Hawaii DNR Form: POLST, Comfort Care Only Bracelets, and How They Work
Searching for a "Hawaii DNR form" leads to confusion because Hawaii uses different medical-order systems for facility and out-of-hospital care. The Provider Orders for Life-Sustaining Treatment (POLST) form provides portable medical orders, while the Comfort Care Only (CCO-DNR) program provides out-of-hospital identification.
Understanding which does what — and which one EMS actually follows — is the difference between your wishes being honored and full resuscitation being performed against your will.
The POLST Form: Hawaii's Version of a DNR
The Hawaii POLST is a bright lime-green form that converts a patient's treatment preferences into active, enforceable medical orders. Unlike an advance directive, which is a planning document, a POLST is a set of medical orders that take effect immediately.
A POLST can specify:
- Section A: Whether to attempt CPR or allow natural death (this is the DNR component)
- Section B: Level of medical interventions — full treatment, selective treatment, or comfort-focused treatment only
- Section C: Antibiotics — full treatment, limited treatment, or comfort measures only
- Section D: Medically administered nutrition, including feeding-tube choices
The form must be signed by the patient (or their authorized surrogate) and the attending physician, advanced practice registered nurse (APRN), or physician assistant (PA). You cannot create a POLST on your own. It requires a clinical conversation about your current medical condition.
The most recent version was revised by the Hawaii Department of Health in May 2023, incorporating input from Kokua Mau, the statewide hospice and palliative care organization.
The Comfort Care Only Bracelet
The CCO bracelet is a physical, wearable identifier that tells EMS responders the patient has a valid CCO-DNR order. When paramedics arrive at a scene on any Hawaii island, they look for the bright lime-green POLST form or the state-approved orange CCO-DNR bracelet or necklace before deciding treatment.
EMS relies on a valid POLST or CCO-DNR identification physically present for out-of-hospital orders; an advance directive alone is not a pre-hospital medical order. When the valid identification is present, EMS provides comfort care and withholds CPR, defibrillation, intubation, and cardiac medications.
CCO bracelets or necklaces are typically ordered through the patient's healthcare provider or through Kokua Mau. They are distinct from generic medical alert bracelets — only the state-approved orange CCO-DNR identification carries legal weight with Hawaii EMS.
POLST vs. Advance Directive: They Do Different Things
An advance directive under HRS Chapter 327E is a planning document. Its agent authority normally activates when your primary physician determines you lack capacity, unless Part 1 elected immediate authority; the AHCD itself is not a pre-hospital medical order.
A POLST is a set of current medical orders for someone with a serious illness or advanced frailty. It goes into effect the moment it is signed and travels with you — on the refrigerator door, in the ambulance, to the emergency room.
| Feature | Advance Directive | POLST |
|---|---|---|
| Who creates it | The patient | Patient + attending physician/APRN/PA |
| When it activates | When capacity is lost | Immediately upon signing |
| Who follows it | Hospital care teams | EMS, hospitals, care facilities |
| What it covers | Agent designation + treatment preferences | Specific medical orders (CPR, intubation, feeding) |
| Required for out-of-hospital orders | No | A valid POLST or CCO-DNR identification is used |
Some people with a serious illness may use both, depending on their medical situation. The advance directive covers long-term decision-making authority. The POLST or CCO-DNR identification covers applicable out-of-hospital orders.
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Who Should Have a POLST
A POLST is not for everyone. It is designed for people who:
- Have a serious, life-limiting illness (cancer, advanced COPD, end-stage renal disease)
- Are in advanced age with increasing frailty
- Live in a care facility (nursing home, assisted living, residential care home)
- Have a condition where full resuscitation would cause more suffering than benefit
Healthy adults do not need a POLST. They need an advance directive that names a healthcare agent and documents treatment preferences for a future scenario. The POLST becomes relevant when the medical situation shifts from hypothetical to active.
Getting a POLST on Neighbor Islands
On Oahu, most hospital systems (Queen's Health System, Hawaii Pacific Health, Kaiser Permanente) have integrated POLST discussions into their palliative care and discharge planning workflows. On the Big Island, Maui, and Kauai, access to the clinical conversation required for a POLST can be harder to arrange — fewer palliative care specialists, longer waits for appointments, and limited hospice coverage in rural areas.
Kokua Mau maintains resources and provider directories for all islands. Your primary care physician can also initiate the POLST conversation — it does not require a specialist.
Connecting Your DNR Wishes to Your Advance Directive
The Hawaii Advance Directive & Living Will Kit includes a POLST coordination reference that explains how your advance directive treatment instructions align with each POLST section — so your planning documents and your active medical orders say the same thing.
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