What Is a DNR Order?
A DNR (Do Not Resuscitate) order is a medical order directing health-care professionals not to start cardiopulmonary resuscitation (CPR) if a person's heart stops beating or the person stops breathing. You may also see the terms DNAR (Do Not Attempt Resuscitation) or Allow Natural Death (AND) used for substantially the same clinical decision. T
he terminology varies by institution and state, but the central idea is the same: if the patient experiences cardiopulmonary arrest, the medical team should not initiate the resuscitative measures covered by the order. The American Medical Association's guidance on orders not to attempt resuscitation describes these orders as instructions directing the health-care team to withhold resuscitative measures in accordance with the patient's wishes.
A DNR is fundamentally different from a document that merely states what a patient would like to happen. A DNR is a clinical order. The patient may request it, consent to it, or have a legally authorized health-care agent or surrogate participate in the decision when the patient lacks capacity, but the decision must ultimately be converted into an appropriate medical order under the law and clinical rules of the jurisdiction.
That distinction is important because an advance directive does not automatically function as a DNR in every setting. The National Institute on Aging explains the difference between advance directives, out-of-hospital DNR orders, and POLST-type medical orders. It notes that POLST and similar forms are medical orders that can be acted upon immediately in an emergency.
The precise legal requirements vary considerably by state. In some jurisdictions, a DNR must be signed by a physician; in others, the law permits certain nurse practitioners or physician assistants to issue or sign particular medical orders.
California, for example, permits its POLST to be signed by a physician, nurse practitioner, or physician assistant under the applicable statutory rules. New York similarly permits its MOLST to be signed by a physician, nurse practitioner, or physician assistant.
So the safest way to understand the rule is not simply "only a doctor can create a DNR." The better rule is that a DNR is a medical order issued and documented by an authorized health-care professional under state law, rather than a document the patient can create and make effective entirely on their own.
What Does a DNR Do?
A standard DNR is deliberately narrow. It addresses what happens when cardiopulmonary arrest occurs. It does not ordinarily mean that the patient wants all medical treatment stopped.
For example, a person with a DNR may still receive oxygen, antibiotics, medication, dialysis, pain medication, treatment for an infection, surgery, or other appropriate medical treatment unless separate instructions or orders limit those interventions. The AMA's ethical guidance on advance directives and end-of-life care makes clear that a DNAR decision does not, by itself, establish that other medically appropriate treatment should be withheld.
This is one of the most important concepts to understand about DNRs: "Do not resuscitate" does not mean "do not treat." A patient can simultaneously have a DNR and request aggressive treatment for an illness while still declining CPR if the heart or breathing stops.
A DNR also does not, by itself, appoint a person to make health-care decisions. A health-care proxy, medical power of attorney, or other health-care-agent document serves that separate purpose.
Likewise, a living will can provide instructions concerning treatments such as mechanical ventilation, artificial nutrition, or other life-sustaining measures, but it is legally distinct from a DNR order. The federal MedlinePlus explanation of advance directives provides an accessible overview of these different functions.
The practical distinction can therefore be summarized this way: an advance directive tells the health-care system about your wishes and, where applicable, names who should make decisions for you; a DNR converts one particular decision—whether to attempt resuscitation—into a medical order.
In-Hospital DNR vs. Out-of-Hospital DNR
The setting matters.
An in-facility DNR is generally entered into the patient's medical record while the patient is receiving care in a hospital, nursing facility, hospice program, or other health-care setting. It directs the staff treating the patient not to initiate CPR if the patient experiences cardiac or respiratory arrest.
An out-of-hospital DNR is designed for situations in which the patient is at home, in an assisted-living facility, or otherwise outside a hospital. Its purpose is to communicate the DNR decision to emergency medical personnel who may arrive after a 911 call. States commonly use a standardized form, identification device, registry, or some combination of these mechanisms.
