Reference — Professional Practice
Advance Directives & Code Status Reference
Advance directives let patients keep making decisions after they lose the ability to voice them. The nurse’s job: know which documents exist, what each one actually authorizes, and who speaks for the patient when no document does.
Educational use only. Advance directive law, surrogate hierarchies, and POLST programs vary significantly by state — verify with facility policy and your state’s statutes. This material supports nursing education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional policy, or medical direction. Always follow facility protocols and current provider orders.
The Documents
Living will
What it is: Written statement of the treatments a person does or doesn't want (ventilation, tube feeding, dialysis) if they can't speak for themselves
When it applies: Only when the patient lacks decision-making capacity, typically in terminal illness or persistent unconsciousness as defined by state law
Nursing role: Locate it, get it on the chart, and flag conflicts between the document and the current plan to the provider
Durable power of attorney for healthcare (healthcare proxy)
What it is: Legally designates a person to make healthcare decisions when the patient cannot
When it applies: Activates on incapacity; the agent's decisions should follow the patient's known wishes, not the agent's preferences
Nursing role: Verify identity, document contact information, and direct the team's decision conversations to the right person
DNR / DNI orders
What it is: Provider orders: no CPR (DNR) and/or no intubation (DNI) at arrest. A living will is not a DNR — it requires a provider order to be actionable at a code
When it applies: Immediately, exactly as written, until rescinded — patients/surrogates can change their minds at any time
Nursing role: Know each patient's code status before you need it; DNR never means do-not-treat — full comfort, symptom, and other care continue
POLST / MOLST (portable medical orders)
What it is: Signed medical orders translating end-of-life wishes into specifics (resuscitation, intubation, hospitalization, artificial nutrition) that travel across settings
When it applies: Designed for seriously ill/frail patients; valid in the field — EMS can honor POLST, unlike a living will
Nursing role: Bright-colored form stays with the patient between facility and home; reconcile it with inpatient orders on every admission
When There’s No Document — Surrogate Hierarchy
If an incapacitated patient has no directive, state law typically assigns decision-making in descending order (details vary by state):
- Court-appointed guardian (if one exists)
- Healthcare agent named in a durable power of attorney
- Spouse / legally recognized partner
- Adult children
- Parents
- Adult siblings
- Other relatives or close friends per state statute
Surrogates are asked to use substituted judgment — what the patient would have wanted — falling back to the patient’s best interest when wishes are unknown. Family conflict about the decision goes to the ethics committee, not a hallway vote.
The Nurse’s Role
Ask about advance directives at admission (the Patient Self-Determination Act requires facilities to ask and to provide information), get copies on the chart, and make sure the team knows they exist. Know every patient’s code status at the start of your shift. Nurses witness many documents but follow facility policy on witnessing directives — some prohibit caregiver-witnesses. When a patient wants to change their wishes, facilitate the conversation with the provider promptly and document it. And when a code starts on a full-code patient whose family shouts “she didn’t want this!” — the code continues until a valid order says otherwise; sort the documents out in parallel, not instead.
NCLEX Pearls
- ✦A living will is not a DNR — at a code, only a provider's DNR order stops CPR.
- ✦DNR ≠ do not treat: comfort care, symptom management, and all other treatment continue.
- ✦Patients and authorized surrogates can revoke or change directives at any time — including verbally, per policy.
- ✦The healthcare agent outranks family members in the hierarchy; a guardian outranks the agent.
- ✦POLST is a portable medical order EMS can follow; a living will alone is not.
- ✦Admission assessment includes asking about advance directives — that's federal law (PSDA).
Related Resources
Standards & sources
Fact-checked Jun 21, 2026This page is written to align with ANA Code of Ethics & Scope/Standards of Practice · NCSBN · HIPAA (U.S. HHS). It is an educational summary, not a citation of any single document — always verify specific doses, values, and protocols against current guidelines and your facility policy. How we source content →