot feed myself, I do not want artificial feeding" or "I value quality of life over length of life." Advance directives are broad and values-based but not always specific enough for immediate medical decisions.

A MOLST (Medical Orders for Life-Sustaining Treatment) or POLST (Physician Orders for Life-Sustaining Treatment)—the terms vary by state—is an actual medical order, typically on a specific brightly colored form, signed by a doctor. It translates your wishes into specific medical instructions: CPR Yes/No, artificial feeding Yes/No, hospitalization for acute illness Yes/No, antibiotics Yes/No. It is a medical order that travels with you—to the hospital, to the nursing home, in the ambulance.

POLST/MOLST originated to address a problem: advance directives sat in people's files unread when emergencies occurred. POLST/MOLST puts the actual medical orders in the open, often on a bright pink or yellow form that paramedics and hospital staff immediately recognize.

Simplified: Advance directive = your values written down. POLST/MOLST = doctor's specific medical orders based on those values.

A POLST/MOLST form typically presents four to six major decision categories:

CPR (Cardiopulmonary Resuscitation): Yes = attempt CPR if your heart stops. No = do not attempt CPR (this is the DNR choice).

Mechanical Ventilation: Yes = if you cannot breathe on your own, place you on a breathing machine. No = do not intubate; use comfort measures instead.

Hospitalization for Acute Illness: Full Treatment = admit to hospital for serious illness, aggressive intervention. Limited Intervention = admit only for comfort care. No = remain in nursing home, comfort care only.

Artificial Nutrition/Feeding Tube: Yes = use feeding tube if you cannot eat safely. Comfort Feeding Only = eat by mouth if possible, but do not place feeding tube. No = no artificial feeding at all.

Antibiotics for Infection: Yes = treat infections with antibiotics. Limited = antibiotics only for comfort (e.g., for urinary infection causing symptoms). No = no antibiotics; allow natural death from infection.

Comfort-Focused Care: Most POLST forms now include a section explicitly addressing comfort—pain relief, emotional support, spiritual care—as a value alongside or instead of life extension.

Each section presents your preference clearly so any medical provider who encounters the form immediately understands your wishes without ambiguity.

POLST/MOLST is not for everyone and not necessarily for someone young and healthy. It is appropriate when:

• You have a serious chronic illness (advanced cancer, end-stage COPD, advanced heart disease)
• Your doctor believes you have a reasonable chance of dying within the next year or two
• You have advanced dementia
• You are in a nursing home
• You are considering hospice or palliative care

The conversation should happen between you, your doctor, and ideally your healthcare proxy (if you have named one). Your doctor explains your current medical situation and prognosis, and then asks, "Given what might happen, what matters most to you?" Some people say, "I want every attempt to stay alive—do everything." Others say, "I want comfort and time with family, not aggressive machines." Neither answer is wrong; they reflect different values.

Completing POLST/MOLST is not about giving up or choosing to die. It is about clarifying what kind of medical care fits your values if your illness worsens. Someone might choose "Full Treatment CPR + Mechanical Ventilation + Hospitalization" and still have a MOLST form because they want clarity about their preferences.

Yes, absolutely. You can change your mind about any of these orders at any time, for any reason. You do not need permission or justification.

If you change your mind:

• Talk to your doctor, who will complete a new POLST/MOLST form reflecting your new wishes
• The new form is dated and signed by your doctor
• Old versions should be clearly marked as "revoked" or "superceded"
• Notify your nursing home, your healthcare proxy, your family—whoever has copies
• Do not just tell people verbally; ensure new written orders exist

Changing your mind is normal. You might complete a POLST saying "Comfort Care Only" when you first enter a nursing home, then change it to "Limited Intervention" after adjusting to facility life. You might authorize a feeding tube initially, then change your mind weeks later. These changes are respected.

POLST/MOLST forms are specifically designed to be portable. The idea is that the form follows you from place to place: from your home to the nursing home, from the nursing home to the hospital, in the ambulance with paramedics.

However, portability sometimes breaks down in practice. A nursing home might not share the form with the hospital. A hospital might initiate aggressive treatment before learning about a POLST. Paramedics might not look for the form in a home.

To maximize portability:

• Keep a copy on your refrigerator (many people tape it there so paramedics see it)
• Give a copy to your healthcare proxy and family members
• Ensure the nursing home scans it into the electronic medical record, not just files it in a chart
• Wear a medical alert bracelet or necklace stating you have a POLST/MOLST
• Tell your doctor, "If I am transported to the hospital, please ensure my MOLST comes with me"
• When moving from one facility to another, explicitly ask staff to transfer the form

Nothing guarantees 100% portability in an emergency. But these steps minimize the risk that your orders are lost or forgotten.

Once a POLST/MOLST form is signed by a doctor and placed in your medical record, it becomes a binding medical order. Nurses and doctors are required to follow it.

If you have a "No CPR" order and your heart stops, staff do not perform CPR—they provide comfort care. If you have "No Mechanical Ventilation" and you cannot breathe, they do not intubate; they give oxygen, manage breathing symptoms, but not mechanical ventilation.

Violating a POLST/MOLST order—performing CPR when DNR is ordered, for example—is serious. It is a violation of patient autonomy, potentially legal liability, and grounds for complaint.

However, enforcement can sometimes be imperfect. In a chaotic emergency, the wrong orders might be followed. A hospital might initiate aggressive treatment before locating the MOLST. This is why redundancy matters: multiple copies, healthcare proxy awareness, family alertness. If you see orders being violated, speak up immediately.

Ideally, much earlier than you think necessary. Here is the hard truth: the best time to discuss your treatment wishes is while you are healthy and can think clearly.

Many people wait until they are seriously ill or until admission to a nursing home. By then, they might be confused, in pain, or emotionally overwhelmed. They might hesitate to appear "negative" or "giving up" when discussing a MOLST. Conversations are harder when illness has already frightened someone.

Better timing:

• After your 50th birthday, start thinking about your values and talking with family
• After any serious health event—heart attack, stroke, major surgery—have the conversation with your doctor
• Before you enter a nursing home, complete an advance directive and ideally a POLST/MOLST
• If you have multiple chronic conditions (diabetes, heart disease, kidney disease), have the conversation now
• If you have named a healthcare proxy, sit down together and discuss your wishes—do not leave them guessing

These conversations are uncomfortable, but they become much easier and clearer when you are calm and healthy. And they prevent crisis decisions made under pressure when you are very ill.

Your wishes often evolve as your condition changes. Someone might want "Full Treatment" initially but change to "Comfort Care Only" after three months in a nursing home. Someone might be adamant about "No Feeding Tube" but reconsider if they develop treatable swallowing difficulty. This is normal and expected.

As your situation changes, talk to your doctor again. Discuss what you are experiencing—pain, decline in function, fear, acceptance, hope, exhaustion. Your doctor can explain what medical options exist given your new situation and help you decide if your previous POLST/MOLST still reflects your values.

When you change your wishes, new orders are written. Old ones are revoked. Your healthcare proxy and family should be notified. The nursing home should update its records.

Many people change their wishes toward comfort-focused care as they age or become more ill. Others maintain their preference for aggressive treatment. Both are valid. The goal is that your orders at any given moment reflect your current values, not decisions made months or years ago when circumstances were very different.