End of Life Directives DNR POLST and Allow Natural Death Orders
Key Points
- Advance directives, POLST, DNR/DNI, and AND orders serve different legal and clinical functions.
- DNR/DNI limits resuscitation or intubation at arrest events; it does not mean “no care.”
- POLST is a portable medical order for serious progressive illness and must follow the patient across settings.
- Allow Natural Death (AND) emphasizes comfort-focused care and dignity without prolonging dying.
Pathophysiology
End-of-life planning addresses decisions during physiologic decline when decisional capacity may fluctuate or be lost. Clear directive tools reduce ambiguity, prevent non-value-concordant interventions, and improve safety during rapid deterioration.
Classification
- Advance directive/living will: Patient-stated preferences for future care and proxy designation.
- POLST: Current medical orders for people with limited life expectancy, portable across settings.
- DNR/DNI: Event-specific limits during cardiopulmonary arrest or respiratory failure.
- AND/comfort-care-only: Priority on symptom relief and natural dying course.
Nursing Assessment
NCLEX Focus
Verify what each order does and does not authorize before urgent events occur.
- Assess whether directive documents exist, are current, and are readily retrievable.
- Assess patient capacity and authorized surrogate status when decisions are updated.
- Assess team understanding to prevent misinterpretation of DNR as withdrawal of all treatment.
- Assess alignment between documented orders and current goals of care.
Nursing Interventions
- Ensure clear charting, bedside indicators, and handoff communication of code status.
- Reinforce that comfort care and symptom treatment continue regardless of DNR status.
- Escalate inconsistencies between family requests, directives, and clinical orders promptly.
- Support values-based conversations with providers, ethics, and palliative/hospice teams.
Order-Mismatch Hazard
Misunderstanding directive scope can result in unwanted resuscitation or unwanted treatment limitation.
Pharmacology
Medication plans should remain goal-concordant: comfort-focused pharmacology is appropriate under DNR/AND orders, while nonbeneficial escalation should be avoided when inconsistent with documented goals.
Clinical Judgment Application
Clinical Scenario
A terminally ill patient has DNR status, but family demands full CPR during sudden decompensation.
Recognize Cues: High-stakes order conflict with emotional family distress. Analyze Cues: Potential mismatch between understanding and legal care plan. Prioritize Hypotheses: Immediate priority is lawful, patient-centered, and compassionate action. Generate Solutions: Confirm documentation, involve provider, and provide rapid family explanation. Take Action: Follow valid orders while escalating support resources. Evaluate Outcomes: Care remains value-concordant with reduced conflict risk.
Related Concepts
- powers-of-attorney-and-advance-directives - Proxy authority and advance-planning foundations.
- balancing-spiritual-preferences-safety-and-ethical-boundaries - Values conflicts and ethical resolution.
- dying-process-physiology-and-family-education-priorities - Clinical decline context for directive execution.
- informed-consent-and-implied-consent-in-nursing - Capacity and surrogate-decision safeguards.
- patient-and-nurse-bill-of-rights-in-care - Rights-based care framework.
Self-Check
- How is POLST operationally different from a living will?
- Why is DNR not equivalent to “no treatment”?
- What nursing steps reduce directive-related errors during emergencies?