DNR, DNI, DNH, POLST – The Alphabet Soup of Advance Directives

What is an Advance Directive?

Advance Directive is a broad category of legal medical instructions for your healthcare. A Living Will, Health Care Proxy (Durable Power of Attorney for Health), Do Not Resuscitate Order (DNR), Do Not Intubate (DNI), Do Not Hospitalize (DNH) and POLST are all types of advance directives. (Jump to Lessons Learned)

Advance directive – This document tells the medical community your wishes concerning medical treatments at end of life.

• Anyone 18 and older should have one, typically a living will and/or healthcare proxy, and it should be updated throughout your lifetime. An advance directive cannot be created by someone that has no decision-making ability or is developmentally disabled.
• These are not a good in an emergency. EMT’s can’t take the time to read or evaluate these long, multi-page documents. Once emergency personnel have been called, they must do what is necessary to stabilize a person for transfer to a hospital. They do not have to honor living wills or healthcare proxy. Source: Caring Info
• Advance directives can and do get lost in hospitals. Keep the original and give a copy to the hospital. It is supposed to stay with your hospital chart, but as your chart grows, it may rest with an earlier admission to the emergency room and not get passed to ICU etc.

Living Will – This document allows you to approve or decline certain types of medical care if you are unable to make decisions and choices on your own. In most states living wills take effect only under circumstances such as terminal injury or permanent unconsciousness.

• Five Wishes – Written in everyday language, it was created by the non-profit Aging with Dignity and is best used as a conversation starter with loved ones. It approaches the end of life conversation in a non-threatening way by including questions on music or readings you might want to have at a service after you have passed. It can be downloaded from the internet, but check that Five Wishes is recognized in your state.

Healthcare Proxy (Durable Power of Attorney for Healthcare) – In this document, you name a person to be your proxy (agent) and make your healthcare decisions if you are not able to do so. Your proxy can speak on your behalf and make decisions according to directions you gave earlier. The law does not allow the agent to be a doctor, nurse, or other person providing healthcare to you unless it is a close relative.

Do Not Resuscitate – This hospital order means that if you stop breathing or your heart stops, medical staff will not attempt to revive you by trying to re-start your heart and breathing. The attempt to resuscitate after death is very hard for the frail, older adult who usually winds up with rib fractures and punctured lungs.

• The DNR must be signed by the doctor.
• There are several types of DNR forms:
  • DNR-A status indicates comfort care only; the comfort care order set should be completed routinely for all DNR-A patients. It is used to allow natural death to occur.
  • DNR-B status implies some active medical care is being continued
  • An “Out of Hospital DNR” order is for outside the hospital; in an ambulance or at home, for example.
• Any DNR is only good for the environment in which it was created (e.g. hospital). If you move from another facility (e.g. nursing home), back to the hospital, you must redo the DNR for each treatment setting.
• Some hospitals require a new DNR order each time you are admitted. If you are hospitalized, ask if a new one is required.
• A DNR is not good if you are in an ambulance transport to another facility. If you code on the ride, EMT’s will do a full treatment unless you have given them a DNR and the hospital decides to accept it.

Do Not Intubate (DNI) and Do Not Hospitalize (DNH)– these are two more legal documents that give you control over your medical decisions.

• Like the DNR, these documents are only good for the environment is which it was created. They are not portable documents.

How is the POLST form different from other end of life documents?
The POLST form is a medical order that must be followed always, in all places. These actionable medical orders complement your Advance Directive and Living Will. Doctors that follow the directions of the POLST form in good faith are protected from liability by the POLST law itself, while doctors and others that willingly ignore POLST directions will face consequences, both legal and professional. Unlike the Advance Directive the POLST form does not require the patient to have lost their decision-making process. There is no age limit on the POLST and it applies immediately. Unlike the DNR, the POLST form is portable across settings.

Lessons Learned:

• Have these medical documents readily available in case of emergency: Medication list, POLST form and Advance Directives in a plastic bag that is attached by a magnet to your refrigerator. Having them in one place means you can easily bring them with you in an emergency.
• Create an electronic copy of all these documents so you can email them from your phone and have the hospital print it out.
• This website walks you through five steps to help think through your wishes for your health care. Using questions and videos it helps you share this with your family and friends and have the conversation with medical providers. Prepare for your care
• Your Live Your wishes is a program on this website Your Life Wishes that gives you easy steps to think through and ways to have conversations with your loved ones on about your medical wishes.
• An easy to understand explanation of advance directive and living wills. Source: Follow the Money

Disclaimer: The material in this blog is for educational purposes only. It is not intended to replace, nor does it replace, consulting with a physician, lawyer, accountant, financial planner or other qualified professional.

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With thanks to my collaboration partner Jon Sugarman, BSN, MSN – Adult/Geriatric Care, DPN, Certificate, Psychiatric/Mental Health Nursing
Jon’s work in every setting is based on his mission: “to improve and protect the health of older patients for the purpose of maximizing the quality of their lives.”