The difference is practically significant. A DNR buried in a hospital chart may not be accessible to an ambulance crew arriving at the patient's home. An out-of-hospital order is specifically designed to bridge that gap.
State law controls the exact procedure. Michigan, for example, has a specific Do-Not-Resuscitate Procedure Act, Mich. Comp. Laws §§ 333.1051–333.1067, governing out-of-hospital DNR orders and related identification mechanisms. California's Emergency Medical Services Authority similarly maintains state-approved procedures and forms for DNR and POLST orders.
The practical consequence is that a DNR intended for use at home must satisfy the state's out-of-hospital requirements. A generic note saying "Do Not Resuscitate" may not be enough for EMS to rely upon.
The Critical Difference Between DNR, POLST, and MOLST
DNR, POLST, and MOLST are often mentioned together because they all involve medical orders governing end-of-life or emergency treatment, but they are not interchangeable terms.
A DNR is primarily about one question: If the patient's heart stops or the patient stops breathing, should CPR be attempted?
A POLST is broader. POLST traditionally stands for Physician Orders for Life-Sustaining Treatment and refers to a system for converting a seriously ill or medically frail patient's goals into actionable medical orders.
Depending on the state's form, a POLST may address CPR as well as the level of medical treatment to provide if the patient is seriously ill. For example, whether to use intubation and mechanical ventilation, whether to transfer the patient to a hospital, and what level of other life-sustaining treatment is appropriate.
The National Institute on Aging's advance-care-planning guidance distinguishes POLST-type orders from ordinary advance directives because they are designed to give clinicians actionable orders.
MOLST—usually Medical Orders for Life-Sustaining Treatment—is generally a state-specific version or name for this broader medical-orders framework. New York is a prominent example. Its Department of Health explains that MOLST is an approved medical order form for patients with serious health conditions and that it can address CPR and other life-sustaining treatments.
The terminology is therefore a source of unnecessary confusion. POLST is the broader national paradigm; MOLST is one state's implementation or name for that paradigm. Other jurisdictions use names such as POST, MOST, TPOPP, or other variations.
New York provides a particularly clear illustration. Its Department of Health states that the current MOLST is the authorized form for documenting nonhospital DNR and DNI orders in New York and that the form can also contain other life-sustaining-treatment orders. In other words, a MOLST is considerably broader than a simple DNR. See the New York MOLST program.
California provides another illustration. Its Emergency Medical Services Authority's POLST guidance describes POLST as a medical-order process for seriously ill patients to specify the types of treatment they wish to receive.
The easiest way to keep the three concepts straight is to think in terms of scope:
DNR: CPR or no CPR after cardiac or respiratory arrest.
POLST: a broader set of immediately actionable medical orders concerning CPR and other life-sustaining treatment.
MOLST: the name used by some states for their version of the broader POLST-style medical-order system.
A POLST or MOLST can therefore contain a DNR decision, but a DNR is not automatically a POLST or MOLST.
DNR Does Not Automatically Mean DNI
Another common misunderstanding is the assumption that declining CPR necessarily means declining intubation.
DNI (Do Not Intubate) is a separate instruction concerning the insertion of an endotracheal tube and the use of invasive mechanical ventilation. Some forms combine DNR and DNI decisions, while others treat them separately.
New York's MOLST illustrates the distinction particularly well because its form allows DNR and DNI decisions to be documented separately. The New York Department of Health's MOLST program explains how these and other life-sustaining-treatment choices can be addressed within the same medical-order framework.
This distinction matters because a patient may have different preferences for different stages of an emergency. Someone could decline chest compressions after cardiac arrest but still want certain forms of respiratory support while the heart is beating.
Conversely, someone might want CPR but not want intubation, depending on the circumstances and the options permitted by state law and the applicable medical-order form.
A patient should therefore discuss CPR, intubation, hospitalization, artificial nutrition, antibiotics, and other life-sustaining treatments separately, rather than assuming that one decision automatically determines all the others.
