April 16th is National Health Care Decisions Day (NHDD). This day focuses its efforts on increasing knowledge of medical decision making and advance care planning. Advance care planning includes living wills and health care power of attorney or surrogate decision maker. These documents are important for EVERYONE to have. Not just older people or those with life threatening illness. We never know when accidents or illness can happen. We owe it to ourselves and our families to outline what kind of medical treatment we would want and whom we would want to make decisions for us if we were not able.
While these are important discussions, I’ve noticed they often don’t include code status, do not resuscitate (DNR), or Physician/Medical Orders for Life Sustaining Treatment (POLST/MOLST). These plans are just as important as other forms of advance care planning—especially for persons with a life threatening illness. Let’s take this chance to understand what these acronyms really mean.
What is Code Status?
- Code status gives healthcare providers guidance for the level of medical care that should be provided in the event that your heart should stop beating or you should stop breathing.
- Each facility has a different structure and/or policy for code status and level of care orders. You may ask your care team to provide you with information about the facility’s level of care orders/structure.
- You can change your mind about your code status at any time; but your healthcare provider MUST update the order in your medical record.
- The order should be informed by wishes you have made clear in your advance directive – and your family/decision makers should be aware of these wishes.
What is DNR?
- DNR is a medical order given by a healthcare professional.
- DNR means Do Not Resuscitate. It applies when you are in a hospital or other medical facility.
- In its simplest terms, if someone were to walk into your room and find that you had no pulse (your heart was not beating) or you were not breathing, you would not want efforts to be taken to start your heart again or to help your breathe.
- This includes cardiopulmonary resuscitation(CPR), defibrillation, intubation (breathing tube), or medicines to help your blood pressure (pressors).
- Facilities may have different terms and abbreviations for this, including Do Not Attempt Resuscitation (DNAR) or Allow Natural Death (AND).
- Some facilities separate CPR from intubation and have a separate order called Do Not Intubate (DNI) or Do Not Attempt Intubation (DNAI).
What is POLST/MOLST?
Physician orders for life sustaining treatments (POLST) or medical orders for life sustaining treatments (MOLST) is another type of advance care planning document that works in concert with your advance directive. POLST/MOLST provide medical orders for emergency personnel (paramedics) as to what treatments to provide in case of a medical emergency when the patient cannot speak or communicate. Other differences from a living will include:
- POLST/MOLST is for persons with serious, life limiting illness – especially those whose care providers feel they have 1 year or less to live.
- POLST/MOLST is a portable document – “you can take it with you.” Unlike a DNR/DNI order, POLST follows you regardless of where you are receiving care—the hospital, a nursing home, your home, or even if you are being transported in an ambulance. The goal is to avoid unwanted medical treatments and hospitalizations.
- POLST/MOLST must be completed by the healthcare provider and the patient/surrogate together.
- POLST/MOLST programs do vary by state, but most follow the standardized content of the National POLST paradigm. Read more about your state’s POLST/MOLST program.
It is important that we understand these concepts as they fall under the advanced care planning umbrella. Establishing your code status is important for the healthcare providers caring for you. These choices should be informed by your advance directive. For example, in your advance directive if you have selected “I do not want cardiopulmonary resuscitation,” you should also have a DNR order. If you do not have an advance directive and are unable to make medical decisions for yourself, your family will be approached by the healthcare team to make these decisions on your behalf. All the more reason to have the advance directive available – to provide guidance to your family about the kind of care you would want to have.