Eduovisual
Ethics, Communication & Professionalism
Do-not-resuscitate and POLST/MOLST orders
— DNR/DNAR (Do Not Resuscitate/Attempt Resuscitation): a physician order in the medical record that withholds CPR and ACLS in the event of cardiopulmonary arrest. Does NOT limit any other treatment (antibiotics, ICU, dialysis, pressors, intubation for non-arrest indications) unless separately specified.
— DNI (Do Not Intubate): separate order; a patient can be DNR-but-OK-to-intubate, or full code but DNI (uncommon, must be clarified).
— POLST/MOLST (Physician/Medical Orders for Life-Sustaining Treatment): a portable, signed medical order that travels with the patient across care settings (home, SNF, ED, hospital). Addresses CPR, level of medical intervention (full/selective/comfort), artificial nutrition, and sometimes antibiotics.
— Advance directive / living will: a legal document expressing patient preferences; it is not an active medical order and does not bind EMS.
— Any serious or life-limiting illness: metastatic cancer, NYHA III–IV heart failure, GOLD D COPD, ESRD, advanced dementia, ALS, cirrhosis MELD ≥15.
— Admission to ICU, before high-risk surgery, at SNF/LTC admission, on hospice referral, after a sentinel decline (fall with fracture, recurrent aspiration, weight loss).
— Age alone is not an indication; functional trajectory and prognosis are.
— The primary/attending physician with the longitudinal relationship is preferred; do not defer entirely to consultants or trainees for goals-of-care framing.
— Elderly patient with advanced dementia, recurrent aspiration pneumonia, admitted from SNF — family asks "what should we do?"
— Patient with metastatic pancreatic cancer presenting to ED with hypotension; chart shows outpatient POLST marked Comfort Measures Only.
— Post-op patient with prior DNR who is now arresting from a reversible intraoperative cause.
— Adult child requesting "do everything" while patient (capacitated) wants comfort-focused care.
— Patient's values and goals, not procedures first. Ask: "What gives your life meaning? What would be an unacceptable outcome?" before "Do you want chest compressions?"
— Understanding of current illness and prognosis — correct misconceptions (e.g., CPR success on TV ~70%; real in-hospital survival to discharge ~17%, far lower in metastatic cancer/multiorgan failure: 0–5%).
— Prior advance directive, healthcare proxy/durable power of attorney for healthcare (DPOA-HC), existing POLST.
— Religious, cultural, and family decision-making norms.
— Decision-making capacity at this moment for this decision.
— Reframe (status has changed), Expect emotion, Map values, Align, Plan.
— Make a recommendation based on values — do not present resuscitation as a neutral menu ("Given what you've told me, I'd recommend we focus on comfort and not attempt CPR").
— Communicate a choice
— Understand the relevant information
— Appreciate how it applies to oneself
— Reason through options consistent with stable values
— Capacity is decision-specific and time-specific: a patient may have capacity to refuse CPR but not to manage finances.
— A psychiatric diagnosis, intoxication, or dementia label does NOT automatically remove capacity.
— Higher-stakes/irreversible decisions warrant a more rigorous capacity assessment ("sliding scale").
— Competence is a legal determination made by a court.
— Capacity is a clinical determination made at the bedside by any physician.
— 1) Court-appointed guardian (if exists)
— 2) Durable power of attorney for healthcare (DPOA-HC / healthcare proxy) — patient-designated; trumps family
— 3) Spouse (or domestic partner where recognized)
— 4) Adult children (majority rule typical)
— 5) Parents
— 6) Adult siblings
— 7) Other relatives / close friend familiar with values
— Exact order varies by state statute — Step 3 tests the principle, not state-specific minutiae.
— Expressed wishes > substituted judgment (what would the patient want?) > best interest (only if values truly unknown).
— Section A — CPR: Attempt resuscitation vs Do Not Attempt Resuscitation. Only applies when patient has no pulse and is not breathing.
— Section B — Medical Interventions: Full Treatment (all including intubation, ICU) / Selective Treatment (IV fluids, antibiotics, non-invasive ventilation; no intubation/ICU) / Comfort-Focused Treatment (symptom relief only; transfer only if comfort cannot be achieved in current setting).
— Section C — Artificially Administered Nutrition: long-term, trial period, or none.