What a DNR Does Not Do
A DNR does not mean that a person has given up the right to medical care, and it does not mean that health-care professionals should stop providing comfort-focused or otherwise appropriate treatment.
The AMA's guidance on orders not to attempt resuscitation emphasizes that decisions concerning resuscitation are distinct from the separate question of what other medical treatment should be provided. Appropriate symptom management and other treatment consistent with the patient's goals should continue.
A DNR also does not necessarily determine what should happen before cardiac or respiratory arrest. Suppose a patient has severe pneumonia but is still breathing and has a pulse.
A DNR alone does not tell the medical team whether to administer antibiotics, oxygen, intravenous fluids, hospitalization, or mechanical ventilation. Those decisions require separate clinical instructions or orders where the patient's wishes call for them.
This is precisely where a POLST or MOLST can become more useful for a seriously ill patient: rather than addressing only the final event of cardiac or respiratory arrest, it can provide a broader set of treatment orders covering what should happen during serious deterioration before arrest occurs.
Why a Living Will Alone May Not Be Enough in an Emergency
A living will is a part of an advance directive. It allows a person to document preferences about future medical treatment in case the person later loses the ability to communicate or make decisions.
An advance directive may address CPR, ventilators, artificial nutrition, dialysis, and other interventions, depending on state law and the document's contents. MedlinePlus provides a useful overview of advance directives and health-care decision-making documents.
But an advance directive and an actionable emergency medical order serve different functions.
The problem becomes especially apparent outside a hospital. An ambulance crew arriving at a patient's home needs a legally recognized mechanism that it can rely on immediately.
Whether a living will alone is sufficient for EMS depends on state law and EMS protocols. In many jurisdictions, EMS is expected to begin resuscitation unless an authorized out-of-hospital DNR, POLST, or equivalent order is available and satisfies the state's requirements.
That is why the National Institute on Aging separately discusses out-of-hospital DNR orders as mechanisms for communicating a person's wishes concerning resuscitation outside a hospital.
The practical lesson is simple: do not assume that a living will sitting in a filing cabinet will function like an out-of-hospital DNR. A person who specifically wants EMS not to perform CPR at home should ask the appropriate health-care professional about the legally recognized out-of-hospital order used in that state.
How DNRs Fit With Advance Directives and Medical Powers of Attorney
These documents are best understood as parts of a larger advance-care-planning system rather than competing alternatives.
An advance directive records the patient's preferences and may designate a health-care agent or proxy to make decisions if the patient loses decision-making capacity. A living will focuses primarily on treatment preferences, while a health-care power of attorney or health-care proxy identifies the person authorized to make decisions. See the National Institute on Aging's explanation of advance directives and MedlinePlus's overview.
A DNR then addresses the specific medical decision concerning resuscitation.
A POLST or MOLST goes further by translating a seriously ill patient's goals and preferences into a broader set of signed medical orders that can follow the patient across settings.
These documents are therefore complementary. Creating a POLST or MOLST does not necessarily eliminate the value of an advance directive, and completing an advance directive does not necessarily eliminate the need for an appropriate out-of-hospital medical order.
The patient's wishes remain central. The American Medical Association's ethics guidance recognizes the patient's right to participate in decisions about life-sustaining treatment and the importance of advance directives in communicating those preferences when the patient later lacks capacity.
When Should Someone Consider a DNR?
A DNR is not limited to people who are actively dying. The more important question is whether the person's goals and medical circumstances make a decision about CPR appropriate.
For someone who is seriously ill, medically frail, or facing a condition in which CPR would be unlikely to produce an outcome consistent with the person's goals, a clinician may recommend discussing resuscitation preferences in advance.
The POLST/MOLST framework is particularly directed toward patients for whom specific treatment decisions are likely to arise in the foreseeable future. New York, for example, identifies people with serious health conditions and others at increased risk of death or substantial decline as appropriate candidates for MOLST discussions. The New York Department of Health's MOLST guidance provides the state's criteria and procedures.
