POLST vs DNR

The plain difference, in one paragraph

A DNR answers one question: if my heart stops, should you try CPR? A POLST answers four or five: should you try CPR? should you intubate me if I can't breathe? should you take me to the hospital? should you give me antibiotics if I have a serious infection? should you feed me through a tube if I can't eat? POLST is intended for patients with serious illness or advanced frailty — not the general adult population.

POLST in detail

POLST began as a project in Oregon in the early 1990s and is now used, under one name or another, in most US states. Depending on the state it goes by: POLST, MOLST (Medical Orders for Life-Sustaining Treatment), POST, MOST, TPOPP, or COLST. The National POLST coalition maintains a state-by-state map of which form is legally recognised where.

A POLST form is filled out as a shared decision between the patient (or the patient's legal surrogate) and a physician, nurse practitioner, or physician assistant. The signing clinician's authority is what makes it a medical order, not a wish list — EMS, ER, and hospital staff are legally required to honour the orders, subject to state-specific scope.

POLST forms typically cover:

• Section A: CPR — attempt resuscitation, or do not attempt resuscitation. This is the section that overlaps with a stand-alone DNR.
• Section B: Medical interventions — full treatment (everything including ICU/ventilator), selective treatment (hospital and IV care but no ICU), or comfort-focused care (treat symptoms without aggressive intervention).
• Section C: Artificially administered nutrition — long-term feeding tube, trial period, or none.

POLST is intended to travel with the patient. The original brightly coloured paper form goes from home to ambulance to ER to ICU and back home if the patient is discharged. Many states have electronic POLST registries the EMS can query as a backup.

DNR in detail

A do-not-resuscitate order, in the strictest sense, instructs clinicians not to attempt CPR (chest compressions, defibrillation, intubation for the specific purpose of restoring spontaneous circulation) if the patient's heart stops. DNRs exist in two main flavors:

• In-hospital DNR: an order written in the patient's hospital chart by their attending physician. Effective only during that hospital admission. The most common type.
• Out-of-hospital DNR (OOH-DNR): a state-specific form, typically signed by a physician, that EMS responders honour at the scene of an emergency. Required because the default EMS protocol when finding an unresponsive person is to attempt resuscitation; an OOH-DNR overrides that default. Available in most US states under varying names.

According to the American Medical Association's ethics guidance on DNR orders, a DNR addresses only resuscitation — it does not direct withdrawal of other care. A patient with a DNR still receives pain management, hydration, hospital admission, antibiotics, and so on, unless additional orders specifically limit those.

The wallet card and end-of-life documents

A wallet emergency card is not a substitute for either POLST or DNR. Neither form is legally enforceable in wallet-card form — the operative document has to be the signed original, often with state-specific colour-coding and identifying numbers.

That said, the wallet card can point to these documents and speed up the conversation:

• “POLST on fridge — comfort care only”
• “Out-of-hospital DNR — orange form, top drawer of bedside table”
• “Healthcare proxy: Sarah Smith, +1-415-555-0102”

For dementia patients, frail elderly, and people with terminal illness, a wallet line pointing to the document is essential because the patient often can't direct paramedics to it themselves. The fridge-card variant is even better because EMS are explicitly trained to check the refrigerator and the front of the fridge is where most POLST forms end up.

Common misconceptions

• “DNR means do nothing.” No. DNR means do not attempt CPR if the heart stops. The patient still receives all other treatment unless additional orders specify otherwise.
• “A POLST is the same as a living will.” A living will (advance directive) expresses wishes for hypothetical future situations. A POLST is a present-tense medical order, signed by a clinician, that EMS and hospital staff must follow now.
• “Everyone should have a POLST.” POLST is for patients with serious or progressive illness — typically those a clinician would not be surprised to lose within the next year. It's not meant for healthy adults, who should rely on an advance directive instead.
• “A POLST overrides what the family wants in the moment.” Generally, yes — it's a medical order signed by the patient or their surrogate when they had decision-making capacity. Family wishes raised in the moment do not override it, though clinicians may pause to confirm intent.