Integrating MOLST into a Community-wide Approach
to Advance Care Planning
Patricia Bomba, MD, FACP
Vice President and Medical Director, Geriatrics
Chair, MOLST Statewide Implementation Team & eMOLST Program Director
Leader, Community-wide End-of-life/Palliative Care Initiative
Chair, National Healthcare Decisions Day New York State Coalition
Patricia.Bomba@lifethc.com
CompassionAndSupport.org
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A nonprofit independent licensee of the BlueCross BlueShield Association
Objectives
 Discuss the nuts and bolts of the MOLST Program as part of an
evidence-based, two-step approach to advance care planning
 Describe effective, shared, informed patient/family medical
decision-making
 Demonstrate the process for patient centered, goals-based
communication
 Identify where MOLST fits into palliative care and new NYSPHL:
FHCDA, PCIA and PCAA
 Prepare for MOLST and palliative care implementation and
quality improvement activities to improve care at the end of life
 Explain how eMOLST improves outcomes, quality, patient
safety; reduces patient harm and achieves the triple aim
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Recognizing MOLST as a Key Pillar of Palliative Care
New Legislative Changes
Patricia Bomba, MD, FACP
Vice President and Medical Director, Geriatrics
Chair, MOLST Statewide Implementation Team & eMOLST Program Director
Leader, Community-wide End-of-life/Palliative Care Initiative
Chair, National Healthcare Decisions Day New York State Coalition
Patricia.Bomba@lifethc.com
CompassionAndSupport.org
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A nonprofit independent licensee of the BlueCross BlueShield Association
Why This Discussion is Important
 Approximately 2.5 million annual US deaths
 Three-quarters are age 65 or over
 Covered by the federal Medicare program
 Medicare recipients double as baby boomers age
• 69 million in 2030 (estimate)
• 35 million in 2000
 Approximately 25 percent of Medicare
spending occurs in the last year of life
 most of it by inpatient hospital care
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 Improve quality and patient safety
 Reduce unwanted readmissions and costs
Thoughtful EOLC Discussions
Benefits
 Improve quality; reduce cost *
 Only 31% of patients with advanced cancer at EOL had had
discussions with physicians about EOLC *
 Patients who had EOL conversations had significantly lower
costs in their final week of life, over $1,000 less *
 “Higher costs were associated with worse quality of death” *
 "End-of-life discussions are associated with less aggressive
medical care near death and earlier hospice referrals.” **
 “Aggressive care is associated with worse patient quality of
life and worse bereavement adjustment.” **
**Arch
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Intern Med. 2009;169(5):480-488
**Associations Between End-of-Life Discussions, Patient Mental Health,
Medical Care Near Death, and Caregiver Bereavement Adjustment
JAMA. 2008;300(14):1665-1673
Palliative Care
 Interdisciplinary care
 aims to relieve suffering and improve quality of life for
patients with advanced illness and their families
 offered simultaneously with all other appropriate medical
treatment from the time of diagnosis
 KEY: focuses on quality of life and provides an extra layer of
support for patients and families
Three Key Pillars with Psychosocial/Spiritual Support
 Advance Care Planning and Goals for Care
Step 1: Community Conversations on Compassionate Care*
Step 2: Medical Orders for Life-Sustaining Treatment (MOLST)*
 Pain and Symptom Management
 Caregiver Support
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*A Project of the Community-Wide End-of-life/Palliative Care Initiative
Continuum of Care Model for Patients with Serious Illness
Medical Management of Chronic Disease
Integrated with Palliative Care
Goals for Care shift
12 mo
Diagnosis
Palliative Care (PC):
Advance care planning & goals for care, pain
and symptom control, caregiver support
Death
Hospice
 Progression of Serious Illness 
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6mo
Bereavement
Palliative Care and Community Perspective
Provides What Patients Want at End-of-life
 Quality end-of-life care
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receiving adequate pain & symptom management* **
avoiding inappropriate prolongation of dying* **
achieving a sense of control* **
relieving the burden on loved ones* **
strengthening the relationship with loved ones* **
respect uniqueness of individual**
provide appropriate environment**
address spiritual issues**
recognize cultural diversity**
communication integral between dying person, family
and professionals**
*Singer, et.al. JAMA 1999; 281: 163-8
**McGraw, et.al. Conn Med 2002; 66 (11); 655-64
Palliative Care Information Act (PCIA)
 Attending health care practitioner must offer
patients with a terminal condition information and
counseling about palliative care
 range of options appropriate to the patient,