— Signatures: patient (or surrogate) AND physician/APRN/PA — both required for validity in most states.
— Patients with serious illness or frailty for whom death within ~1 year would not be surprising.
— Not appropriate for healthy adults — they should use an advance directive instead.
— Brightly colored (often pink/green/lime) form; travels with the patient.
— Honored by EMS, ED, hospital, SNF, and home health.
— Supersedes prior conflicting advance directives for the issues it addresses.
— Review at every transition of care, major clinical change, or change in goals.
— A capacitated patient can void their POLST verbally at any time — document and reissue.
— "DNR" + "Full Treatment" = valid: aggressive care up to but not including CPR at arrest.
— "Attempt CPR" + "Comfort Only" = incoherent; must clarify with patient/surrogate before honoring either.
— Withholds CPR/ACLS at the moment of cardiopulmonary arrest only.
— Does not affect: antibiotics, IV fluids, surgery, ICU admission, dialysis, transfusions, vasopressors for pre-arrest hypotension, or intubation for respiratory failure.
— Separate order; permits BiPAP/HFNC/medical management of respiratory failure but no endotracheal intubation.
— Patient can be DNR + OK to intubate (e.g., reversible COPD exacerbation, wants ventilator support but no CPR).
— Increasingly used language; clinically synonymous with DNR but framed positively. Some institutions prefer it because "DNR" sounds like withdrawal of care.
— All interventions aimed at symptom relief; discontinues labs, vitals q-shift, non-comfort medications.
— Continues: opioids, antiemetics, anxiolytics, scopolamine for secretions, mouth care, repositioning.
— A Medicare benefit (and most private insurance) for patients with prognosis ≤6 months if disease runs its expected course, who elect to forgo curative therapy for the terminal diagnosis.
— Interdisciplinary team: MD, RN, social work, chaplain, aide, bereavement.
— Can be delivered at home, in SNF, or inpatient hospice unit.
— Patient may revoke at any time and return to standard care.
— Not prognosis-dependent; appropriate alongside curative/disease-directed therapy at any stage of serious illness.
— Private space, sit down, minimize interruptions (silence pager), invite family the patient wants present.
— Confirm who is in the room and their roles.
— Ask permission to discuss serious topics.
— Setting; Perception ("What's your understanding of where things stand?"); Invitation ("How much detail would you like?"); Knowledge (deliver prognosis honestly, in plain language, no jargon — "die" and "death," not "pass away"); Emotion (NURSE: Name, Understand, Respect, Support, Explore); Strategy/Summary.
— Avoid menu-style ("Do you want CPR? Pressors? Dialysis?") — overwhelms and shifts burden.
— Use values → recommendation: "Based on what you've told me about wanting to be at home and not on machines, I recommend we focus on comfort and not attempt CPR or ICU care. How does that sound?"
— Active code status order in EHR (Full Code / DNR / DNR-DNI / CMO).
— Note capturing: who was present, capacity assessment, patient's stated values, prognosis discussed, recommendation made, decision reached, plan to revisit.
— Update POLST if outpatient/transitions-of-care relevant.
— At every major clinical change, transfer (ED→floor→ICU→SNF), and at least at each admission.
— Code status does not auto-renew across admissions in many systems — verify on every admission.
— Federal law requiring Medicare/Medicaid-participating hospitals, SNFs, home health, hospice, and HMOs to:
— Ask every adult at admission whether they have an advance directive
— Provide written information on the right to accept/refuse treatment and to execute an advance directive
— Document presence of advance directive in the chart
— Not discriminate based on presence/absence of one
— Does not require patients to have an advance directive — only that they be asked and informed.
— Karen Ann Quinlan (1976): Right of surrogates to withdraw life-sustaining ventilation; established substituted judgment.
— Nancy Cruzan (1990, SCOTUS): States may require clear and convincing evidence of an incompetent patient's wishes to withdraw life support; affirmed competent adults' constitutional right to refuse treatment, including nutrition/hydration.
— Terri Schiavo (2005): Underscored value of explicit advance directives and designated proxies to prevent intra-family conflict.
— Legally and ethically equivalent. Not starting a ventilator and stopping one already in use carry the same moral weight. Clinicians often feel them differently — a key teaching point.
— Legally considered a medical treatment, not basic care, in the US; can be refused or withdrawn like any other intervention.
