Advance Directive vs. POLST: What’s the Difference - and Do You Need Both?
At almost every workshop I give, this question comes up. And it’s simply because there is so much misunderstanding about the two. From the comments and questions I hear from attendees, it’s clear that many have received conflicting or inaccurate information, which understandably adds to the confusion.
POLST stands for Portable Orders for Life-Sustaining Treatment. If you already have an Advance Directive, you may assume you have everything covered when it comes to your future medical care. Then someone mentions a POLST, and suddenly you're wondering: Is that something else I need? Does it replace my Advance Directive? Should I have both?
I get it. These documents are confusing, because they both address medical care when you may not be able to speak for yourself. But they serve very different purposes. So, let’s clear up the confusion.
I think the simplest way to think about it is this:
An Advance Directive helps plan for what might happen someday. A POLST provides medical orders for what should happen now, based on your current health condition.
To help understand what that means, here’s a closer look at each document.
What Is an Advance Directive?
An Advance Directive is a legal document that allows you to express your preferences about future medical care and, depending on your state's documents, identify the person you want making health care decisions for you if you are unable to make or communicate those decisions yourself. This person can be called a health care representative, agent, or proxy depending on the state.
Advance Directives are generally appropriate for all adults, not just people who are older or seriously ill.
Think about a healthy 55-year-old who is seriously injured in a car accident and is unconscious. No one expected this situation, but decisions suddenly need to be made about medical treatment. Their Advance Directive gives important directions to their health care representative and medical providers as to what treatment they do or do not want. It removes a huge burden on others needing to make difficult decisions about their care.
Advantages of an Advance Directive
One of the biggest advantages of having an Advance Directive: you don't have to know what medical crisis might occur in order to plan for one.
An Advance Directive can:
Identify the person you trust to make medical decisions for your.
Provide guidance about treatments you would or would not want.
Give your family and medical providers insight into your values and wishes.
Reduce uncertainty and potential disagreements among family members.
Be completed while you are healthy, long before a medical crisis occurs.
Advance Directives are generally easy to put in place, although signing, witnessing and notarization requirements vary by state. Be sure to follow the requirements of the state in which you live.
There really isn't a "con" to having an Advance Directive, but there are limitations. Because an Advance Directive is completed before a medical crisis occurs, it can’t anticipate every medical circumstance you may eventually face. Your medical providers and health care representative may need to apply the wishes and instructions you expressed in the document to the particular situation that arises.
An Advance Directive is also not a medical order. It is completed by you according to your state’s requirements and does not require a medical provider’s signature to make your treatment wishes valid. This is an important distinction because emergency responders generally can’t act upon an Advance Directive in the same way they can follow a current medical order.
That's where a POLST is different.
What Is a POLST?
It is a medical order intended primarily for someone who is seriously ill or experiencing advanced frailty. Unlike an Advance Directive, it is created in response to your current health condition and requires the signature of an authorized medical provider.
Unlike an Advance Directive, a POLST is not something every adult needs.
Obtaining one involves talking with your health care professional about your current condition, prognosis, treatment options and goals of care. Your decisions on the type of care you do or do not want are then translated into medical orders that health care professionals and emergency responders can follow.
For example, imagine an 82-year-old with advanced heart and lung disease who has been hospitalized several times. She has decided that if her heart stops, she doesn't want CPR. She still wants appropriate medical care but doesn't want aggressive intensive-care treatment that is unlikely to improve her quality of life.
Those aren't simply general wishes about what she might want someday. They are decisions based on her health right now.
A POLST allows those decisions to become medical orders.
Depending on the form used in your state, a POLST may address such things as:
Whether CPR should be attempted.
The desired level of medical treatment.
Whether hospitalization or intensive treatment is appropriate.
Other treatment decisions addressed by that state's POLST form.
One important point: Having a POLST does not automatically mean "Do Not Resuscitate."
A person can have a POLST and still request CPR and other aggressive treatment. The purpose of the form is to document the treatment choices that are appropriate for that individual—not simply to limit treatment.
Do You Need a POLST to Have a DNR?
This is another area that causes a lot of confusion. People sometimes believe they need a POLST simply because they have decided they would not want CPR or other life-saving measures.
Your Advance Directive can certainly express those wishes. For example, you might state that if you are terminally ill, permanently unconscious or in another condition specified in your directive, you do not want treatments that would only prolong the dying process.
But there is an important difference between expressing a wish not to be resuscitated and having a medical order directing emergency personnel not to attempt resuscitation.
An Advance Directive provides instructions for your future medical care and helps your health care representative and medical providers make decisions consistent with your wishes. It is not, however, an emergency medical order.
A DNR—or “Do Not Resuscitate” order—is a medical order directing health care providers not to perform CPR if your heart stops or you stop breathing. For someone who is seriously ill or frail and wants that decision to apply during an emergency, a POLST can be used to document the appropriate resuscitation order.
