END-OF-LIFE MEDICAL ORDERS (ELMO)
End-of-Life Medical Orders are created from careful
between the named patient
and the named terminal-care
who has agreed to give medical care to this patient
at the end of the patient's life.
ELMO replaces and elaborates DNR and POLST.
ELMOs will be in electronic format from the
which will allow them to be expanded as needed
and which will make them easy to share
with all medical caregivers and institutions
that might become involved in the terminal care of this patient.
REJECTING MEDICAL TREATMENTS AT
THE END OF LIFE
A. PROBLEMS WITH
DO-NOT-RESUSCITATE ORDERS (DNR)
B. PROBLEMS WITH
PHYSICIAN ORDERS FOR
LIFE-SUSTAINING TREATMENTS (POLST)
COMPREHENSIVE WRITTEN PLANS
FOR MEDICAL CARE IN THE LAST YEAR
END-OF-LIFE MEDICAL ORDERS (ELMO)
1. DATE, DURATION, & UPDATES
2. IDENTIFYING THE PATIENT AND THE DOCTOR
COMPLETE EXPLANATION OF THE PATIENT'S MEDICAL PROBLEMS
AND THE LIKELY
4. COORDINATION WITH THE PATIENT'S
DIRECTIVE FOR MEDICAL
THE BEST LOCATION FOR DYING
6. THE MOST LIKELY CAUSES OF DEATH
THE PREFERRED METHODS OF MANAGING DYING
8. SPECIFIC MEDICAL ORDERS FOR END-OF-LIFE TREATMENTS
REJECTING MEDICAL TREATMENTS
AT THE END
Earlier attempts to create written plans for the end
have mainly rejected
specific forms of medical treatments.
DO-NOT-RESUSCITATE ORDERS (DNR)
BLANKET DNR ORDERS COULD LEAD TO PREMATURE DEATH.
When checking a list of possible methods of
preventing immediate death,
many patients end up saying "Do nothing to save me from death."
2. ADVANCE REJECTION OF ALL MEDICAL TREATMENTS.
Some potential patients have decided to forgo all
future medical care.
They never want to see a doctor or be taken to a hospital.
DOCTORS DO NOT TATTOO THEIR MEDICAL ORDERS ON THEIR PATIENTS:
PREFERENCE AND DNR
Patients mistakenly believe that saying they do not
want to be resuscitated
will automatically mean they will
not be treated if they begin to die.
INFORMED REFUSAL OF MEDICAL TREATMENTS.
When patients fully understand the implications of
rejecting medical care,
they do have a right to specify in advance what treatments to avoid.
DNR ORDERS ARE ALWAYS SUSPENDED FOR SURGERY AND RECOVERY.
When patients request (or consent to) any medical
they are agreeing to being kept
alive during that treatment,
even if a DNR order has been created by a physician.
DNR ORDERS DO NOT MEAN DO
NOT TREAT OR ALLOW TO
Both laypersons and medical professionals sometimes
DNR orders to mean that this patient is expected to die
and that therefore no
further medical treatment is wanted.
7. SOMETIMES DNR ORDERS ARE ISSUED BY DOCTORS WITHOUT CONSENT.
Patients and families sometimes discover
that Do-Not-Resuscitate orders have been created by their doctors
without their knowledge or consent.
Explore these 7 pitfalls with DNR orders more
LIFE-SUSTAINING TREATMENTS (POLST)
FREQUENTLY THE WRONG PERSON
HELPS THE PATIENT FILL OUT THE POLST.
Even tho the doctor must ultimately sign the POLST,
it often becomes just another item of paperwork in the doctor's office.
Someone else might explain the medical terms used in the POLST,
but this does not lead to any meaningful discussion of end-of-life
POLST CONTAINS NO BACKGROUND MEDICAL INFORMATION.
Because the POLST is only two pages long,
there is no place to explain the medical reasons for the choices made.
Why is this patient
rejecting the specified life-sustaining treatments?
