POLST vs. DNR vs. advance directive What each one does, and which your family actually needs

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An advance directive is a legal document any adult can complete ahead of a crisis. A POLST is a physician's order for someone seriously ill that travels with the patient. A DNR covers CPR only, and can sit inside either.

Families usually meet all three names at once, often on a bad day, in a hospital hallway or at a kitchen table covered in discharge paperwork. The names get used as though they mean roughly the same thing, though each is signed by a different person, activates at a different moment, and carries a different weight when a nurse or paramedic has to act fast. Getting them confused is how a patient's actual wishes go unfollowed. It is also how a form meant to protect someone sits unread in a drawer while the ambulance is already on its way.

The three documents, explained

Advance Directive

An advance directive is a legal planning document, not a medical order. Any adult with decision-making capacity can complete one, whether they are healthy or already ill. It does two things at once. It records general preferences about medical treatment, sometimes called the living will portion. And it names a healthcare agent, a role every state's law recognizes under one name or another, who can decide on the person's behalf once they cannot decide for themselves.

The defining feature of an advance directive is timing. It activates only after the person loses decision-making capacity, and until that point it sits in the background while the person remains fully in charge of their own care. A National Institutes of Health clinical reference puts it plainly: taking effect "usually requires the assessment and declaration of 2 physicians," though it adds that state laws on this vary.

Requirements vary by state, because it is a legal instrument, not a medical form. CaringInfo, a program of the National Alliance for Care at Home, states plainly that "the states vary in their requirements for witnesses, notarization and other specifics." Its state-by-state library confirms most states require either two witnesses or notarization, sometimes both. Free, state-specific forms are downloadable at CaringInfo's advance directive library, and some states now allow the form to be notarized online.

An advance directive signed in one state does not automatically work everywhere. CaringInfo's own guidance is direct about the gap: "one state's advance directive does not always work in another state." Some states honor an out-of-state document only if it is similar enough to their own law, it notes. A parent who splits the year between two states may need a form for each one, not just the one where they happen to live most of the year.

An advance directive is the right starting point for most adults, including ones who feel completely healthy right now. For what the document contains and how to put one in place, see our guide on what an advance directive is and why your parent needs one, and on starting the conversation itself, our guide to talking with a parent who avoids the end-of-life conversation.

POLST (Physician Orders for Life-Sustaining Treatment)

A POLST is a signed physician order, not a planning document. It is completed together by a patient, or their surrogate, and a physician, nurse practitioner, or physician assistant. Because a clinician signs it, emergency responders can act on it directly, without stopping to interpret what a general preferences document might mean in the moment.

POLST is built for people who are already seriously ill or in advanced frailty. A University of Washington caregiving resource center describes that group simply as those "in very poor health, regardless of their age," adding that "most people are too healthy to need a POLST." A healthy adult planning ahead still wants an advance directive first. The same resource is explicit that a POLST "complements an advance directive and is not intended to replace" one, since the directive is still what names a legal decision-maker.

A POLST form typically addresses:

• CPR preference, attempt resuscitation or do not, which is the section that functions as a DNR order
• Level of hospital treatment, from full intervention down to comfort-focused care in place
• Antibiotics and IV fluids, and whether to use a ventilator if breathing needs support
• Medically assisted nutrition, whether to use a feeding tube if the person can no longer eat

A POLST is meant to travel with the patient. It stays with them in a hospital, nursing home, or assisted living record, and at home it belongs somewhere a paramedic would look, commonly a table near the bed or the refrigerator door. That portability is the entire design goal: the orders follow the person, not the building they happen to be in.

State-by-state name variations

It would be tidy to say every state settled on one of three or four names for this form. That is not quite right. The National POLST Collaborative's own program map lists at least ten state variants of the same underlying document. The organization has also updated how it describes itself, without fanfare: its current materials say the name "POLST" has "evolved to stand for 'portable medical order,'" a broader phrase than the original Physician Orders for Life-Sustaining Treatment. The paperwork changed shape a little even while this article was being checked against the source.

• POLST, used in most states, including California, Oregon, Washington, and Colorado
• MOLST (Medical Orders for Life-Sustaining Treatment), New York and Maryland
• MOST (Medical Orders for Scope of Treatment), North Carolina and several others
• POST (Physician Orders for Scope of Treatment), Tennessee and West Virginia
• Other state-specific names, including TPOPP, COLST, DMOST, and IPOST, in the states that adopted their own label

The National POLST Collaborative's state map is the fastest way to confirm the current form and name in a given state, and to find state leadership contacts. If a parent has a form from one state and moves to another, ask the new state's physician to review it and reissue it in the local format rather than assuming it still applies as written.

