Medical Orders for Life-Sustaining Treatments
MOLST Staff Education
Patricia A. Bomba M.D., F.A.C.P.
Vice President and Medical Director, Geriatrics
Excellus BlueCross BlueShield
A Community-wide End-of-life/Palliative Care Initiative project
Objectives
• Background
• Oregon POLST
• Rochester MOLST
• Values, Goals, Expectations
• Implementation & Education
• Questions
www.compassionandsupport.org
Evolving Realities
• Life expectancy has increased
• Increased prevalence of chronic disease
• Increased comorbidities and frailty with
advancing age adding to complexity
• Changing families, healthcare systems,
society and marketplace demands
• Death is “optional”
Gaps and Quality Issues
“Approaching Death:
Improving Care at the End-of-Life”
location of death
pain management
treatment preferences
hospice admissions
Institute of Medicine Report, 1997
Community-wide End-of-life/
Palliative Care Initiative
Advance Care Planning
– Community Conversations on Compassionate Care
Honoring Preferences
– Medical Orders for Life-Sustaining Treatment (MOLST)
Pain Management and Palliative Care
– Community Principles of Pain Management
– CompassionNet
Education and Communication
– Education for Physicians on End-of-life Care (EPEC)
– Community web site: www.compassionandsupport.org
North Country
Malone!
Plat tsburgh
Franklin
Clinton
!
Potsdam !
Watertown
St. Lawrence
Jefferson
!
Watertown
Lewis
Central
Genesee
Niagara
*
*
Western
Buff al o
!
Erie
Chautauqua
**
Cattaraugus
** *
*
Orleans
Rochester
!
Monroe
Batavia
!
Genesee
Wyoming
Liv ingston
!Hornell
Steuben
Allegany
Jamest own
!
Yates
Rome
Oneida
!
Seneca Auburn
Cayuga
Schuyler
***
Chemung
!Elmi ra
Tioga
Ut ica
! Herkimer
Washington
Fult on
Amsterdam
Montgomery
!
Madison
Tompkins Cort land
Chenango
Ithaca
!
*
Utica-Rome
**
Syracuse
!
Onondaga
Wayne
Hamilton
Warren
Oswego
Ontario
Essex
*
Binghamt on
!
Broome
Otsego
Oneonta
Saratoga
Schenectady
Rensselaer
Al bany
Albany
Schoharie
Columbia
Greene
Delaware
Ulst er
Southern Tier
Tri-Cities
Dutchess
Sullivan
Poughkeepsie
Ro chester regio n
Southern Tier reg ion
* ACP/CCCC
Putnam
Westchester
* MOLST
Syracuse region
Rockland
Suffolk
* CPPM
Utica region
Western reg io n
Orange
* EPEC
Nassau
North Country
Malone!
Plat tsburgh
Franklin
Clinton
!
Watertown
Potsdam !
St. Lawrence
Jefferson
!
Watertown
Lewis
Central
Western
Buff al o
!
Erie
Chautauqua
*
Cattaraugus
Orleans
Batavia
!
Genesee
Wyoming
Rochester
!
Monroe
*
Oswego
Ontario
Liv ingston
!Hornell
Steuben
Allegany
Syracuse
!
Onondaga
Wayne
Yates
!
Seneca Auburn
Cayuga
Schuyler
Jamest own
!
*
Utica-Rome
Rome
Oneida
Ut ica
! Herkimer
Washington
Fult on
Amsterdam
Montgomery
!
Madison
Tompkins Cort land
Chenango
Ithaca
!
Chemung
!Elmi ra
Hamilton
Warren
Genesee
Niagara
Essex
Tioga
Binghamt on
!
