Confusion between an Advance Directive (AD) and a Do Not Resuscitate (DNR) order is common when planning for future medical care. Both documents are part of a thorough approach to end-of-life planning, but they serve distinctly different purposes and function in separate domains. Understanding the precise role of each ensures your medical wishes are clearly communicated and legally honored if you become unable to speak for yourself. Clarity in these terms directly impacts the medical actions taken during a crisis.
Understanding the Advance Directive
An Advance Directive (AD) is a broad, legally recognized document outlining your preferences for medical treatment and designating a decision-maker should you become incapacitated. It functions as a planning tool for future healthcare scenarios, not just end-of-life care, and is effective only when you cannot communicate your own wishes. This document is governed by state laws and often requires specific steps like witnessing or notarization to ensure its legal validity.
The AD is usually composed of two primary elements that guide your care. The first component is the Living Will, which serves as a written instruction detailing the types of medical treatments you would want or refuse under specific conditions, such as a terminal illness or a permanent unconscious state. These instructions can cover interventions like the use of ventilators, artificial nutrition and hydration, and pain management.
The second component is the Durable Power of Attorney for Healthcare, also known as a Healthcare Proxy or Agent. This section names a trusted individual legally authorized to make medical decisions on your behalf if you lose capacity. The designated agent is bound to follow the preferences established in your Living Will, but they can also interpret your wishes in situations not explicitly covered by the written instructions.
Understanding the Do Not Resuscitate Order
A Do Not Resuscitate (DNR) order is a specific medical instruction, not a broad legal planning document. Its scope is highly focused, applying only to cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. It instructs healthcare providers not to perform chest compressions, artificial ventilation, or defibrillation—the procedures used to attempt to restart the heart or breathing.
This order must be signed by a physician or other authorized healthcare practitioner and is formally placed within your medical record. The DNR is intended for immediate action within a healthcare setting, such as a hospital or nursing home, though out-of-hospital DNR forms are also available in many states to be honored by emergency medical services (EMS). It is important to note that a DNR order does not mean “do not treat” or “withhold all care.”
A patient with a DNR order continues to receive all other necessary and appropriate medical care, including treatment for pain, antibiotics for infections, and other interventions. The order simply dictates that a single, specific life-saving intervention—CPR—will be withheld if the heart or breathing stops. A DNR is usually discussed and implemented for individuals with serious illnesses or advanced frailty where the chance of successful resuscitation is very low or the potential outcome involves significant disability.
How These Documents Interact and Differ
The fundamental distinction lies in their nature: the Advance Directive is a broad legal planning document, while the DNR is a narrow, actionable medical order. An AD is created by the patient to plan for future incapacity, whereas a DNR must be signed by a physician and is an instruction for immediate medical teams. The AD covers a vast range of potential treatments, including nutrition, hydration, and mechanical ventilation, but the DNR is restricted solely to the refusal of resuscitation.
The two documents interact because the AD often serves as the legal foundation for the DNR order. The wishes expressed in your Living Will, or the instruction given by your Healthcare Proxy, inform the physician that you do not desire CPR. The doctor then converts that preference into the official DNR medical order, which medical staff and emergency responders are required to follow. Without the physician’s signed order, the wishes in a Living Will regarding CPR may not be immediately honored in an emergency.
A standard DNR order is traditionally facility-based, meaning it is most effective within the hospital where it was written. To address this limitation, many states use Physician Orders for Life-Sustaining Treatment (POLST) or similar forms like MOLST. These portable medical orders are signed by a physician and travel with the patient. They can contain a DNR instruction but also address other treatments like intubation and feeding tubes, serving as an actionable medical order honored across different care settings and by EMS. The Advance Directive establishes the patient’s broad desires, which are then translated into the specific, legally binding medical instruction of the DNR or POLST form.