— Legal in select US states (e.g., OR, WA, CA, CO, VT, NJ, NM, ME, HI, NY for limited contexts — varies); requires capacitated adult, terminal illness with ≤6-month prognosis, multiple requests, waiting period, self-administration.
— Distinct from euthanasia (clinician administers), which is illegal throughout the US.
— A capacitated patient's wishes prevail over family objections — full stop. Document capacity carefully.
— Engage family with empathy: their grief is real even if not decisional.
— Identify the legally appropriate surrogate (DPOA-HC > statutory hierarchy).
— When co-equal surrogates (e.g., multiple adult children) disagree: facilitate family meeting, social work, chaplain, ethics consult.
— Restate the substituted judgment standard: "We're not asking what you want — we're asking what she would want."
— Explore meaning. Often = "don't abandon us," "we're not ready," religious obligation, mistrust.
— Time-limited trials: "Let's try the ventilator for 72 hours. If she's not improving, we'll meet again and reassess." Concrete, measurable, with a decision point.
— Clinicians are not obligated to provide treatments that cannot achieve a physiologic goal (e.g., CPR in refractory multiorgan failure).
— Multi-step process: second opinion → ethics consult → palliative care → transfer offer → unilateral DNR only after institutional process followed.
— Nurse or trainee feels current plan prolongs suffering: validate, escalate via ethics consult, palliative care.
— Conscientious objection: a clinician may decline to personally participate in a legal intervention they find morally objectionable, but must not abandon the patient — arrange transfer of care.
— Available 24/7 at most institutions. Free, voluntary, advisory (not binding).
— Appropriate when: surrogate disputes, capacity unclear, futility concerns, moral distress, suspected coercion.
— Mild dementia does not automatically eliminate capacity. Assess decision-specifically.
— Simplify language, use teach-back, allow time, involve family for support (not for the decision unless patient lacks capacity).
— Reassess capacity over multiple visits when feasible — fluctuating in delirium, sundowning.
— Window of opportunity: do it early, while patient can articulate preferences and complete POLST/DPOA-HC.
— Document trigger points: "If I can no longer recognize my children…" or "If I require feeding tube placement…"
— AGS and multiple society guidelines: PEG tubes do not improve survival, prevent aspiration, heal pressure ulcers, or improve quality of life in advanced dementia.
— Recommended approach: careful hand feeding, comfort-focused. Counseling families on this is a Step 3 favorite.
— Clinical Frailty Scale, gait speed (<0.6 m/s), unintended weight loss, recurrent hospitalizations, falls — all prognostic.
— In-hospital CPR survival to discharge in frail elderly with multimorbidity: often <5%.
— POLST should accompany every transfer. Reconcile on arrival.
— Many states require POLST review at SNF admission and annually.
— Minors generally cannot consent or refuse, but assent (developmentally appropriate agreement) should be sought from school-age children and adolescents.
— Parents are surrogates using best-interest standard.
— Mature minor doctrine (state-dependent): some adolescents may consent to specific care (STI, contraception, mental health, substance use) without parental involvement.
— Emancipated minors: married, military, court-declared, sometimes pregnant/parenting — full decisional rights.
— Parental refusal of life-saving treatment (e.g., transfusion in a child with leukemia): override via court order; physician obligation is to the child.
— Several states have "pregnancy exclusion" clauses in advance directive statutes that may invalidate a DNR/withdrawal request during pregnancy — controversial, evolving.
— A capacitated pregnant patient retains the right to refuse treatment for herself; conflicts with fetal interests are ethically and legally complex — involve ethics and legal early.
— Default automatic suspension of DNR for surgery is outdated and inappropriate.
— Required reconsideration is the standard (ASA, ACS): the surgeon/anesthesiologist must discuss with the patient whether to:
— Suspend DNR fully for OR
— Maintain DNR
— Use goal-directed approach (resuscitate only reversible, anesthesia-induced events)
— Document the agreed-upon plan; resume original DNR at a defined postop time point.
— Discuss only after death is declared/imminent and code status is settled. Typically initiated by organ procurement organization (OPO), not the treating team — preserves trust and avoids conflict of interest.
— Unwanted CPR in dying patients: rib fractures, sternal fractures, aspiration, ICU stays, prolonged dying — all without meaningful survival benefit in metastatic/end-stage disease.