Broome
Otsego
Oneonta
Saratoga
Schenectady
Rensselaer
Al bany
Albany
Schoharie
Greene
Delaware
Columbia
Ulst er
Southern Tier
Tri-Cities
Dutchess
Sullivan
Poughkeepsie
Rochester region
Southern Tier region
Syracuse region
Utica region
Western region
Orange
Putnam
Westchester
* MOLST
Rockland
Suffolk
Nassau
Advance Care Planning: A Gift
Clarify values, beliefs
Choose a spokesperson
Understand lifesustaining treatments
Compassion and Support
at the End of Life
Practical issues
Advance Care Directives
For All Adults
For Those Who Are
Chronically Ill or
Near the End of Their Lives
Health Care Proxy Form
Living Will
Organ Donation (optional)
Nonhospital Do Not Resuscitate
(DNR) Order
Medical Orders for Life Sustaining
Treatment (MOLST) form
POLST in Oregon
• Taskforce formed in 1991
• Goal: ensure patient’s end-of-life care
wishes are honored when patient is not
able to speak for him or herself
• Surrogate decision makers may
communicate treatment preferences
Philosophy of POLST
• Individuals have the right to make their
own health care decisions
• These rights include:
– Making decisions about life sustaining
treatment
– Describing desires for life sustaining
treatment to health care providers
– Comfort care while having wishes honored
POLST in Oregon
• Bright pink medical order form for
seriously ill patients
• Signed by MD, DO or NP
• Turns patient preferences into orders
• Goal: ensure wishes are honored
POLST Research
• Study of 180 nursing home residents
– comfort measures only
– do not resuscitate (DNR) order
– transfer to hospital only if comfort measures
fail
Tolle, Tilden, Nelson, & Dunn (1998). A prospective
study of the efficacy of the POLST, JAGS, 46: 1097
POLST Research
• Findings
–
–
–
–
no one received CPR, ICU care or vent
63% had orders for narcotics
2% hospitalized to extend their lives
13% overall hospitalized
• Summary
– POLST CPR orders respected
– high comfort care
– low rates of transfer for aggressive lifeprolonging treatments
POLST : Research
• Study of 58 older adults enrolled in a
Program for All-Inclusive Care for the
Elderly (PACE)
• Reviewed POLST form and records
from last two weeks of life
Lee, Brummel-Smith, Meyer, Drew and London (JAGS 2000)
POLST : Research
• Findings
– CPR use: consistent with directions for
91% of participants
– Medication use: consistent for 46% of
participants
• 33% less invasive, 20% more invasive
– Antibiotics given: consistent for 86% who
had infections
– Feeding tube use: consistent for 94%, IV
fluids for 84%
POLST : Research
• Summary
– effective in ensuring treatment wishes are
honored about CPR, antibiotics, IV fluids
and feeding tubes
– less effective for medical interventions
– more consistently followed than
previously reported for advance directive
forms
Lee, Brummel-Smith, Meyer, Drew and London (JAGS 2000)
POLST Outcomes:
Completed ACD
• 1993: 70% of Portland NH residents
had DNR orders (Teno, et al)
• 1996: 91% with written DNR orders in 8
Oregon NH’s (Tolle, et al)
• 1997: 475 randomly selected Oregon
decedents:
– 67% with written AD
– 93% family felt they knew wishes
Site of Death
“If dying patients want to retain some
control over their dying process
they must get out of the hospital
they are in, and stay out of the
hospital if they are out.”
George Annas, Bioethicist
POLST Outcomes:
Site of Death
Oregon residents who die in hospital
• 1980: 50%
• 1993: 35% (national average: 56%)
• 1999: 31% (lowest rate in the US)
Site of Death:
National and State Data
Deaths Deaths in a Deaths in
at home Hospital
a NH
Oregon (Nat'l Benchmark) 35.10%
32.50%
32.40%
National Mean (Average)
24.90%
50.00%
25.10%
New York
21.20%
61.80%
17.00%
POLST is Spreading
Parts of:
*
*
*
*
*
*
*
*
*
*
*
Georgia, Kansas,
Missouri, New Mexico,
Utah, Washington,
West Virginia,
Wisconsin, New York,
Pennsylvania
From Oregon POLST to
Rochester MOLST
Medical Orders for Life-Sustaining
Treatment
MOLST
• Created by the Communitywide End-of-Life/Palliative
Care Initiative
• Adapted from Oregon’s
POLST form
• Combines DNR, DNI, and
other Life-Sustaining
Treatments
• Incorporates NYS law
www.compassionandsupport.org
MOLST vs. POLST
POLST
– Proprietary about exact form
– Mainly researched in LTC
– Did not fit many New York
State criteria
MOLST
– Adapted to New York State law
– Combines DNR, DNI and other
Life-Sustaining Treatments
– Meets all regulatory
requirements
Pink MOLST Form
• Consistent color: easily identifiable
– facilitate appropriate care desired by patient
• Accuracy: clear, unambiguous medical orders
• Flexible: changes can be made sequentially
– Does not need to be done with each admission
• Portable: transfer PINK across systems
• Availability: Original PINK MOLST with the
patient; make copy to retain in the chart
Health Care Proxy/Living Will
and MOLST
Health Care Proxy/Living Will
– completed ahead of time
– applies only when decision-making capacity is lost
MOLST
–
–
–
–
applies right now
not conditional on losing decision-making capacity
set of physician orders
may carry more weight in medical settings
What Does MOLST Replace?
