MOLST Implementation
Jack Schwartz, Esquire
Damien Doyle, MD, CMD, FAAFP
Marian Grant, DNP, RN, CRNP, ACHPN
Tricia Tomsko Nay, MD, CMD, CHCQM, FAAFP, FAIHQ, FAAHPM
Case #1
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38-year-man who injured his knee.
Being discharged from the hospital to
rehab.
Healthy, no medications.
On discharge, the doctor asks about his
code status.
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Case #1: Take Home Message
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Discuss code status and other relevant
issues from page two of the Maryland
MOLST form.
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Case #2
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68-year-old woman who visits her
physician’s office for a leg wound.
PHM: Diabetes, hypertension, and
peripheral vascular disease.
Doctor orders home health.
No Maryland MOLST form on file.
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Case #2
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Doctor brings up CPR, but patient cuts him
off and says, “Don’t speak of such things.”
Doctor rephrases question, but she says, “I
understand what the form is for, but I will
not talk about these things.”
Doctor respects her right to decline to
discuss the topic.
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Case #2
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Doctor explains that when no limitations are
put on CPR and other life-sustaining
treatments, that she will receive medically
indicated treatments in most circumstances.
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Case #2: Take Home Message
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Respect a patient or authorized decision
maker’s right to decline to discuss an issue.
Whenever possible, inform the patient or
ADM that not making a decision generally
means that all medically indicated
interventions will be done.
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Case #3
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75-year-old woman who fell at home >>>
hip fracture >>> ORIF >>> transferring to
a nursing home for rehab.
Planning to return home.
Makes her own decisions.
Nurse practitioner at nursing home realizes
there is no Maryland MOLST form from the
hospital.
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Case #3
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If my heart stops of I stop breathing, “Do
everything that you can.”
Use a ventilator if it is needed at any time.
I hated the hospital. Never send me back to
a hospital.
I want medical tests to be done if needed.
I want any kinds of antibiotics
that are recommended.
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Case #3: Take Home Message
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Clarify general statements.
Address conflicting wishes immediately.
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Case #3
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During rehab, the patient has a stroke with
right sided hemiplegia.
Now plans to stay in nursing home for longterm care.
Physician readdresses code status and lifesustaining treatments.
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Case #3
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If my heart stops or I stop breathing, “Allow
God to take me.”
Never use a machine to treat me or keep
me alive.
I only want to go to the hospital if I have
severe pain or symptoms you can’t treat in
the nursing home.
I only want medical tests if needed for
symptomatic treatment or comfort.
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Case #3
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I want antibiotics I can take by mouth if I
am in pain from an infection.
I never want any artificially administered
fluids or nutrition, even for a short trial.
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Case #3: Take Home Message
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Clarify general statements.
Reassess the goals of care when there is a
change in condition.
A patient has the right to change his or her
mind.
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Case #4
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100-year-old man with end-stage dementia
who lives with his daughter and son-in-law.
24-hour private duty caregivers.
Being admitted to hospice.
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Case #4
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No Maryland MOLST form.
Two certs of incapacity.
Two certs of end-stage condition.
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Case #4
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Advance directive: If I am in an end-stage
condition, do not resuscitate me . . . Do not
give me any artificial feeding or hydration,
including tube feedings.
His daughter is his health care agent.
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Case #4
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Daughter says he is a DNR-B and wants to
begin artificial feeding and hydration.
She says that nine years ago, her father
meant if he was going to die in a day or
two, not to feed him artificially.
The hospice nurse thinks he will live for a
few months.
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Case #4: Take Home Message
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Honor the patient’s known wishes.
The health care agent cannot override the
patient’s advance directive.
The Health Care Decisions Act affords the
practitioner immunity for good faith efforts
to comply with the act.
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For More Information
marylandmolst.org
MarylandMOLST@dhmh.state.md.us
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