— Undertreatment of DNR patients: misinterpretation of DNR as "do not treat" leads to omitted antibiotics, withheld pain control, exclusion from interventions that could relieve symptoms or reverse acute issues. This is a well-documented quality problem.
— Delayed palliative care consultation correlates with more aggressive end-of-life care, higher cost, lower family satisfaction, and shorter survival in several malignancies (e.g., metastatic NSCLC — Temel trial).
— Code status not reconciled at admission → SNF resident receives unwanted CPR on arrival to ED.
— POLST lost in transfer; default-to-full-code applied.
— Code status documented in a note but not as an active order → bedside team performs CPR.
— Verbal-only DNR not co-signed → not legally binding in some jurisdictions.
— Complicated grief, PTSD in ICU family members (post-intensive care syndrome–family, PICS-F), particularly after witnessed CPR or contested decisions.
— Mistrust of the medical system when conversations are rushed, jargon-heavy, or delayed to the crisis moment.
— Liability is higher for unwanted treatment delivered against documented wishes than for withholding treatment per a valid order.
— Failure to honor a valid POLST can violate state law.
— Indications: serious illness with symptom burden, complex goals-of-care needs, family conflict, prognostic uncertainty, prolonged ICU stay, repeated admissions, considering hospice.
— Early integration improves quality of life, reduces aggressive end-of-life care, and in some cancers extends survival.
— Prognosis ≤6 months if disease runs expected course, patient/surrogate agrees to forgo curative therapy for the terminal diagnosis.
— Triggers: hospice-eligible diagnoses (advanced cancer, ESRD off dialysis, NYHA IV HF on max therapy, GOLD D COPD with recurrent admissions, advanced dementia FAST stage 7, ALS).
— Don't wait for "days left" — median hospice stay in the US is ~17 days; ≥30% enroll in last week of life, missing benefit.
— Surrogate disputes, suspected coercion, capacity ambiguity, conscientious objection conflicts, requests for non-beneficial treatment, withdrawing life-sustaining therapy when team is divided.
— Court orders sought for: pediatric life-saving treatment refused by parents on non-religious or religious grounds where best-interest standard supports treatment; guardianship petitions for incapacitated patients without surrogates ("unbefriended patient").
— Spiritual distress, cultural needs, family system support, post-acute placement, advance directive completion at bedside.
— Many institutions require a second attending's concurrence to declare a treatment "medically inappropriate" and write a unilateral DNR — know your local policy.
| • Advance directive (umbrella term) | ||
| — A written legal document expressing future healthcare preferences if the patient loses capacity. | ||
| — Two main components: living will and DPOA-HC. | ||
| • Living will | ||
| — Specifies which treatments the patient would accept or refuse in defined scenarios (e.g., persistent vegetative state, terminal illness). | ||
| — Limitations: hypothetical, may not match actual clinical scenario, requires interpretation, not a medical order — does not directly bind EMS or floor teams. | ||
| • Durable Power of Attorney for Healthcare (DPOA-HC) / healthcare proxy | ||
| — Designates a specific individual to make healthcare decisions when patient lacks capacity. | ||
| — Generally preferred over living will alone — a human can adapt to unanticipated clinical scenarios; a document cannot. | ||
| — "Durable" = remains effective despite the principal's incapacity. | ||
| • Five Wishes | ||
| — A widely used, legally valid (in most states) advance directive document combining DPOA-HC, living will preferences, and personal/spiritual wishes in lay language. | ||
| • Comparison to POLST | ||
| Feature | Advance Directive | POLST/MOLST |
| Form | Legal document | Medical order |
| For whom | All adults | Seriously ill / frail |
| Who signs | Patient (± witness/notary) | Patient AND clinician |
| Binds EMS | Generally no | Yes |
| Portability | Limited | Designed to travel |
| Scope | Preferences for hypothetical future | Orders for now |
| • Key distinction: Every adult should have an advance directive. Only patients with serious illness should have a POLST. They are complementary, not interchangeable. | ||
| • Board pearl: When both exist and conflict, the POLST (more recent, more specific medical order) generally takes precedence for the issues it addresses — but always reconcile with the patient/surrogate. |
— Same elements: capacity, disclosure (diagnosis, proposed treatment, alternatives, risks/benefits, no-treatment option), voluntariness, understanding, consent/refusal.