POLST HAS AN UNCLEAR RELATIONSHIP WITH
DIRECTIVE FOR MEDICAL
Because it has a later date, sometimes the POLST
any Advance Directive for Medical Care previously created by the
Should the earlier written plans for end-of-life-care be ignored?
POLST HAS A VERY LIMITED RANGE OF MEDICAL OPTIONS.
POLST forms usually offer only three options for
end-of-life medical care:
(1) maximum medical treatments; (2) intermediate care; (3) comfort-care
How meaningful are these three check-boxes?
POLST DOES NOT HAVE ENOUGH SPACE TO EXPLAIN CHOICES.
Usually, the exact medical condition of the patient
at the time
would be more important than the plans in a POLST.
Without more facts, how can the option selected by applied?
SOMETIMES 'ADVISORY' OR 'DRAFT' POLSTS ARE CREATED.
Preliminary end-of-life plans are sometimes created,
with even less consultation between the patient and the doctor.
Even without legal standing, such documents could have terrible
POLST WAS POORLY NAMED.
These medical orders do not deal exclusively with forms of
Patients want more than simple refusal of specified medical treatments.
Read a complete exploration of each of these
James Leonard Park
1. DATE, DURATION, & UPDATES
End-of-Life Medical Orders are intended
for the last year of the patient's life.
Up until the beginning of what will probably be the last 12 months of
the patient should create a comprehensive Advance Directive for Medical
The Advance Directive should be reviewed by the patient's primary-care
who might not be the
physician most responsible for this patient's terminal care.
When the physicians caring for this specific patient
agree that they would
surprised if this patient were to die within the next 12 months,
then it is time to create a specific, written end-of-life medical plan.
Terminal care and palliative care should be included
in the ELMO.
The expected effective duration of these medical orders
is projected to be the rest
of this patient's life.
But if there is any change in this period of application,
that should be noted in this first section of the ELMO whenever it is
It might take some time for this patient to select
the best terminal-care doctor.
They should have meaningful discussions concerning each part of
And this first section of the resulting document should list each of
this physician and this patient got together to discuss the end-of-life
The duration of each
consultation should also be noted,
which will show all readers that these were comprehensive discussions,
not just filling out more
When other family members help create
these end-of-life plans,
their participation should also be noted in this section of the ELMO.
This would be especially important if some of these family members
are named as formal proxies or surrogates, who will carry forward the
when the patient is no longer able to make day-to-day medical
The End-of-Life Medical Orders will be in English
wherever English is the primary language of the medical professionals.
Because English is the operative language of this health-care system,
all of the other orders are already in English.
Translation to and from other languages
might be part of the process of creating an ELMO.
This would be especially important if the patient and/or the proxies
do their thinking in
some other language.
And because this is such an important health-care document,
there might be more than one translation
just to make certain that everyone understands
what is being
decided and put into writing.
The official date of the ELMO will be
the date when
both the doctor and the patient sign it,
affirming that they will follow the end-of-life plan
as laid out in
the best of their abilities.
Because the original ELMO will be in electronic
these signatures will also be electronic.
Perhaps a photograph could be taken of the doctor and the patient
(and any proxies or family members) having their end-of-life
And the staff person who actually puts the agreement into electronic
will be a witness that these people did meet and create this agreement.
Sometimes either the original ELMO or some later
revision of it
will be an agreement between
the terminal-care doctor and the proxies
for the patient.
When the patient loses decision-making capacity, the proxies take over.
Any changes in the End-of-Life Medical Orders
must be authorized by at least two persons fully able to decide:
(1) the terminal-care physician &
(2) the named patient if still able to make medical decisions
or the authorized proxies/agents for this patient
if the patient is no longer able to engage in meaningful discussions.
The person who actually enters the electronic
changes to this document
should make certain of the identifies of the physician and patient or
This staff person is acting as a witness
just as he or she was a witness for the original creation of the ELMO.
Whenever there are any revisions to the ELMO,
the new dates will appear in this first section of the document.