For example, suppose Susan is healthy and completes an Advance Directive at age 60. She indicates that she would not want life-sustaining treatment if she were terminally ill with no reasonable possibility of recovery. That does not mean paramedics should withhold CPR if Susan unexpectedly collapses from cardiac arrest at age 62. Her Advance Directive describes what she wants under particular future circumstances; it is not a standing order telling EMS not to resuscitate her. Therefore, EMS will provide the treatment needed for the situation.
Now suppose Susan is 85 and has advanced heart disease. After discussing her condition and prognosis with her medical provider, she decides she does not want CPR if her heart stops. At that point, a POLST containing a Do Not Attempt Resuscitation order may be appropriate. Because the POLST is a medical order, it can direct emergency personnel not to begin CPR.
So, you don't need a POLST simply because your Advance Directive says you would not want life-prolonging treatment. The question is whether your current medical condition and treatment preferences have reached the point where those wishes need to be translated into medical orders that health care providers and emergency responders can follow now.
That is one of the primary reasons POLST exists: not to replace your Advance Directive, but to turn appropriate treatment decisions into actionable medical orders when serious illness or frailty makes that necessary.
The Biggest Difference: Instructions vs. Medical Orders
Here's another way to distinguish the two.
Suppose paramedics arrive at your home and you are unconscious.
Your Advance Directive might say that you would not want prolonged life support under certain circumstances. It might also identify your daughter as the person authorized to make medical decisions for you.
But the paramedics don't yet know whether your condition fits those circumstances, and an Advance Directive generally isn't a medical order that emergency responders can simply follow.
A POLST is different.
Because it contains medical orders, emergency medical personnel can use it to determine such things as whether CPR should be attempted and what level of treatment you have chosen.
That distinction is important:
Advance Directive = "Here are my wishes and who I want to speak for me if I can't."
POLST = "Given my current medical condition, here are the medical treatments I want—or don't want—right now."
What Happens If You Have a Medical Emergency Away From Home?
Some states and health care systems offer electronic access to your Advance Directive, but you shouldn’t assume a hospital or medical provider – especially in another state – will be able to locate yours. That’s why it’s important your health care representative has a copy they can provide to the treating facility. You may also want to consider having a digital copy your health care representative can access and asking your health care provider whether your Advance Directive can be added to your electronic medical record.
As for a POLST, one of the most important features it has is right in its name: it is portable.
The medical orders aren't intended to apply only when you're at home, in a hospital or living in a care facility. They are intended to travel with you.
But that raises an important practical question:
How will emergency responders know you have a POLST if you collapse at the grocery store, a restaurant or while visiting someone else's home?
The answer depends somewhat on where you live. Since I am based in the Pacific Northwest, let’s look at the differences in two neighboring states:
Oregon: A Statewide POLST Registry
Oregon has an additional safeguard: the Oregon POLST Registry, a secure statewide database designed to make POLST orders available during a medical emergency.
If emergency responders are treating someone who cannot communicate and don't have the person's paper POLST available, authorized EMS personnel can contact the Registry's Emergency Communication Center. If the patient can be identified and matched to a POLST in the Registry, EMS can obtain the medical orders.
Imagine Mary collapses while shopping and cannot communicate. The paramedics don't find a POLST with her, but they are able to identify her. If Mary has a current POLST in the Oregon Registry, EMS may be able to obtain her medical orders through the Registry rather than relying upon someone finding the paper form at her home.
That's a significant benefit—but only if Mary's current POLST is actually in the Registry and can be matched to her.
How Do You Make Sure Your Oregon POLST Is Registered?
In Oregon, the health care professional who signs a POLST is generally responsible for submitting it to the Oregon POLST Registry unless the patient chooses not to have it registered.
But don't simply assume everything has been taken care of.
After completing a new POLST—or changing an existing one—it's a good idea to verify that the Registry has the current version.
Patients and their authorized representatives can contact the Oregon POLST Registry to verify whether a POLST is on file. Identity verification is required before information is released.
So, if you have an Oregon POLST, add one more step to your checklist:
Confirm that your current POLST has been received and entered into the Oregon POLST Registry and that the information is correct.
Even with the Registry, it is still wise to keep copies accessible and make sure family members and caregivers know that you have a POLST. Emergency treatment may need to begin before responders can identify you and determine whether POLST orders are available.
For more information visit: Oregon POLST Program and Registry
Washington: Making Your POLST Accessible Is Especially Important
Washington also uses POLST as a portable medical order, and Washington EMS personnel are trained regarding the use of POLST orders.
A properly completed and signed Washington POLST doesn't necessarily have to be the original paper document for it to be useful. Washington EMS guidance recognizes completed and signed copies, digital images and faxes of the POLST.
However, Washington does not currently have the same operational statewide POLST Registry available to EMS that Oregon has. Washington is working toward an electronic POLST form and statewide registry, but until that system is operational, making the actual POLST available remains especially important.
Consider Bill, who lives in Washington and has a POLST indicating that he does not want CPR. He collapses while having lunch at a restaurant and cannot communicate.
If his POLST—or a valid copy or digital image—can be located and provided to EMS, those medical orders can guide his care. But unlike in Oregon, responders currently cannot simply contact a statewide POLST registry to determine whether Bill has one.
For Washington residents, this makes accessibility particularly important.
