What’s the difference between an advance directive and DNR, and what do I need?
While most estate planning clients come in focused primarily on the need for a will, incapacity planning is another important part of the process. Incapacity planning includes planning ahead for financial and medical decision-making.
For a typical estate planning client, the medical incapacity planning documents we prepare are a medical power of attorney, an advance directive to physicians (aka “living will”), and a HIPAA release. I’m often asked about Do Not Resuscitate forms, commonly known as “DNRs.”
You may be wondering: is a DNR the same thing as an advance directive? The answer is no. They are different documents with different purposes and different target groups.
When you sign an advance directive, you are expressing, in advance, whether you would or would not like to receive life-sustaining measures (feeding tubes, ventilators, etc.) in the event that you later become incapacitated and are suffering from either a terminal or irreversible decision. I describe the advance directive in shorthand as the “life support or not” document. The advance directive allows you, while you’re competent, to offer direction for your physicians and family for some distant day if the need should arise.
This document becomes effective only once 3 conditions are met: 1) you are unable to make medical decisions due to illness or injury, 2) you will die without life support, and 3) you have been diagnosed with either a terminal or irreversible condition. You might sign that document, live another 50 years, and pass away with your advance directive having never come into play.
Even if you sign an advance directive in my office and you get into a car wreck on the way home and go to the hospital with this document in hand, so long as the conditions are not yet met, this document will not go into effect. Even if you are in a coma or other serious condition, this document will not go into effect, so long as your condition is neither terminal nor irreversible.
If the day comes that the conditions are met, your advance directive allows the past, competent, version of yourself to offer guidance in the present day to your healthcare providers and family members. This can serve as a great relief for a loved one serving as your agent under a medical power of attorney, who can act with greater certainty that they are honoring your wishes.
Who should have an advance directive? I believe every adult should have one and include it in every estate plan I prepare unless a client prefers not to have one.
So that’s the advance directive, but what’s a DNR, and how is it different? Unlike an advance directive, which can be signed by any competent adult regardless of their health, a DNR form is signed by a terminally or irreversibly ill person or their surrogate decision-maker, such as medical power of attorney. The DNR form directs the person’s healthcare providers not to provide resuscitation measures, including CPR, defibrillation, and similar measures.
In the absence of a DNR, a patient is presumed to be “full code”, which is to say, if the patient stops breathing or their heart stops, all resuscitation measures should be taken to keep them alive. You don’t have to tell your doctor that you want to be full code: we all are by default. Signing a DNR is opting out of full code status. Once a patient has a DNR, it’s noted on their patient chart and the care team may also put a DNR sign on the patient’s door and/or above their bed.
The DNR is often signed when a person is admitted to hospice, and thus it is usually signed by the person’s medical agent and physician. If a now-terminally ill person had previously executed an advance directive indicating a desire to discontinue or withhold life support, it would be appropriate for the person’s medical agent to sign a DNR on their behalf to ensure that the wishes expressed in the advance directive are honored.
Who should have a DNR form? Almost no one. While I routinely prepare advance directives, I never draft DNR forms for estate planning clients. The only people for whom a DNR is appropriate are people who are already near death and for whom the ultimate cause of death is irrelevant.
Signing a DNR prematurely would be telling your care providers that you don’t want to be full code status, and that if you stop breathing or go into cardiac arrest, you don’t wish to be resuscitated. In essence, it’s telling your care providers “don’t touch!” Certainly, this makes sense when a person is in their final stage of life already and resuscitation would serve only to prolong their death rather than their life. But if you’re reading this and you are presently a reasonably healthy person, a DNR is not appropriate for you. An otherwise healthy person might fall unconscious or suffer cardiac arrest for any number of reasons but, after resuscitation, recover to enjoy a high quality of life. A DNR would prevent that.
TL;DR version: everyone should have an advance directive, almost no one should have a DNR, and if you, in your advance directive, indicate that you would not want life support, down the road, it would be appropriate for your medical agent to sign a DNR on your behalf if the need arose.