— A capacitated patient can refuse any intervention — including CPR (DNR), intubation, transfusion (e.g., Jehovah's Witness adult), dialysis, ANH.
— Code status discussions may involve sensitive prognostic information; share with surrogates as appropriate, not necessarily extended family without permission.
— Autonomy: patient's right to direct their care (DNR/POLST honors this).
— Beneficence: acting in patient's best interest (recommending comfort care when appropriate).
— Non-maleficence: avoiding harm (unwanted CPR is harm).
— Justice: equitable access to advance care planning — minorities, low-SES, non-English-speakers are systematically less likely to have ACP. Address proactively.
— Administering opioids/sedatives to relieve suffering in a dying patient, even if it may secondarily hasten death, is ethical and legal when:
— Intent is symptom relief, not death
— Action itself is morally neutral or good
— Bad effect is not the means to the good effect
— Proportionality between benefit and risk
— Distinct from euthanasia — intent and proportionality differ.
— Use of sedation to relieve refractory symptoms at end of life; ethically accepted under double-effect reasoning when other measures have failed.
— Ensure POLST/MOLST is completed, signed by patient/surrogate AND clinician, and physically accompanies the patient.
— Document in discharge summary: code status, surrogate name and contact, DPOA-HC status, hospice/palliative enrollment.
— Communicate directly with receiving clinician (SNF medical director, PCP, hospice MD) — warm handoff reduces errors.
— Revisit goals at annual wellness visits (Medicare reimburses Advance Care Planning, CPT 99497/99498).
— Update with each major clinical change: new cancer diagnosis, hospitalization, functional decline.
— Confirm hospice election, primary diagnosis, level of care (routine home, continuous home, inpatient respite, general inpatient).
— Medications: discontinue non-symptom-directed drugs (statins, bisphosphonates, tight glycemic control, most anticoagulants depending on goals).
— Continue: opioids, antiemetics, anxiolytics, bowel regimen, mouth care.
— Address caregiver burden — refer to social work, respite resources, support groups.
— Anticipatory grief counseling, bereavement services (covered by Medicare hospice benefit up to 13 months post-death).
— Advance care planning documentation is a CMS quality measure.
— High-quality end-of-life care metrics: <10% receiving chemo in last 14 days of life, hospice enrollment >3 days before death, no ICU admission in last 30 days for terminal patients.
— Patient-level: revisit at admissions, ICU transfers, new metastases, hospice enrollment, change in functional status, new surrogate.
— Practice-level: maintain registries of seriously ill patients flagged for ACP; use EHR best-practice alerts.
— VitalTalk, Ariadne Labs Serious Illness Conversation Guide, Respecting Choices — evidence-based curricula proven to improve clinician communication.
— Communication is a trainable skill, not a personality trait — Step 3 endorses ongoing CME.
— Goal concordance (did care delivered match expressed wishes?), family satisfaction (FS-ICU), quality of dying and death (QODD) — used in QI.
— Black, Hispanic, and Asian-American patients are less likely to complete ACP/POLST, more likely to receive aggressive end-of-life care, less likely to enroll in hospice.
— Drivers: historical mistrust, communication barriers, religious/cultural values, clinician bias, access.
— Mitigation: culturally tailored conversations, language-concordant care or trained medical interpreters (not family), community partnerships.
— Code status order sets, banner displays of POLST/DNR, automatic re-verification prompts at transfer.
— Adverse event review: any CPR performed against documented wishes is a sentinel event requiring root cause analysis.
— Medicare covers ACP discussions (CPT 99497 first 30 min, 99498 each additional 30 min) — separately billable, even without face-to-face problem-oriented visit.
— Patients owe no copay when ACP is part of the annual wellness visit.
— A capacitated adult may refuse life-sustaining treatment for any reason or no reason — religious, idiosyncratic, or unexplained. The physician's role is to ensure the decision is informed and voluntary, not to agree with it.
— Even an "unwise" refusal does not negate capacity if the four elements are intact.
— Sudden POLST change at insistence of one family member with financial interest.
— Patient deferring all answers to a relative who interrupts or speaks over them.
— Inconsistent stated preferences across visits.
— Action: interview patient alone, involve social work, consider elder abuse screening and mandatory reporting if suspicion of exploitation. Elder abuse reporting is mandatory in nearly all US states for healthcare providers.
