Advance Directives Guide: Living Wills, Healthcare Proxy, DNR Orders, and POLST Forms Explained
Advance directives are legal documents that capture your healthcare wishes when you can no longer communicate them yourself. For families navigating senior care, these documents are among the most important — and most commonly delayed — pieces of planning. This guide explains each type of directive, what they do and don’t cover, state-specific requirements, and how to put them in place.
Why Advance Directives Are Essential
Every year, families face urgent medical decisions — often in hospital hallways under enormous stress — without guidance from their loved one. Without advance directives:
- Medical teams default to aggressive intervention, regardless of the patient’s likely preferences
- Family members may disagree about what the patient would have wanted
- Courts may be required to intervene to appoint a legal guardian, a process that is expensive and slow
- Patients who would have chosen comfort-focused care may receive treatment they would have rejected
Advance directives remove the guesswork. They give medical teams clear authority, give families a decision framework, and give the patient the assurance that their wishes will be respected even if they cannot speak for themselves.
Document 1: Living Will (Healthcare Directive)
A living will is a written statement of your healthcare preferences if you become incapacitated and cannot make decisions. It typically addresses:
- Whether you want life-sustaining treatment (ventilators, CPR, feeding tubes) if you are terminally ill or in a persistent vegetative state
- Whether you want artificial nutrition and hydration
- Your preferences for pain management and comfort care
- Organ and tissue donation wishes
What a Living Will Covers and Doesn’t Cover
A living will applies to situations where you are unable to make decisions and have a terminal condition, end-stage illness, or persistent vegetative state (exact triggering conditions vary by state). It does not apply to everyday medical decisions made while you are competent.
Living wills describe preferences in narrative or checkbox form — they are a statement of wishes, not a medical order. Clinical staff cannot act on them directly in all situations, which is where a POLST form (discussed below) becomes important.
State-Specific Requirements
Living will laws vary significantly by state:
- Some states require two witnesses; others require notarization
- Some states prohibit certain individuals from serving as witnesses (beneficiaries, healthcare providers, relatives)
- Some states use specific statutory forms; others accept any written statement meeting basic requirements
- Some states combine the living will and healthcare proxy into a single “Advance Healthcare Directive” document
Use a form specific to your state. Resources: your state’s Department of Health, the National Healthcare Decisions Day organization, or Five Wishes (a nationally recognized document valid in most states).
Document 2: Healthcare Proxy (Healthcare Power of Attorney / Medical POA)
A healthcare proxy (also called a Healthcare Power of Attorney or Medical POA, depending on the state) designates someone — your “healthcare agent” or “proxy” — to make medical decisions on your behalf if you become incapacitated.
This is often the most important advance directive because:
- Medical situations are complex and unpredictable
- A living will cannot anticipate every scenario
- A trusted person who knows you can advocate for your values in real time
Choosing a Healthcare Proxy
Your proxy should be:
- Someone who knows your values and healthcare preferences deeply
- Willing to honor your wishes even under pressure from family, religion, or medical staff
- Available to respond quickly in an emergency
- Ideally not the same person responsible for financial decisions (to prevent conflicts of interest)
Common choices: spouse, adult child, sibling, close friend. Avoid naming your primary physician (conflict of interest) or multiple co-proxies (creates confusion in urgent decisions).
Scope of Authority
Your proxy can make decisions about:
- Consent for surgery, medications, and procedures
- Withdrawal or limitation of treatment
- Discharge planning and care setting preferences
- Access to medical records
The proxy’s authority is typically limited to situations where you lack decision-making capacity — confirmed by a physician.
State Requirements
Most states require the healthcare proxy document to be:
- Signed by the principal (the person creating the document)
- Witnessed by two adults who are not named as agent, related by blood or marriage, or beneficiaries of your estate
- Some states require notarization in addition to witnesses
Document 3: DNR Orders (Do Not Resuscitate)
A DNR order is a medical order — not simply a legal document — that instructs healthcare providers not to perform CPR (cardiopulmonary resuscitation) if your heart stops or you stop breathing.
DNR vs. Living Will
This is one of the most common points of confusion:
- A living will is a legal document expressing your preferences
- A DNR is a medical order signed by a physician that has immediate operational effect for the care team
A living will that says “I do not want CPR” does not automatically create a DNR order. Your physician must translate that wish into a DNR order in your medical record.
Types of DNR Orders
In-hospital DNR: Applies only while you are hospitalized. If you are transferred or discharged, this order may not follow you.
Out-of-hospital DNR (OOH-DNR): A portable order valid for emergency responders (EMS) in community settings — at home, in assisted living, in a nursing home. EMS is typically required to attempt resuscitation unless they see a valid OOH-DNR. This order must be signed by your physician and you (or your proxy).
DNR Comfort Care: Some states use combined orders that pair DNR status with comfort-care-only treatment directives, covering more clinical scenarios than a simple DNR.
Important Limitations
EMS personnel in most states cannot honor a living will alone in an emergency. They respond to OOH-DNR forms and, in some states, POLST forms. If you want EMS to honor your resuscitation wishes, a physician-signed portable order is essential.
