An Allow Natural Death order is a signed physician order that tells medical staff to withhold CPR and other aggressive interventions when your heart or breathing stops, and to focus instead on comfort: pain relief, symptom management, and routine care during the dying process. It carries the same clinical effect as a Do Not Resuscitate order but frames the instruction around the care that continues rather than the care that is withheld. To take effect, it must be discussed with a physician, signed, and documented in your medical record.
How It Differs From a DNR
Clinically, the two orders produce the same outcome. Neither permits chest compressions, defibrillation, or intubation when the patient arrests. The difference is emphasis. A DNR tells the team what not to do. An AND order tells the team to allow the underlying disease or injury to take its course while continuing comfort-focused care.
The shift in terminology was introduced partly to soften the phrase “Do Not Resuscitate,” which can sound to families like the medical team is giving up. Research on whether patients themselves prefer one term is mixed; one study of patients with advanced cancer found no statistically significant difference in acceptability. Surrogates and family members have shown a stronger preference for the AND framing in several studies. Both terms appear on medical forms depending on the state and facility, and some institutions use them interchangeably.
Who Can Request One
Any competent adult can ask a physician about an AND order. These orders are most common among patients with terminal or serious chronic conditions, but they are not limited to people who are actively dying. The American Medical Association’s guidance on advance care planning encourages physicians to raise these conversations with patients regardless of age or current health.1American Medical Association. Advance Care Planning
The threshold requirement is decision-making capacity at the time the order is created. You need to understand what resuscitation involves, what comfort care without it looks like, and the likely consequences of declining aggressive intervention. If you lack capacity, a legally designated healthcare proxy or someone holding durable power of attorney for healthcare can authorize the order, provided the decision reflects your previously expressed wishes or, where those are unknown, your best interests.
A physician’s signature is what turns the document into an enforceable order. The physician reviews your medical condition, confirms the order fits the clinical picture, and documents it in your chart. Without that signature, the paper is a statement of preference, not a medical order.
For children, parents or legal guardians serve as decision-makers alongside the pediatric care team. Pediatric orders are typically renewed every few days during rapidly changing hospital conditions and roughly every 90 days for children receiving care at home.
Getting the Order Signed and Documented
The form asks for basic identifying information: your full legal name, date of birth, address, and the attending physician’s name and contact details. It then asks you to indicate specific choices about interventions to accept or decline, including CPR, mechanical ventilation, and artificial nutrition, and to specify which comfort measures should continue, such as oxygen for breathing ease, oral fluids, and pain medication.
Signing requirements vary by state. The general pattern involves the patient (or authorized representative) and the physician both signing, plus two witnesses with no financial or familial connection to the patient. Some states accept notarization as an alternative to one or both witnesses, and a handful require both. Where notarization is needed, standard in-person notary fees typically run between $2 and $25 per signature, though some states have no set maximum.
One point of common confusion: the federal Patient Self-Determination Act of 1990 does not set the form requirements for these directives. It requires Medicare- and Medicaid-participating hospitals, nursing facilities, hospice programs, and home health agencies to inform patients of their rights under state law to create advance directives and to document in the medical record whether the patient has one.2Office of the Law Revision Counsel. 42 USC 1395cc – Agreements With Providers of Services Form rules come from each state’s own advance directive statutes.
POLST Forms
In most states, the practical vehicle for an AND order is a POLST form (Physician Orders for Life-Sustaining Treatment), sometimes called MOLST, POST, or COLST depending on the state. As of 2024, 43 states and the District of Columbia have codified POLST programs or have an officially recognized state form. A POLST is not a general advance directive like a living will. It is a specific, portable physician order printed on a brightly colored form (often pink or green) designed to travel with you across care settings. Emergency responders are trained to recognize and follow it.
You can get POLST forms through your physician’s office, a hospital social work department, a hospice organization, or your state’s department of health website. The form is completed during a conversation between you (or your surrogate) and a qualified healthcare professional, then signed by both. A completed POLST is immediately actionable, unlike a living will, which requires interpretation.