— Patient transferred from SNF to ED without POLST → resuscitated against wishes.
— Code status not re-entered as an active order on transfer from ICU to floor.
— Mitigation: mandatory code status order on every admission/transfer; structured handoff (I-PASS) including code status.
— A clinician who declines, on personal moral grounds, to participate in withdrawing a ventilator must:
— Inform the team
— Not impose personal beliefs on the patient
— Ensure timely transfer of care to a willing colleague — non-abandonment is non-negotiable.
— Suspected elder abuse, dependent adult abuse, or coercion uncovered during a goals-of-care discussion → report to Adult Protective Services per state law, even if the patient asks you not to.
— Verbal DNR orders should be co-signed within institutional time limits.
— Conflicting POLST sections must be reconciled before honoring — when in doubt, default to treatment and clarify urgently.
— In-hospital arrest, overall survival to discharge: ~17–25%
— Out-of-hospital arrest, survival to discharge: ~10%
— Metastatic cancer, in-hospital CPR survival to discharge: ~0–7%
— Advanced dementia, post-CPR meaningful recovery: vanishingly low
— Public perception (per TV/media): 60–75% — correct this misconception
— Capacitated patient's current spoken wishes > valid POLST > DPOA-HC decisions > living will > statutory surrogate hierarchy > best-interest determination
— DNR, DNAR, AND (Allow Natural Death)
— DNI (Do Not Intubate)
— POLST/MOLST/MOST/POST (state variants)
— DPOA-HC (Durable Power of Attorney for Healthcare)
— PSDA (Patient Self-Determination Act, 1990)
— ANH (Artificial Nutrition and Hydration)
— CMO (Comfort Measures Only)
— Bright pink (CA), green (OR), lime/lavender (varies) — designed to be visually obvious in the chart and on the refrigerator at home.
— "Would I be surprised if this patient died in the next 12 months?" — if no, initiate ACP/POLST conversation.
— Useful tool for families wanting "everything" — define endpoints (clinical, time-based) and decision points explicitly.
— Two physicians (attending + hospice MD) certify ≤6-month prognosis if disease runs expected course; patient elects to forgo curative therapy for terminal diagnosis.
— Legally and ethically equivalent — repeatedly tested.
— Does NOT prolong life, prevent aspiration, or improve quality of life. Hand feeding preferred.
— 72M with metastatic cancer, alert, oriented, says he wants DNR; daughter insists "do everything." Answer: honor patient's wishes, write DNR order, support daughter.
— SNF resident with valid signed POLST (DNR, Comfort Only) and an older living will requesting "all measures." Answer: POLST controls; it is the active medical order.
— Mild dementia patient refuses dialysis after thorough discussion, articulates values, demonstrates understanding. Answer: has capacity, honor refusal; do not override based on diagnosis alone.
— DNR patient scheduled for hip ORIF after fall. Answer: required reconsideration — discuss with patient/surrogate; do not automatically suspend.
— Family of advanced dementia patient with recurrent aspiration asks about PEG. Answer: counsel that PEG does not improve outcomes; recommend careful hand feeding, palliative care consult.
— Dying patient on hospice with severe dyspnea; nurse worried morphine might "hasten death." Answer: uptitrate morphine for symptom relief; intent is comfort, ethically appropriate.
— Incapacitated patient, no advance directive; estranged spouse vs devoted adult daughter disagree. Answer: spouse is the default surrogate (unless DPOA-HC designates otherwise or jurisdiction differs); engage ethics if conflict persists.
— Parents refuse life-saving transfusion for child on religious grounds. Answer: seek emergent court order; treat to save life. (Adult Jehovah's Witness with capacity: honor refusal.)
— DNR patient with pneumonia and sepsis. Answer: full antibiotics, IV fluids, admission, even ICU if goals align; DNR only affects response to cardiopulmonary arrest.
— EMS resuscitates SNF patient despite valid POLST (Comfort Only). Answer: redirect to comfort care, family meeting, incident report, QI review.
A DNR order limits only CPR at cardiopulmonary arrest; a POLST/MOLST is a portable, signed medical order that translates a seriously ill patient's goals into actionable instructions across all care settings — and both must be grounded in a capacity-informed, values-first conversation that is documented, revisited, and respected.