DNR (Do Not Resuscitate)

A DNR is a specific physician order instructing emergency responders and medical staff not to attempt CPR if the person's heart or breathing stops. It addresses exactly one decision: resuscitation, yes or no.

A DNR is a subset of what a POLST covers. When a physician completes a POLST with a patient, the CPR section of that same form functions as the DNR order. That is why the National POLST patient guide describes "No CPR" in that section as, in effect, a do-not-resuscitate order. A standalone DNR is also possible: a patient can request one without completing a full POLST, per the National POLST patient guide to the form.

A DNR does not mean "withhold care." It has no bearing on pain management, antibiotics, surgery after an injury, or any other form of treatment. It governs the act of CPR and nothing else. Families sometimes read a DNR as a decision to provide no care at all. That reading is not accurate, and it is worth saying out loud to whoever else in the family will see the form.

Like a POLST, a DNR needs a physician's signature. The same NIH clinical reference states that in most states, a signed DNR is the only advance directive EMS providers are legally required to honor. A line in an advance directive that says "I do not want CPR" states a wish. It becomes an order emergency responders must follow only once a physician issues the actual DNR.

Side-by-side comparison

When each document is appropriate

Advance directive: any adult planning ahead

An advance directive fits any adult who wants their medical wishes on record before a crisis forces the question. That includes healthy adults in their 40s and 50s, not only people who are already older. It is especially worth doing soon after a serious diagnosis, an early dementia finding, or a family history of sudden illness. The window to complete it while capacity is fully intact can close faster than a family expects, and an estate planning attorney can bundle an advance directive in with a will and any trusts.

A hospital admission is another practical opening: some intake teams walk patients through the paperwork on the spot, which is a low-effort way to get it done if a parent is already sitting in the waiting room anyway.

POLST: for someone seriously ill

A POLST becomes relevant once a person has a serious, progressive illness or advanced frailty. It is the document that turns an advance directive's general wishes into specific, signed orders that travel with the patient into any care setting.

A physician, nurse practitioner, or physician assistant starts the POLST conversation, not the family. If a parent's diagnosis fits, raising the topic with the treating doctor or a hospice or palliative care team is one of the more consequential things a family can do. Our guide on what to expect from hospice care at home covers how that team fits into the picture once someone qualifies.

DNR: for one specific decision about CPR

A standalone DNR fits when a patient, or their surrogate, has clearly decided against CPR if the heart or breathing stops. This applies in a hospital, a nursing facility, or at home. At home, the DNR, or the CPR section of a POLST, needs to be somewhere EMS can find it, not filed away in a cabinet in another room.

What happens when documents conflict

Conflicts happen more often than families expect. A parent might have an advance directive from years ago stating "no heroic measures," alongside a newer POLST requesting full intervention because their outlook changed after a recovery. Or a POLST gets updated at a hospital visit without anyone telling the healthcare agent named years earlier in the advance directive.

There is no single federal rule that untangles every version of this conflict; state law and a given hospital's own policy both play a role. What is consistent follows directly from what each document is. A signed physician order such as a POLST or DNR is what emergency responders act on in the moment, since responders cannot pause mid-emergency to interpret a general advance directive the way a healthcare agent could.

The more reliable fix is prevention: review every document together, ideally with the treating physician, whenever health status changes in a meaningful way. Confirm the advance directive, any POLST, and the named healthcare agent all point in the same direction, and make sure the agent is holding current copies of everything, not the version from three years ago.

Where to get each document

• Advance directive: Free, state-specific forms through CaringInfo's advance directive library, or through a hospital patient advocate, a palliative care team, or an estate planning attorney.
• POLST / MOLST / MOST / POST: Completed with, and signed by, a licensed physician, nurse practitioner, or physician assistant. The treating doctor or a hospice or palliative care team starts this conversation; the National POLST state map lists the form and program for a specific state.
• DNR: Issued by a physician. In a hospital or nursing facility, ask the care team directly. For a home DNR, the primary care physician or a specialist can issue it; some states require EMS providers to attempt resuscitation unless the family produces a state-approved advance directive document.