This will assure all who read it that they are reading the latest
which will include up-to-date information
about the medical condition and any new medical plans for this patient.
IDENTIFYING THE PATIENT AND THE DOCTOR
This second section of any ELMO clearly identifies
name, address, telephone number, medical records numbers, etc.
should also be named and identified in this
If and when the patient is no longer able to make further end-of-life
this individual (or committee) has been authorized
to make medical decision on behalf of the named patient.
All contact information for the proxies should be included here.
Sometimes the patient is already beyond making any
In that case, the ELMO must be created by the physician and the
The physician who has agreed to provide terminal
care to this patient
will next be identified.
This might be the primary care physician for this patient,
but if some other physician is likely to give terminal medical care,
that terminal-care doctor should create the ELMO with this
This helps to distinguish end-of-life care from
all the other forms of
medical care that will be provided to this
before it becomes obvious this patient has begun the last few
months of life.
For example, if the patient expects to enter a
hospital or hospice,
the physician who will be most responsible for the terminal care
should be the medical professional who creates this ELMO with this
Normally all medical care aimed at cure
will be handled by other primary-care physicians and various
When these medical professionals would not be surprised
if this patient were to die
within the next 12 months,
then it is time to create a formal, written end-of-life
This criterion of 'not being surprised by death'
is more open and comprehensive than "terminal illness",
which in many official documents means less than 6 months to live.
If the terminal-care physician changes for
the earlier ELMO will be revised and/or replaced by a new document,
showing the exact agreements between this new terminal-care physician
and the patient and/or the proxies for this patient.
The patient with End-of-Life Medical Orders
is known to be approaching death,
but the specific medical condition of the patient
might make it difficult to predict a definite month of death.
3. COMPLETE EXPLANATION OF
AND THE LIKELY
This third section of the End-of-Life Medical Orders
will be created by the doctor
who knows the most
about the medical history of this patient.
This might not be the same doctor who will provide terminal medical
But when these are different doctors,
they should agree about this section of the ELMO.
And various specialists might be identified
as having treated specific medical problems of this patient.
Because the ELMO is an electronic document,
this part explaining the diagnoses
of the various medical problems of the patient
can be as long as necessary
to give a full picture
of how this patient is likely to meet death.
Some patients might have long lists of
Which of these named diseases or conditions
have the greatest potential to cause the patient's death?
Everything in this diagnosis and prognosis
should be explained in terms that laypersons can understand.
Technical medical terms and test might be named,
but everything should also be presented in ways
that can easily be understood by this patient and/or the proxies.
And even when several doctors contribute to this
one specific physician should be named as the terminal-care doctor.
This doctor takes charge of the end-of-life care for
COORDINATION WITH THE PATIENT'S
DIRECTIVE FOR MEDICAL CARE
When this patient already has a written Advance
Directive for Medical Care,
the Advance Directive might be a good beginning place for creating the
This patient has already thought carefully about what kinds of medical
he or she wants at the end of life.
When this patient gets together with this
they will probably know more about the physical condition
of the patient
than when the Advance Directive was created and/or revised.
Some of the original plans might now be
irrelevant or impossible.
This could lead to changes in the Advance Directive.
But more likely the End-of-Life Medical Orders
will take into account the specific medical changes
that will now shape the remaining medical decisions for this
The ELMO does
not replace the Advance Directive.
But to the greatest extent possible,
this doctor and this patient are now agreeing
just what kinds of medical treatments will be applied or avoided.
When more details are needed concerning the patient's end-of-life plans,
the earlier Advance Directive might be the best place to find such
The ELMO and the AD should refer to each other,
showing where and how the other will be found.
5. THE BEST LOCATION FOR DYING
Medical Orders are only created
when the patient is obviously in the last phase of life:
Death is coming within the next few months.
Thus the doctor and patient are creating the best plans
for these last months, weeks, or days.
Becoming thus serious about the actual processes of
means that the patient has passed the general wish to 'die at home'
is almost universal.