• Replaces previous DNR/DNI forms
• Old forms still valid
• It does NOT replace NY State Health Care
Proxy forms (or a living will)
• Preferences for other life-sustaining therapies
DNR Order
State of New York
Department of Health
Nonhospital Order Not to Resuscitate
(DNR Order)
Person's Name:___________________________________
Date of Birth: _____/_____/_____
Do not resuscitate the person named above.
Physician's Signature ____________________
Print Name _________________________
License Number ____________________
Date _____/_____/_____
It is the responsibility of the physician to determine, at least every 90 days, whether this
order continues to be appropriate, and to indicate this by a note in the person's medical
chart.
The issuance of a new form is NOT required, and under the law this order should be
considered valid unless it is known that it has been revoked. This order remains valid and
must be followed, even if it has not been reviewed within the 90 day period.
DOH-3474 (2/92)
It Does NOT
Replace the NYS
Nonhospital
Order Not to
Resuscitate form
(DNR Order)
MOLST
Values, Goals and Expectations
Clarify Values and Beliefs
• Every one has a personal sense of
– who we are
– what we like to do
– control we like to have
– goals for our lives
– things we hope for
Hope, Goals, Expectations
• Hope, goals, expectations change with illness
• Physician’s role to clarify goals, treatment
plan
• Members of the team’s role to support
patient’s goals
Potential Goals of Care
• Cure of disease
• Relief of suffering
• Avoidance of premature
• Quality of life
death
• Maintenance or
improvement in function
• Prolongation of life
• Staying in control
• A good death
• Support for families and
loved ones
Multiple Goals of Care
• Multiple goals often apply simultaneously
• Goals are often contradictory
• Goals are sometimes unrealistic
• Certain goals may take priority over others
Goals May Change
• Some take precedence over others
• Gradual shift in focus of care
• Expected part of the continuum of medical
care
7-Step Protocol
1. Create the right setting
2. Determine what the patient and family know
3. Explore what they are expecting or hoping for
7-Step Protocol
4. Suggest realistic goals
5. Respond empathetically
6. Make a plan and follow-through
7. Review and revise periodically
Reviewing goals,treatment priorities
• Goals guide care
• Assess priorities to develop initial plan of care
• Review with any change in
–
–
–
–
health status
advancing illness
setting of care
treatment preferences
MOLST
Implementation and Education
MOLST:
Who Should Have One?
• Anyone choosing:
– Do not resuscitate
– Allow natural death
• Anyone choosing to limit medical
interventions
• Anyone eligible/residing in LTC facility
• Anyone who might die within the next
year
Pre-Hospital
& Acute Care
MOLST
LTC
Office
MOLST
• Implementation Issues
– Development of policies and procedures
– Integration of Policies and Procedures
across the continuum of care
– Discharge or Transfer
– Accountability
MOLST
• Education
– Staff
•
•
•
•
Medical
Hospital
Long Term Care
EMS
– Community
• Community Conversations on Compassionate Care
MOLST Summary
• Individuals have the right
–
–
–
–
–
–
–
make their own health care decisions
patient-centered care
focused on patient goals of care
reflect patient values and beliefs
discuss their preferences
information is documented
information is clear, unambiguous,
flexible, portable, available, honored
MOLST Summary
• “Portable” medical order form
• Travels with patient
• Can translate an advance directive
into physician’s orders
• DOES NOT replace an advance
care directive
• DOES NOT replace the NYS
Nonhospital Order Not to
Resuscitate form (DNR Order)
Resources
• MOLST form, supplemental
documentation, detailed
MOLST review and FAQ’s are
available as a copyrighted
download-able PDF file at
– www.compassionandsupport.org
– pink forms available from Health
Plan …fax reorder form to 585238-4400
MOLST
Questions