Document 4: POLST Form (Physician Orders for Life-Sustaining Treatment)
The POLST form (called MOLST, MOST, TPOPP, or similar names in different states) translates your end-of-life wishes into a set of actionable medical orders signed by a physician or nurse practitioner.
What POLST Covers
A POLST form typically addresses:
- CPR preferences: Attempt resuscitation or DNR
- Medical interventions: Full treatment (ICU, intubation), limited interventions (no intubation, no ICU but comfort-focused care), or comfort measures only
- Artificial nutrition: Long-term feeding tube vs. assisted hand feeding vs. no artificial nutrition
Who Should Have a POLST
POLST is designed for people with serious illness, advanced age, or frailty — not for healthy adults. It is most appropriate for:
- Nursing home residents
- Hospice patients
- People with advanced dementia or terminal illness
- Seniors with multiple serious chronic conditions
For healthy individuals, a living will and healthcare proxy are sufficient. POLST complements those documents for those closer to end of life.
POLST Is Portable and Immediately Actionable
Unlike a living will, POLST is a physician’s order. EMS, hospitals, and care facilities can act on it immediately without waiting for a physician to issue orders. Keep the original (or a bright-colored copy — many states use pink or yellow forms) accessible, not locked away.
How Advance Directives Work Together
Think of these documents as a layered system:
| Document | Purpose | Who Follows It |
|---|---|---|
| Living Will | States your preferences | Guides proxy and physicians |
| Healthcare Proxy | Names a decision-maker | All healthcare providers |
| DNR (OOH-DNR) | Medical order — no CPR | EMS and all care settings |
| POLST | Medical orders — scope of care | EMS, hospitals, care facilities |
In an ideal scenario:
- Your healthcare proxy advocates for your wishes using the living will as a guide
- A POLST gives clinical staff clear, physician-authorized orders to act on immediately
- A DNR (if desired) is captured in both the POLST and as a standalone medical order
Creating Your Advance Directives: Action Checklist
- Complete a Healthcare Proxy form using your state’s specific template
- Complete a Living Will (or combined Advance Healthcare Directive) using your state form or Five Wishes
- Discuss your wishes with your named proxy in detail — don’t just hand them the document
- Provide signed copies to your healthcare proxy, primary physician, any specialists, and hospital system (most now allow upload to patient portals)
- Keep the originals accessible at home — not in a safe deposit box
- Ask your physician about a POLST if you have serious illness, frailty, or advanced age
- If you want EMS to honor your wishes, get an OOH-DNR from your physician
- Review all documents every 3–5 years and after any major health change
- Notify your healthcare proxy of any updates or changes to your wishes
State-Specific Considerations
California: Uses Advance Health Care Directive (AHCD) combining proxy and living will. POLST form is widely used. Witnesses cannot include the patient’s healthcare provider or their employees.
New York: Uses Health Care Proxy form (separate from living will). MOLST form used instead of POLST. Proxy cannot be a witness.
Texas: Uses Medical Power of Attorney and Directive to Physicians (living will equivalent). OOH-DNR form specific to Texas required for EMS.
Florida: Five Wishes accepted. OOH-DNR (yellow form) required for EMS. POLST program in development.
Pennsylvania: POLST available. Two witnesses required for living will; witnesses cannot be healthcare providers or have a financial interest in the estate.
Always use your state’s current form — forms are updated periodically and outdated versions may not be honored.
Frequently Asked Questions
Can I change my advance directives? Yes, at any time while you have decision-making capacity. Destroy old copies, create new documents, and notify your proxy and physician.
What if my proxy makes a decision I wouldn’t have made? This is why choosing the right proxy and having detailed conversations about your values matters more than the document itself. Your proxy has legal authority, so selection is critical.
Do advance directives expire? No legal expiration in most states, but should be reviewed after major health changes, change in proxy availability, or every 3–5 years.
What happens if I don’t have a healthcare proxy? Medical decisions will be made by the next of kin hierarchy defined by your state (often spouse, then adult children, then siblings) — which may not reflect your wishes and can create conflict between family members.
Does a living will work across state lines? Most states include reciprocity provisions and will honor a living will from another state if it substantially meets their requirements. However, creating a state-specific document if you split time between states is safer.
Can a healthcare proxy overrule a living will? Generally, yes — a proxy has ongoing authority to make decisions based on the full clinical picture. The living will guides but doesn’t absolutely bind the proxy. This is another reason why deep conversations about your values matter more than the document alone.
Is a POLST the same as a DNR? No. A POLST covers a broader range of treatment decisions. A DNR is one component of a POLST (the CPR section), but POLST also addresses medical interventions and artificial nutrition.
Taking Action
Most people underestimate how quickly these documents become necessary. A sudden stroke, accident, or rapidly progressing illness can create decision-making incapacity overnight. Completing these documents when you are healthy and clear-headed is a gift to your family — removing a devastating burden from people already under enormous stress.
Start with your state’s healthcare proxy form today. It’s the most important single document and typically takes less than 30 minutes to complete.