Where to Keep the Order
Filing matters as much as signing. The original should go to the hospital’s medical records department, with a copy in your primary care physician’s chart. If you are receiving hospice care at home, the hospice team needs a copy too. For patients at home, keep the form somewhere visible and accessible. Emergency responders arriving at a house have minutes, not time to search through filing cabinets. Taping the form to the refrigerator or near the bed is standard practice. Anyone named as a healthcare proxy should also carry a copy.
If You Travel or Move
Enforceability in a new state is generally supported but not guaranteed. Most states have provisions recognizing out-of-state advance directives, typically accepting a directive if it was valid where signed or if it meets the requirements of the state where treatment is delivered. Some states apply a presumption of validity unless the provider has reason to doubt authenticity. POLST forms, though, are state-specific, and a form from one state may not be instantly recognized by EMS in another. If you spend significant time in more than one state, completing a POLST in each is the safest approach.
Military personnel have a separate federal option. An advance medical directive executed through the military legal assistance program is exempt from state form requirements and must be given the same legal effect as a directive prepared under the state’s own laws.3Office of the Law Revision Counsel. 10 USC 1044c – Advance Medical Directives of Members and Dependents
What Happens When the Moment Comes
When a patient with a valid AND order goes into cardiac or respiratory arrest, the clinical response shifts entirely toward comfort. Staff will not perform chest compressions, use a defibrillator, insert a breathing tube, or start artificial feeding. They will give medications to ease pain and respiratory distress, typically morphine or a similar drug. They continue routine physical care: repositioning to prevent bedsores, mouth care, and hygiene. The goal is to manage symptoms without attempting to reverse the underlying cause of death.4American Medical Association. Orders Not to Attempt Resuscitation (DNAR)
Paramedics follow the same principle. They are trained to look for the AND or POLST form on arrival. If a valid order is present and accessible, they will not initiate resuscitation. If the form cannot be located, most EMS protocols require them to begin full resuscitation until they can confirm the order exists. That is why visibility matters so much at home.
Changing Your Mind
p>You can revoke an AND order at any time, for any reason. Tell your attending physician, and they are required to remove the order from your medical record. A healthcare agent can request revocation on your behalf if you cannot communicate. Beyond notifying the physician, destroy all physical copies of the form and any associated identification, such as the colored wristbands some hospitals use to flag the order for staff. Old copies left in circulation create a real risk that a provider will follow an outdated directive during an emergency.
Even without a formal revocation, revisit the directive periodically. Best practice calls for reviewing it at every hospital admission and at annual wellness visits, especially for older adults or anyone with a serious diagnosis. A directive that reflected your wishes five years ago may not match what you want today.
If a Provider Ignores the Order
A valid AND order is a binding medical directive. When a provider performs resuscitation or other aggressive interventions against a patient’s documented wishes, the patient or family may have legal recourse. Courts have increasingly recognized claims for what is sometimes called wrongful prolongation of life, where the harm is the suffering caused by unwanted medical treatment rather than the treatment’s failure.
Successful claims have been brought under several legal theories, including medical battery, negligence, breach of fiduciary duty, and intentional infliction of emotional distress. Damages can include compensation for the physical pain of unwanted interventions and the emotional harm to the patient and family, with reported outcomes ranging from settlements in the hundreds of thousands of dollars to a million-dollar resolution, varying widely by jurisdiction.
Most states provide some legal immunity to providers who follow a valid directive in good faith. That protection generally does not extend to providers who override a directive without first notifying the patient or family so they can seek care elsewhere. The emerging standard is that hospitals have an obligation to know about existing directives and to honor them.
The Default Without One
Without a valid AND order or DNR on file, the default in every healthcare setting is full resuscitation. Medical teams will perform CPR, use defibrillators, intubate, and apply every available intervention to restart the heart and restore breathing. This is true even if family members verbally object at the bedside. Verbal wishes, no matter how clearly expressed, do not override the standard protocol. The only reliable way to prevent unwanted resuscitation is a signed, accessible physician order, and the conversation with a doctor should happen well before a crisis rather than during one.1American Medical Association. Advance Care Planning