Education Corner – Advance Care Planning Documents & The Donation Process

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Advance care planning documents have almost no role in the initial aspects of resuscitative care.

Misperceptions with Regards to Advance Care Planning Documents

  • Nationwide living wills (LW) are inappropriately considered “do not resuscitate” (DNR) orders (misperception held 78% of the time).
  • DNR orders are inappropriately equated to comfort care / end-of-life care (misperception held 64% of the time).

Danger of these misperceptions Lack of Action!

Challenges with EOL Care Documents

  • Living wills – not read and understood, lack of clarity of who the Attending is, lack of clarity on definition of “terminal”, and do not address donation.
  • Physician Orders for Life-Sustaining Treatment (POLST) – DNR checked most often on POLST and does not equate to do not treat, e.g. intubation, ventilation, feeding, etc., and does not address donation.
  • DNRs—sometimes inappropriately placed without informed consent from patient and/or family, LW confused as DNR orders, often misinterpreted as “do not treat” and does not address donation.





**Patient safety checklist – see Alliance organ donation toolbox. “Checklists & Forms” category

Organ Donation & Advance Care Planning Documents

  • Advance care planning documents typically do not address donation.
  • A previous declaration to donate supersedes any advance care planning document (unless it specifically addresses donation).
  • If a document does not address the question of organ donation:
    • It does not mean it is not an option—directives should not hinder the donation process.
    • Follow CMS guidelines and hospital policies on maintaining patients for purposes of determining donation potential (see reference).
  • Question whether DNR is being interpreted correctly.

Summary Points:

  1. A LW is not a DNR..
  2. DNR is not “do not treat”.
  3. A LW and POLST are not the same.
  4. Use the patient safety checklist** every time to individualize care and clarify the discussion regarding donation.

**Patient safety checklist – see Alliance organ donation toolbox. “Checklists & Forms” category

Taken from a webinar presentation by Ferdinando L. Mirarchi, DO, FAAEM, FACEP (UPMC Hamot). A special thanks to Dr. Mirarchi for his contributions in this inservice.

Editor: Hedi Aguiar RN, MSN, Director of Programs and Communications, The Alliance,
This Education Corner is available for downloadThe Alliance grants permission for the distribution and reproduction of this educational communication.



Mirarchi FL, Doshi AA, Zerkle SW, Cooney TE. TRIAD VI: How Well Do Emergency Physicians Understand Physicians Orders for Life Sustaining Treatment (POLST Forms? Journal of Patient Safety. 11(1): 1-8.

Mirarchi FL, Cammarata C, Zerkle SW, Cooney TE, Chenault J, Basnak D. TRIAD VII: Do Prehospital Providers Understand Physician Orders for Life-Sustaining Treatment Documents? Journal of Patient Safety. 11(1): 9-17.

Additional references:

CMS Conditions of Participation: §482.45(a)(5)

How to Interpret a Living Will?

Physicians Orders for Life Sustaining Treatment.

Understanding Your Living Will; What You Need to Know Before a Medical Emergency.

What Do DNR orders Really Mean?


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