Choosing a DNR is not the same thing as choosing to hasten death. The order concerns whether to attempt resuscitation after cardiopulmonary arrest. It does not authorize euthanasia or physician-assisted death, and it does not direct a clinician to cause death. Rather, it establishes that CPR and related resuscitative measures should not be initiated when the specified conditions occur.
Revoking or Changing a DNR
A DNR is not necessarily permanent. A patient with decision-making capacity can generally change or revoke the decision, subject to the procedure established by state law and the applicable health-care system.
For this reason, a change in wishes should be communicated promptly to the treating clinicians, and outdated copies or identification materials should be replaced or removed where appropriate. MedlinePlus guidance on advance directives also emphasizes the importance of communicating changes to the people and providers involved in a person's care.
The same principle applies to POLST and MOLST orders. These documents are intended to reflect the patient's current goals and medical condition. New York, for example, requires MOLST orders to be reviewed when a patient transitions between care settings and when the patient's preferences or medical condition changes. The New York Department of Health's MOLST protocol explains the review process.
The Legal Framework Behind DNR Decisions
There is no single federal statute that creates one uniform DNR system for every state. DNR law is largely a matter of state law, which is why terminology, forms, signatures, witnessing requirements, EMS procedures, and the authority of surrogates can differ substantially from one jurisdiction to another.
Federal law does, however, recognize the broader legal framework surrounding advance directives. 42 U.S.C. § 1395cc(f) requires Medicare-participating institutions to maintain policies concerning patients' rights under state law to make medical decisions, including the right to accept or refuse treatment and the right to formulate advance directives. The statute is available through Cornell Law School's Legal Information Institute.
The constitutional background also matters. In Cruzan v. Director, Missouri Department of Health, 497 U.S. 261 (1990)*, the U.S. Supreme Court recognized a constitutionally protected liberty interest in refusing unwanted medical treatment. It also permitted states to establish evidentiary requirements for determining the wishes of an incapacitated patient.
The case was not specifically about a DNR form, but it remains one of the leading Supreme Court decisions underlying the legal framework for refusing life-sustaining treatment. The decision is summarized through Oyez.
State statutes then provide the more direct legal authority for DNRs and medical orders.
For example, New York's Public Health Law contains a specific statutory framework for nonhospital orders not to resuscitate. New York Public Health Law § 2994-BB addresses nonhospital DNR orders and the obligations of health-care personnel who encounter a valid order. New York's broader MOLST program is grounded in the state's Public Health Law, including Public Health Law § 2994-b; the New York Department of Health's MOLST protocol identifies the statutory basis for the program.
Michigan has taken a similarly direct statutory approach through its Do-Not-Resuscitate Procedure Act, Mich. Comp. Laws §§ 333.1051–333.1067, which establishes procedures for executing and recognizing out-of-hospital DNR orders.
These examples illustrate why DNR guidance should never be written as though one form or procedure applies nationwide. The governing law is generally the law of the state in which the patient is receiving care, particularly for out-of-hospital treatment and EMS response.
Conclusion
A DNR is best understood as a narrow, actionable medical order about CPR, not as a general instruction to stop medical treatment.
An advance directive is the broader legal planning document that records treatment preferences and can name a person to make decisions when the patient cannot.
A DNR converts the decision about CPR into a medical order.
A POLST expands the concept by converting a seriously ill patient's goals into a broader set of immediately actionable medical orders.
A MOLST is a state-specific form or program implementing that broader medical-orders approach; New York is a prominent example.
The documents should therefore work together rather than be treated as substitutes. Someone creating an advance-care plan should consider not only what treatments they would want, but also which document or medical order will actually communicate those decisions to clinicians and EMS in the setting where an emergency is most likely to occur.
Because DNR, POLST, and MOLST requirements are governed heavily by state law, the final step should always be to verify the form, signing requirements, revocation procedure, and EMS recognition rules in the state where the patient lives and receives care.