ZDoggMD on Advance Directives and DNR: Why Most Patients Die Without Them

This article discusses ideas from ZDoggMD — Dr. Zubin Damania, MD , Stanford/UCSF-trained internist, founder of the Health 3.0 movement. Full archive: zdoggmd.com | YouTube @zdoggmd

Advance directive completion rates have increased significantly over the past two decades — and still only about 37% of Americans have any advance care planning document. Among those who do, many documents are not available where care is delivered, are not specific enough to guide decisions in real clinical situations, or don't reflect the patient's current preferences. ZDoggMD has addressed the gap between the principle of advance care planning and the messy reality of how it functions.

Why Advance Directives Fail in Practice

Traditional advance directives (living wills, healthcare proxies) are completed once, filed somewhere, and rarely revisited. Patients' preferences change as their health evolves — what a healthy 55-year-old would want in case of sudden cardiac arrest may differ significantly from what they want after a debilitating stroke or metastatic cancer diagnosis. A document signed a decade ago may not reflect current preferences.

POLST (Physician Orders for Life-Sustaining Treatment) — called MOLST, MOST, or POST in some states — is a physician order set that converts patient preferences into immediately actionable medical orders. Unlike an advance directive, POLST is designed to travel with the patient across care settings and is immediately recognizable to EMS, emergency physicians, and nursing facilities. ZDoggMD has advocated for POLST as a more actionable tool for patients with serious illness.

The "Death Panel" Problem

The 2009 political controversy over end-of-life counseling (the "death panel" smear) set back advance care planning nationally — provisions that would have reimbursed physicians for advance care planning conversations were removed from the ACA. Medicare finally began reimbursing these conversations in 2016. ZDoggMD has been consistent: helping patients think through and document their wishes is not rationing care — it is delivering the care patients actually want.

These Conversations Deserve Full Attention

Goals-of-care and advance care planning conversations are among the most important in medicine. They require complete physician presence — not split attention between the patient and the keyboard. NoPajamaTime handles the documentation so you can be fully there.