Advance Directive Legal Help:Living Wills, POLST, DNR Orders, and End-of-Life Planning

State-specific statutes. Many states have specific living will or natural death statutes. Federal Patient Self-Determination Act (1990) requires hospitals to inform patients.

Living will typically applies in specific medical situations: terminal illness with no reasonable medical probability of recovery, persistent vegetative state, end-stage condition. Specific conditions per state.

Cardiopulmonary resuscitation (CPR), mechanical ventilation, artificial nutrition (tube feeding), artificial hydration, dialysis, antibiotics, blood transfusions, surgery, comfort care. Specific preferences per individual.

Most living wills specify continuing comfort care including pain medication, even when other treatments declined. Hospice care often appropriate.

Catholic, Jewish, Muslim, and other religious traditions have specific guidance on end-of-life care. Living wills can address specific religious requirements.

Some states limit living will effectiveness during pregnancy. Specific state provisions affect treatment preferences during pregnancy.

Most states require: in writing, signed by declarant, witnessed by 2 witnesses (with specific witness restrictions in many states). Some require notarization. Specific state forms typical.

Many states restrict who can witness: not relative, not heir, not healthcare provider, not employee of healthcare facility. Specific state requirements.

Generally only when patient unable to make or communicate decisions. Healthcare providers determine inability based on medical assessment. Specific procedural requirements.

Healthcare providers generally must follow living will. Conscience clauses may allow individual providers to refuse but with transfer to compliant provider. Specific provider obligations.

Living will can be modified or revoked at any time during capacity. Methods: written revocation, oral revocation in presence of witnesses, physical destruction. Specific procedural requirements.

Critical: healthcare providers must have access to living will. Wallet card with location information. Provided to primary physician. Provided to family members. Some states have registries.

Do-Not-Resuscitate order. Medical order directing healthcare providers not to perform cardiopulmonary resuscitation if patient stops breathing or heart stops.

Within hospital setting. Order written in medical chart by physician based on patient or proxy decision. Effective during hospitalization.

Outside hospital (home, nursing home, ambulance). Specific state-authorized forms or wristbands. Effective in those settings. Different from hospital DNR which doesn't extend to other settings.

DNR addresses only CPR. POLST addresses CPR plus other interventions. POLST more comprehensive for seriously ill patients.

Patient's prognosis (survival likelihood with CPR, quality of life if survived). Patient's values and preferences. Family input. Patient often signs based on extensive medical information.

Survival to discharge after in-hospital CPR: approximately 17-20%. Survival to discharge after out-of-hospital CPR: approximately 8-10%. Lower survival in elderly and seriously ill. Specific factual considerations.

Terminal illness, advanced age with comorbidities, advanced frailty, patient preference based on values. Specific medical assessment. Not equivalent to giving up; just declining specific intervention.

Common misconception. DNR specifically about CPR. Other treatments continue: medications, comfort care, IV fluids if appropriate, surgery if appropriate, etc. Specific to patient's overall plan.

Patients with DNR orders often wear distinctive wristband (varies by hospital). Visible to all healthcare providers in emergency.

Some healthcare systems use 'AND' (Allow Natural Death) instead of DNR. More positive framing. Same medical effect. Specific institutional preference.

Patient can revoke DNR at any time during capacity. Specific procedural requirements. Healthcare providers update records.

Family members sometimes disagree with patient's DNR decision. Patient's autonomy generally controls if patient has capacity. Healthcare provider mediation available.

Critical: healthcare providers must have access. Best practice: copies to primary physician, family members, healthcare proxy. Wallet card with location. Some states have registries.

Out-of-state hospitalization. Most states honor out-of-state advance directives. Specific state law variations. Best practice: directives prepared for state of residence.

Review every 5-10 years. Plus after major life events: serious illness, family changes, religious or values changes. Update as needed.

Critical: discuss preferences with family and healthcare proxy. Surprise advance directives create family conflict. Explicit conversations about values and preferences.

Provider conscientious objection: must transfer patient to complying provider. Provider misinterpretation: clarify with provider, escalate within hospital. Persistent non-compliance: formal complaint.

Family disagreement with documented preferences. Patient's documented wishes generally control. Healthcare ethics committee available for assistance. Court intervention as last resort.

Advance directive effective only when patient unable to make decisions. Capacity determination: physician assessment. Specific procedural requirements vary by state.

Living will + healthcare proxy + POLST (if seriously ill) + DNR (if appropriate). Coordinated documents. Specific situations call for specific documents.

Specific concerns about mental illness and treatment. Mental health advance directive separate document. Specific state procedures.

Some religious traditions have specific guidance. Sample directives from religious organizations available. Specific provisions reflecting religious values.

Common comprehensive advance directive form combining: healthcare proxy, living will, comfort preferences, family communications. Used in many states. Specific state acceptance varies.

Non-profit organization providing guidance on advance care planning conversations. Discussion frameworks. Useful resources for family communication.