A sudden death might
be expected and welcomed at home.
But a managed dying
will probably take place in some other location.
However, if the patient has sufficient support in
the home environment,
this setting could be modified
as needed to make it a good location for
What special equipment and accommodations must be provided
to make this an appropriate place to meet death?
At-home hospice programs can help with all such details.
Since this End-of-Life Medical Order is being
in preparation for the last months of this patient's life,
the practical arrangements should be made at the same time.
Delaying making these
arrangements will always be worse
than making these arrangements too soon.
And the very process of making the nest for dying
will make everyone more aware of the fact that death is coming.
If this death is going to take only a few days,
then a hospital-death can be
Perhaps the patient is already living in a hospital
and there does not seem to be any reason to change locations for dying.
The end-of-life plan embodied in the ELMO
can be presented to the hospital administration for its approval.
If this will be a quick death because of the methods of dying selected,
then its duration might be within what can be tolerated by the hospital.
A more likely location for dying is a residential
While the patient is still able to move from place to place,
it might be wise to visit
various available residential hospices
to see which would be best for this patient and his or her family.
The doctor should also have some input into this choice of location.
Will this terminal-care physician provide care
in the location preferred by the patient and/or the family?
If there are no reasonable residential hospice
then a nursing home
might be the best location for dying.
This will also require some advance planning,
since some nursing homes have a policy
of always trying to transfer
dying patients to the local hospital
for the last few hours of dying.
Also some nursing homes have policies that might discourage
the chosen methods of managing dying described later in the ELMO.
7: The Preferred Methods of Managing Dying)
When we are dying, we do not want to become involved
about exactly what is permitted within a particular system of medical
Earlier POLST forms sometimes rejected
But this cannot be made effective
unless an alternative
location for dying has already been prepared.
If the chosen location for dying is different
from the location where the patient is already living,
then some plan should be presented here
for deciding just when and
how to transfer the patient
to the planned location where the dying process will be
these might become the most receptive places to actualize ELMOs.
6. THE MOST LIKELY CAUSES OF DEATH
Because the End-of-Life Medical Orders
are definitely about how this patient will approach death,
it will omit the various medical treatments
that have already been tried to prevent death.
The curing and healing parts of medical care have now mostly ended.
In creating these end-of-life medical orders,
the doctors are agreeing that they would not be surprised
if this patient dies within the next 12 months.
The doctors are well aware of the medical problems
that will lead to this patient's death.
If there are several medical problems in this
they can all be named in order of importance.
This patient will ultimately have a death-certificate created by a
In the space for the causes
what are the most likely medical problems to be named?
Sometimes the patient has not fully grasped that
death is coming.
So these End-of-Life Medical Orders will put into writing
what might have been an implicit
For example, if and when this patient is admitted to
a hospice program,
the most likely causes of death
will already be named on the admission form.
And if the pathway towards death is very clear,
the hospice program and the terminal-care doctor can agree in advance
will be named as the principal causes of death.
7. THE PREFERRED METHODS OF
Because this will be a managed death
rather than a death fought as a retreating action to the last ditch,
the terminal-care doctor and the patient can agree in advance
just which medical methods
of managing dying would be
In modern medical care, it has become possible for
the first time
to distinguish the methods
of dying from the causes
Up until now, these were usually exactly the same phenomena:
When heart-failure was the cause of death,
dying took place when the heart stopped working.
When cancer was the cause of death,
the patient died when the cancer overwhelmed the body.
When bacteria were the case of death,
the patient died when the body could no longer fight off the infection.
But now that we die while receiving medical care,
the specific forms of medical support (and their withdrawal or
will become the primary methods
of managing dying.
This seventh section of the ELMO will be created
by the terminal-care physician and the patient.
It is important to have these plans in writing
in order to avoid any possible conflicts at the end of life
over the methods that will be used to ease this patient's process of
The following four possible medical methods of
can be used in any
Each method has a chapter-long explanation linked from its name.
