Do-Not-Resuscitate (DNR) Orders and Physician Orders for Life-Sustaining Treatment (POLST)
The do-not-resuscitate (DNR) order placed in a patient’s medical record by a physician informs the medical staff that CPR should not be done in the event of cardiac arrest. This order has been useful in preventing unnecessary and unwanted invasive treatment at the end of life.
Physicians discuss with patients the possibility of cardiopulmonary arrest, describe CPR procedures and likely outcomes, and ask patients about treatment preferences. If the patient is incapable of making a decision about CPR, a surrogate may make the decision based on the patient’s previously expressed preferences or, if such preferences are unknown, in accordance with the patient’s best interests.
Living wills and durable powers of attorney for health care are not typically available in emergency situations and thus may be ineffective. Almost all states have specialized DNR protocols for patients who are living at home or in any nonhospital setting. These protocols typically require the signing of an out-of-hospital DNR order by both the physician and patient (or the patient’s surrogate) and the use of a special identifier (eg, a bracelet or brightly colored form) that is worn by or kept near the patient. If emergency medical personnel are called in case of emergency and see an intact identifier, they will provide comfort care only and not attempt resuscitation. These protocols are important to know because, normally, emergency medical technicians are not expected to read or rely on a living will or durable power of attorney for health care.
Many patients with advanced illness face heightened challenges in having their wishes respected not only with respect to CPR but with respect to any critical care decision. To provide better care planning for patients with advanced illness, most states have adopted, or are in the process of adopting, some version of a program commonly called Physician Orders for Life-Sustaining Treatment (POLST). Other names for the program have included Medical Orders for Life-Sustaining Treatment (MOLST), Physician Orders for Scope of Treatment (POST), and Medical Orders for Scope of Treatment (MOST). The programs follow a common paradigm but typically have somewhat different forms and policies. The most common criterion for qualifying as advanced illness in these programs is if the clinician would not be surprised if the patient were to die within the next year.
The POLST process is initiated by health care providers and results in a set of medical orders that is portable across all health care settings and addresses CPR, along with overall goals of treatment (comfort care only, full curative treatments, or limited treatments in between) and other critical care decisions, such as the use of artificial nutrition and hydration. These programs can help physicians best honor their patients' wishes regarding goals of treatment and help ensure continuity across care settings.
POLST and similar programs do not exist in every state or community, but their development is spreading rapidly. A national POLST task force provides a clearinghouse at www.polst.org.