If you have a Washington POLST:
Keep a copy where it can easily be found.
Make sure family members and caregivers know that you have one and where it is located.
Consider how an accessible copy or digital image could be made available when you're away from home.
If you live in a residential or care facility, ask how your POLST is made available if you are transported elsewhere.
Simply keeping a digital copy somewhere on a locked phone may not be particularly helpful if emergency personnel can't access it.
For more information visit: Washington State Department of Health POLST information
The Lesson in Both States: Don't Just Complete It—Make It Accessible
Whether you live in Oregon, Washington or another state, completing a POLST is only part of the process.
Ask yourself a very practical question:
If I were unconscious and the person treating me had never met me before, would they be able to find my medical orders?
In Oregon, that means confirming that your current POLST is in the statewide Registry while also keeping copies accessible.
In Washington, where a comparable statewide EMS-accessible registry is not yet operational, it is especially important to make sure your POLST—or a valid copy or digital image—can be located when needed.
And if you travel, remember that POLST laws, forms and registries vary by state. Before an extended trip or move, ask your health care provider whether you should take additional steps to make sure your medical orders can be recognized and followed at your destination.
Does a POLST Replace an Advance Directive?
No.
This is probably the most important misconception to clear up.
A POLST and an Advance Directive are not competing documents. For someone who is seriously ill or frail enough to need a POLST, the two documents are generally designed to work together.
One particularly important difference is that an Advance Directive can identify the person you want making health care decisions for you if you cannot make them yourself. A POLST is not intended to replace that broader planning.
So even if you have a POLST, your Advance Directive can still be extremely important.
When Would Someone Want Both?
Consider this example.
John has an Advance Directive that he completed years ago. It identifies his wife as the person he wants making health care decisions for him and says that he doesn't want his life artificially prolonged if he is terminally ill with no reasonable chance of recovery.
Years later, John develops advanced cancer.
After talking with his doctor about his prognosis and treatment options, John decides that he doesn't want CPR if his heart stops and prefers less aggressive treatment rather than repeated hospitalizations.
His Advance Directive still matters. It provides broader guidance about his wishes and identifies the person who can speak for him if necessary.
But now a POLST may also be appropriate because John has a current serious illness and is making specific medical decisions that health care professionals may need to act upon immediately.
In that situation, having both can make a great deal of sense.
Are There Any Downsides to a POLST?
The biggest concern isn't really the POLST itself—it's having one when it isn't appropriate or failing to keep it current.
A POLST reflects decisions made in light of a person's current medical condition. If that condition changes significantly, or the person's goals or treatment preferences change, the POLST should be reviewed and, when necessary, updated.
That's why a healthy 50- or 60-year-old generally shouldn't obtain a POLST simply because they are doing estate planning and want to "cover all the bases."
For a healthy person, an Advance Directive is the appropriate planning tool.
Years later, if that person's health changes significantly, a conversation about whether a POLST is appropriate can take place with their health care provider.
There is another potential risk worth considering: outdated medical orders can create confusion.
If you change your mind about the treatment you want, don't simply tell your family. Talk with your health care provider about updating or voiding your POLST and make sure old copies are replaced. If you live in a state with a registry, such as Oregon, make sure the registry reflects the current orders as well.
So, Which One Do You Need?
For most adults, the starting point is simple:
Have an Advance Directive.
You don't need to wait until you're older or sick. In fact, completing one while you're healthy is exactly the point—you are planning for circumstances you can't predict.
A POLST is different.
If you have a serious progressive illness, significant frailty or another medical condition that makes it important to establish specific treatment orders now, talk with your health care provider about whether a POLST is appropriate for you.
And if you reach the point where a POLST makes sense, don't assume it means your Advance Directive is no longer necessary.
You may very well want both.
The Advance Directive addresses the bigger picture: Who should speak for me, and what are my wishes if I can't speak for myself?
The POLST addresses the immediate medical question: Given my health today, what treatments do I want health care providers to give—or not give me?
Together, they can provide a much clearer picture of the care you want.
One Final Thought
Estate planning isn't only about deciding what happens to your property after you die. Some of the most important planning you can do involves what happens while you're still alive but unable to speak for yourself.
If you already have an Advance Directive, take it out and review it periodically. Make sure the person you've chosen to speak for you is still the right person. Make sure that person knows they've been chosen, understands your wishes and knows where your documents can be found.
And if you or someone you care for is dealing with a serious illness or increasing frailty, ask the medical provider a simple question:
"Is it time for us to talk about a POLST?"
If the answer is yes, don't stop once the form is signed. Ask how the POLST will be made available in an emergency, what happens when you're away from home and, if your state has a registry, how you can verify that your current orders are actually there.
Because the goal isn't simply to have the paperwork completed.
The goal is to make sure the right people can find it—and follow it—when it matters most.
Disclaimer
The information provided in this article is intended for general educational and informational purposes only and should not be considered legal, financial, tax, or other professional advice. Laws and individual circumstances vary and may change over time. Always consult with a qualified attorney, financial professional, tax advisor, or other appropriate professional regarding your specific situation.