Usually the patient will be receiving some drugs
intended to ease all of the symptoms of the disease or injury.
And now that the patient has entered the last phase of life,
there are no further dangers associated with using too much medication.
Addiction and dependence are no longer
This patient will never return to ordinary life.
Do this patient and this doctor agree in advance
to use whatever level of
medication for pain and other symptoms
that the patient finds best?
And are they agreeing in advance not to worry
if the drugs used to control terminal symptoms
might also shorten
the process of dying?
Even if the increased pain-medication
causes the date of death to come somewhat sooner,
everyone agrees in advance to list as the cause of death
the underlying disease or condition
that brought this patient's life to an end.
Comfort-care or palliative care
should never be listed as a cause of death.
Sometimes the pain and other symptoms of dying
are so terrible that the patient and the doctor agree
to keep the patient
for the rest of the process of dying.
This means that the physician will order
that drugs be continuously
given so that the patient will never awaken.
If this patient and this doctor agree to use
method of managing dying,
let that decision be put into writing here in the ELMO.
And if they do have this advance agreement,
the proxies for the patient can ask for induced terminal coma
even after the patient has lost all meaningful capacity
to authorize this method of managing dying.
curative treatments and life-supports.
Usually when the End-of-Life Medical Orders come into effect,
all curative treatments have already been abandoned.
But if this has not been explicitly acknowledged by everyone involved,
let it be stated in the medical record:
All medical treatments and drugs that were aimed at curing the patient
have now ended or been withdrawn.
If even more obvious methods of life-support were in use
as a respirator or a feeding-tube—
can also be discontinued
if agreed in advance in these End-of-Life Medical Orders.
All life-sustaining medical treatments are now finished.
Also, as a part of giving up all life-supports,
this patient and this doctor can agree in advance
to give up all means of providing food and water to this patient.
This is standard medical practice when terminal sedation is ordered.
Since the patient will be completely unconscious for what remains of
there is no point in providing nutrition and hydration by tubes.
In some locations on the Earth,
the doctor is permitted to prescribe some chemical means
by which the patient's life will
Usually the other methods of dying mentioned above
will be completely satisfactory to achieve a peaceful and painless
But if this patient and this doctor
are operating within a jurisdiction with a right-to-die law,
they also have this additional method of choosing death.
As mentioned at the beginning of this list,
the doctor and the patient can agree on
any combination of these
methods of dying.
Of course, if it is legal to choose gentle poison
and if they have fulfilled all of the stated requirements
for using this method of dying,
they will not have to consider any of the other methods:
They will apply for permission to give this patient
lethal chemicals that will bring immediate death.
It should be noted that the first four methods of
are all within the normal
practice of medicine.
No special permission is required from other individuals or
The doctor and the patient have complete freedom
to choose any combination of the first four methods of managing
The patient and the patient's family might have some
concerning the doctor-approved normal methods of managing dying.
If so, let these be explained in this section of the End-of-Life
The causes of death
have already been established in Section 6 of the ELMO.
Now the patient, the family, & the terminal-care doctor
will project what
combination of methods of managing dying
will be most appropriate for achieving the best last day for this
SPECIFIC MEDICAL ORDERS FOR END-OF-LIFE TREATMENTS
Given the diagnosis and prognosis by the
terminal-care physician (3),
the advance care plans written by the patient (4),
the selected and organized location for dying (5),
the most likely causes of death for this patient (6),
& the agreed-upon combination of methods of managing dying (7),
should more specific medical orders be created
for the last few months or weeks of this patient's life?
For example, should Do-Not-Resuscitate orders be
If this patient and this doctor have agreed in advance
that this patient should be
allowed to die
whenever the next life-threatening event happens,
then this section of the End-of-Life Medical Orders
should explicitly include those directions:
When this patient begins to die from any cause,
no efforts will be started to
save the patient from death.
are usually very unwise
because some medical
problems can easily be resolved
and the patient will have some additional meaningful days of
But if this patient and this doctor have decided
that the patient will leave
the freeway at the next exit no matter what,
then they can prohibit any attempts to save the patient from
For the benefit of everyone involved,
especially those who know little about how death usually comes,
the terminal-care doctor should explain in this section
the most likely pathway
towards death for this patient.
