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.
As part of care planning for seriously ill patients, physicians discuss with patients the possibility of cardiopulmonary arrest in light of their immediate medical condition, 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. Additionally, first responders are almost always required to initiate life support unless a valid DNR order or POLST form is in place and presented to them. All states have specialized DNR protocols or a POLST program for patients who are living at home or in any nonhospital setting. DNR 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.
Physician Orders for Life-Sustaining Treatment (POLST)
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), Medical Orders for Scope of Treatment (MOST), Clinical Orders for Life-Sustaining Treatment (COLST), and Transportable Physician Orders for Patient Preferences (TPOPP). The programs follow a common paradigm but 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 or two.
The POLST process is initiated by health care providers through discussions with the patient or surrogate about the patient’s current condition and goals of care. It 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 usually 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 organization provides a clearinghouse at www.polst.org.