Advance Directives and POLST for Dementia
One is a legal document in a drawer. The other is a medical order that paramedics will actually follow. Most families only have the first.
Key takeaways
- An advance directive is a legal document the person writes. A POLST is a medical order a clinician signs after a conversation.
- Paramedics generally follow a POLST or a DNR. They do not follow a living will. That single fact decides what happens when somebody calls 911.
- A POLST travels with her — into the ambulance, the emergency room, the facility chart. An advance directive usually sits in a drawer.
- POLST is for people who are seriously ill or frail. Advanced dementia qualifies.
- It covers four things: CPR, whether to transfer to the hospital, intensive treatment including ventilation, and artificial feeding.
- Dementia needs its own conversation, because the standard forms assume a decision point that dementia never provides.
- Names and rules vary by state — POLST, MOLST, POST, COLST. Ask what yours is called.
What is the difference between an advance directive and a POLST?
One is a legal document she writes for the future. The other is a medical order a clinician signs for right now.
Almost every family has heard of the first and almost none have the second, and the gap between them is where unwanted resuscitations happen.
- Advance directive — a legal document, completed by her, for a future in which she cannot speak. Includes the living will and the healthcare power of attorney. Nobody signs it but her and her witnesses.
- POLST — a portable medical order, completed by a clinician after a conversation with her or her decision-maker, describing what to do now. It has a doctor's or nurse practitioner's signature on it, which is what gives it force.
What a POLST covers
Four decisions, each answerable separately.
- CPR if her heart stops and she is not breathing.
- Whether to transfer to the hospital, or treat where she lives and only transfer if comfort cannot be achieved.
- Intensive treatment, including intubation and mechanical ventilation.
- Artificially administered nutrition, including feeding tubes.
The second one carries more weight in dementia than families expect. Hospital transfer is frequently the single most burdensome thing that happens to someone with advanced dementia — unfamiliar rooms, restraints, delirium, decline — and much of it can be avoided by treating in place. A POLST that says comfort-focused treatment, transfer only if comfort needs cannot be met here changes what happens on a Sunday night, without waiting for anyone to reach you.
It is not all-or-nothing. Full CPR with no hospital transfer is a coherent combination. So is comfort-focused care with antibiotics. The form exists to let those decisions come apart.
Why dementia needs its own conversation
Standard forms assume a moment of crisis. Dementia gives you a decade of gradual change instead.
Most advance directives are written around a scenario — terminal illness, permanent unconsciousness — and ask what should happen then. Dementia does not work that way. There is no day the illness announces itself as final. She will be moderately impaired for years, then severely impaired for years, and every intervention question arrives repeatedly along the way.
Dementia-specific supplements exist for this. They let someone record different instructions at different stages: what she would want treated while she still knows her family, and what she would want when she no longer does. Given how long the late stage can run, that distinction does real work.
Some versions also address assisted feeding by hand, which is genuinely contested. States differ, facilities differ, and a directive refusing hand feeding may not be honored where she lives. If that matters to her, raise it with an attorney and with the facility, and find out now rather than discovering later that nobody will act on it.
Doing it in the right order
Directive early, while she can still write it. POLST later, when frailty makes an emergency likely.
- Right after diagnosis: healthcare power of attorney, living will, HIPAA authorization. She has to sign these herself and the window closes — see what happens when she can no longer sign.
- Have the conversation while she can be in it. Not what she wants done, so much as what she is afraid of, what would make a day worth having, and where the line is for her. Write down her actual words. Those sentences will carry you through decisions the forms never anticipated.
- When she becomes frail or advanced: ask her doctor for a POLST. It requires a conversation, not just a signature.
- Distribute it. The original travels with her. Copies to the facility chart, the primary care office, hospice if involved, and every family member who might call 911. Many states have a registry — ask.
- Put it somewhere paramedics will look. On the refrigerator or the back of the front door. That sounds undignified; it is what emergency responders are trained to check.
- Review it after every hospitalization. A POLST written two levels of function ago may no longer say what anyone would choose today.
None of this is about giving up. It is about being the one who decides, instead of leaving it to whoever is on shift when the phone rings.
Frequently asked questions
Do we need both?
Can I sign a POLST for her if she no longer has capacity?
Does a DNR mean she gets no treatment?
What is a dementia-specific directive?
Decide it now, so nobody has to guess later.
Day to Day Dementia is built by people who learned this the hard way and wrote it down so you would not have to. Join the waitlist for the guides as they are released.
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- National POLST. About the POLST Form.
- Advance Directives. StatPearls, National Center for Biotechnology Information.
- Alzheimer's Association. Legal Documents.