Do Not Resuscitate Massachusetts: DNR Orders, MOLST, and What EMS Will Actually Honor

Writing "do not resuscitate" on a piece of paper and taping it to your refrigerator does not work. When paramedics arrive at a Massachusetts home and find a patient in cardiac arrest, they are trained and legally required to begin CPR immediately — unless they see a valid, recognized medical order form signed by a clinician. A handwritten note, a health care proxy, or a hospital bracelet from a previous admission will not stop resuscitation efforts.

Massachusetts has specific forms and protocols governing DNR orders. Getting this right is a matter of minutes, not days.

The Two Valid DNR Instruments in Massachusetts

Massachusetts recognizes two forms that direct EMS to withhold CPR:

Comfort Care / Do Not Resuscitate (CC/DNR): A standalone medical order focused exclusively on one decision — withholding cardiopulmonary resuscitation. It directs EMS and clinical providers not to perform chest compressions, intubation, or cardioversion if the patient's heart stops or they stop breathing. The CC/DNR addresses nothing else: not antibiotics, not feeding tubes, not hospitalization.

MOLST (Medical Orders for Life-Sustaining Treatment): A broader medical order form that covers CPR plus multiple other treatment categories — medical interventions (full, selective, or comfort-focused), artificial nutrition, and antibiotics. A MOLST form that specifies "Do Not Attempt Resuscitation" functionally includes the DNR directive plus additional treatment instructions.

Both forms are legally binding on EMS personnel and all clinical providers across every care setting in Massachusetts — emergency rooms, nursing homes, hospice programs, and home visits.

Who Can Sign a DNR Order

A DNR is a medical order, not a personal legal document. You cannot sign it alone. The process requires:

1. The patient (or their Health Care Agent, if the patient lacks capacity) consents to the order
2. A clinician — physician, nurse practitioner, or physician assistant — co-signs the form after a clinical discussion about the patient's condition, prognosis, and treatment preferences

The clinical discussion is mandatory. A clinician cannot simply hand you the form and ask you to sign. They must explain the medical implications: what CPR involves, what the realistic outcomes are given your specific condition, and what comfort-focused care looks like as an alternative.

DNR Does Not Mean "Do Not Treat"

One of the most common and most dangerous misconceptions: a DNR order does not mean doctors stop providing medical care. It means one thing only — no CPR if your heart stops.

A patient with a DNR order still receives:

• Pain management and comfort care
• Antibiotics for infections (unless a MOLST specifies otherwise)
• Medications for chronic conditions
• Wound care, physical therapy, and other ongoing treatments
• Emergency treatment for non-cardiac conditions
• Hospital transfers when medically appropriate

If you want to limit treatments beyond CPR — such as refusing mechanical ventilation, artificial nutrition, or hospitalization — you need a MOLST form, not a standalone CC/DNR.

How EMS Handles DNR Situations in the Field

When Massachusetts EMS responds to a cardiac arrest, their protocol follows a strict hierarchy:

1. Look for a valid form: EMS checks for a MOLST or CC/DNR form. These are printed on recognizable, often brightly colored paper. The form must be signed by both the patient (or agent) and a clinician.
2. If a valid form exists: EMS follows the orders on the form. For a CC/DNR, they withhold CPR and provide comfort measures. For a MOLST, they follow the specific instructions for each treatment category.
3. If no valid form exists: EMS begins full resuscitation efforts immediately, regardless of what family members say, regardless of any written notes or verbal instructions, and regardless of any health care proxy document present.
4. If both a MOLST and a CC/DNR exist: EMS follows the most recently signed document.

A Health Care Proxy alone does not stop CPR. The proxy appoints a decision-maker, but in a cardiac arrest situation, there is no time for the agent to exercise decision-making authority. EMS needs a pre-signed medical order.

Where to Keep Your DNR or MOLST

The form must be physically accessible. EMS will not search your house:

• On the refrigerator door (the traditional location — EMS is trained to check there first)
• Near the front door or in a visible location in the main living area
• With the patient at all times if in a care facility
• In a wallet-sized copy for emergencies outside the home
• In your electronic health record — ask your physician to scan the form into the system

When the ePOLST Registry launches in Massachusetts in Spring 2027, EMS will also be able to access your MOLST orders electronically, reducing the risk of a missing paper form.

Revoking a DNR

A DNR order can be revoked at any time. If the patient regains capacity and changes their mind, a verbal statement to any healthcare provider is sufficient. The clinician documents the revocation and a new set of orders (or no orders) goes into effect.

A Health Care Agent can also revoke the DNR if they determine that the patient's wishes have changed or if the patient's medical condition has improved in ways that alter the analysis.

The Massachusetts Advance Directive & Living Will Kit includes a MOLST/ePOLST reference guide and a personal directive template for documenting your CPR and treatment preferences before a clinical conversation occurs.

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