Advance directives occupy a different legal space from MOLST and DNR orders, and that difference matters in the field.

An advance directive — whether it is a living will or a healthcare proxy designation — is a legal document created by the patient, usually with an attorney or through a state-provided form. It reflects the patient’s expressed wishes for their own care. It is a meaningful document. But it is not a physician’s order.

In prehospital settings, EMS operates on physician orders. A MOLST and a DNR are both signed by a physician. An advance directive is not. What this means practically: if the only document present is a living will, EMTs cannot treat it as a MOLST. They can use it as guidance — particularly if it is consistent with the clinical picture — but it does not carry the same immediate operational weight.

The healthcare proxy is a different matter. If a patient lacks decision-making capacity and a designated healthcare proxy is present, that person has legal authority to make medical decisions on the patient’s behalf. That authority is meaningful and should be respected. But it still cannot override a valid physician’s order. If a MOLST says Comfort Measures Only and the healthcare proxy is demanding aggressive intervention, the MOLST takes precedence. The proxy’s authority exists in the absence of a physician’s order — not in competition with one. These distinctions matter because they are exactly what gets sorted out in the first minutes on scene.