# A community health nurse is leading an advance care planning education session at a senior wellness fair. Which statements about advance directives, POLST forms, and DNR orders are accurate? Select all that apply.

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> language: en  
> subject: Personal Hygiene  
> category: BCC

## Question

A community health nurse is leading an advance care planning education session at a senior wellness fair. Which statements about advance directives, POLST forms, and DNR orders are accurate? Select all that apply.

1

You can revoke or change your advance directive, POLST, or DNR at any time as long as you have decisional capacity, including by a clear verbal request to the clinical team

2

A POLST form is a clinician-signed medical order that translates your treatment preferences into immediately actionable orders and travels with you across care settings

3

An advance directive typically includes a living will and a durable power of attorney for healthcare; it becomes effective only when you lose the capacity to make your own decisions

4

Verbal preferences expressed only to family members are legally binding nationwide and require no written documentation to be honored

5

Your healthcare proxy may override the decisions you wrote in your living will whenever the proxy believes a different choice would be better for you

6

A DNR order automatically prohibits all medical treatments, including intravenous fluids, antibiotics, and supplemental oxygen, not just cardiopulmonary resuscitation

## Explanation

A person with decision-making capacity may revoke or change an advance directive, POLST, or DNR, including by clearly communicating current wishes to the clinical team (Choice 1). A POLST is a clinician-signed portable medical order that translates treatment preferences into actionable orders (Choice 2). An advance directive commonly includes a living will and healthcare power of attorney and guides care when the person loses decision-making capacity (Choice 3). Family-only verbal preferences are not automatically legally binding nationwide and should be documented through the applicable process (Choice 4). A healthcare proxy must follow applicable written directives rather than override them based on personal preference (Choice 5). A DNR limits resuscitation after cardiopulmonary arrest; it does not by itself prohibit fluids, antibiotics, oxygen, or other treatments (Choice 6).

## In-depth explanation

Frame the documents in three layers. Layer 1 — Advance directive: patient-authored, prospective, kicks in only when capacity is lost; combines living will (preferences) plus durable power of attorney (named decision maker). Layer 2 — POLST/MOLST: clinician-signed medical order, immediately effective, portable across hospital/ECF/EMS, designed for seriously ill or frail patients to translate AD preferences into actionable orders covering CPR, ventilation, artificial nutrition, antibiotics, and hospitalization scope. Layer 3 — DNR/AND: a single specific order limiting CPR only; never affects other treatments. Key teaching points: capacity-bearing patient can revoke any of these at any time including verbally; family/proxy cannot override the patient written directives when those directives apply; PSDA mandates hospitals ask about AD on admission; surrogate decision making sequence is patient preferences → substituted judgment → best interest.

## Clinical scenario

Senior wellness fair at a community center. Audience: 35 older adults aged 65 to 88, several with new diagnoses of advanced cancer or heart failure, asking about advance care planning. Nurse presenting a 30-minute educational session followed by individual counseling.

## Key concepts

- **Advance Directive (AD)** — Patient-authored document or set of documents (living will plus durable power of attorney for healthcare) describing future treatment preferences and naming a surrogate decision maker; takes effect only when the patient loses decisional capacity
- **POLST** — Physician or Provider Orders for Life-Sustaining Treatment: a clinician-signed, immediately actionable medical order designed for seriously ill or frail patients that addresses CPR, intubation, antibiotics, artificial nutrition, and hospitalization across care settings
- **Substituted Judgment** — Surrogate decision-making standard requiring the proxy to make the choice the patient would have made if able, based on prior expressed values, written directives, and life patterns; best interest is used only when prior preferences cannot be inferred

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