What progression of the diseases should be expected?
And what will happen as each predictable phase of dying unfolds?
What is the expected time-frame for each turning-point?
How will medical care be adjusted for each predictable
Because the terminal-care physician knows how to
he or she can explain the most likely progression towards death
for laypersons who are perhaps witnessing dying for the first time.
And when each new phase begins,
the terminal-care physician will make adjustments in the care-plan.
For example, when should the drugs to control symptoms be adjusted?
If approved in advance, when should terminal sedation begin?
When should all life-supports
be withdrawn, including food and water?
Comprehensive End-of-Life Medical Orders will
all such details of the terminal
always with the knowledge that the plans might change
if unforeseen medical events intervene.
But within practical limits, this patient and this doctor
have created a complete a
story of how this patient will meet death.
ELMOs have no check-boxes,
because these are so easy to misunderstand or even abuse.
Check-boxes, such as used in POLSTs,
leave no room for explanation.
Even if the physician and the patient wish to insert details,
there is no easy way to do this in a two-page form.
End-of-Life Medical Orders explain everything in
rather than check-marks.
Because ELMO is an electronic document,
we can use as many words as needed,
with no prior expectations or limitations.
Check-marks are open to abuse.
What prevents someone from adding a check-mark, even months later?
When one section has no boxes checked,
anyone with a pen can change the fate of that patient.
A computer will store the ELMO,
with everything explained in plain English.
Electronic sharing makes it best to have only one original,
altho there should be automatic computer back-up somewhere else.
This computer medical order will be password
with a current list of everyone authorized to read that ELMO.
Whenever there are changes,
they can be sent out to everyone who has a right to know
—with the link
to the new ELMO.
Many people might have been consulted to create this
but only the terminal-care physician and the patient (or proxies)
can change these
Because these end-of-life medical orders are stored
there will be no confusion created by multiple paper copies.
And when the ELMO is changed,
there is no need to collect and destroy all the earlier documents.
Printing the ELMO from the electronic version will
But the original stays in is very-secure computer location.
And anyone taking important actions based on the ELMO
should check to see if the computer file has been updated.
The most recent date of revision appears at the beginning.
James Leonard Park is an independent philosopher.
He encourages consumers to control their medical
He has not yet selected his terminal-care physician.
But when that choice has been made,
he will attempt to create an ELMO with that physician.
He is the author of a comprehensive book about
Creating Your Own Advance Directive for Medical Care.
His longest book is How
Safeguards for Life-Ending Decisions.
discussion of ELMO is Chapter 45.
Much more about him will be found on his personal
the last link below.
above text is a draft of a
that might be used to create a new form of advance medical
Please suggest additional sections that should be included in an ELMO.
What changes should be made to clarify what is already included?
What problems with this kind of document might arise?
And how could such problems be prevented?
Send all comments, questions, and suggestions to:
James Park, e-mail;
May 22, 2015; Revised 5-23-2015; 6-3-2915; 6-10-2015; 10-2-2015;
4-6-2016; 4-20-2016; 6-13-2016; 6-29-2016; 12-21-2016; 12-20-2017;
How has this chapter about ELMO changed
Did you originally think that AD, DNR, and/or POLST
Do you agree that the likely causes
of death should be included?
What do you think of the discussion of methods of managing dying?
Do you like the idea of creating a nest for dying?
Will you attempt to create an eight-part ELMO
for yourself or someone you love for the last year of life?
indicated in the Background at the beginning of this chapter,
End-of-Life Medical Orders (ELMO)
intended to replace
Physician Orders for Life-Sustaining Treatment (POLST)
the following reasons: Problems
ELMO would also replace the even briefer DNR order:
the beginning of this website