including other appropriate treatment options
 prognosis; risks and benefits of various options
 patient’s “legal rights to comprehensive pain
and symptom management at the end of life”
 obligation to refer if not willing, or does not feel
qualified
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 Effective February 9, 2011; Amended 2012
Palliative Care Access Act (PCAA)
 Hospitals, nursing homes, home care
agencies and two types of assisted
living residences (enhanced and
special needs)
 establish policies and procedures
regarding palliative care, including access
to information and counseling
 shall facilitate access to appropriate
palliative care consultations and services
 Effective September 27, 2011
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Family Health Care Decisions Act (FHCDA)
NYSPHL Article 29-CC and Article 29-CCC
 FHCDA is Public Health Law (PHL) Article 29-CC
 Part of Laws of 2010, Chapter 8
 Applies to all health care decisions in general hospitals and
residents of nursing homes, including MOLST orders
 effective June 1, 2010
 Part of Laws of 2010, Chapter 8
 repealed PHL § 2977 (Nonhospital orders not to resuscitate)
 created a new PHL Article 29-CCC (Nonhospital orders not to
resuscitate)
 Decisions regarding hospice care, including the
withdrawal or withholding of life-sustaining treatment
 effective September 19, 2011
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Family Health Care Decisions Act, Laws of New York, Chapter 8. Effective June 1, 2010
Family Health Care Decisions Act (FHCDA)
Public Health Law (PHL) Article 29-CC
 Allows surrogates to make medical decisions
 Routine medical treatment
 Major medical treatment (2nd MD must concur)
 Decisions to WH/WD LST, including DNR
• Higher clinical and surrogate standards and special
requirements apply
 Includes patient safeguards to ensure
 sound medical treatment
 decisions are consistent with the patient's wishes or
in the best interest, if wishes are unknown
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Family Health Care Decisions Act, Laws of New York, Chapter 8. Effective June 1, 2010
Family Health Care Decisions Act
 DOES NOT eliminate the need for
open and honest conversations with
loved ones about your wishes and
desires for medical care.
 DOES NOT eliminate the need for
advance care planning or to have
advance directives on file with your
doctors, your attorney and your family
members.
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Advance Care Planning
Compassion, Support and Education along the Health-Illness Continuum
Advancing chronic illness
Multiple comorbidities, with
increasing frailty
Chronic disease or
functional decline
Healthy and
independent
Maintain &
maximize
health and
independence
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© Patricia A. Bomba, M.D., F.A.C.P.
Death with
dignity
Advance Directives and
Actionable Medical Orders
Traditional ADs
Actionable Medical Orders
For All Adults
For Those Who Are Seriously Ill
or Near the End of Their Lives
Community Conversations on
Compassionate Care (CCCC)
 New York
 Health Care Proxy
 Living Will
 Organ Donation
 State-specific forms:
e.g. Durable POA for
Healthcare
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Medical Orders for Life-Sustaining Treatment
(MOLST) Program
 Do Not Resuscitate (DNR) Order
 Medical Orders for Life Sustaining
Treatment (MOLST)
 Physician Orders for Life Sustaining
Treatment (POLST) Paradigm
Programs
CompassionAndSupport.org
CaringInfo.org
© Patricia A. Bomba, M.D., F.A.C.P.
CompassionAndSupport.org
POLST.org
Health Care Proxy / Living Will
vs. 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 actionable medical orders
 approved by NYSDOH for use in ALL
settings, including the community
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Differences Between POLST/MOLST
and Advance Directives
Characteristics
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POLST
Advance Directives
Population
For the seriously ill
All adults
Timeframe
Current care
Future care
Who completes the
form
Health Care
Professionals
Patients
Resulting form
Medical Orders
(POLST)
Advance Directives
Health Care Agent or
Surrogate role
Can engage in
discussion if patient
lacks capacity
Cannot complete
Portability
Provider responsibility
Patient/family
responsibility
Periodic review
Provider responsibility
Patient/family
responsibility
Bomba PA, Black J. The POLST: An improvement over traditional advance directives.
Cleveland Clinic Journal of Medicine. July 2012; V 79, No.7: 457-464.
Community Conversations on Compassionate Care
Five Easy Steps
1.
Learn about advance directives
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2.
3.
Remove barriers
Motivate yourself
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4.
View CCCC videos
Complete your Health Care Proxy and Living Will
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5.
NYS Health Care Proxy
NYS Living Will
Advance Directives from Other States
Have a conversation with your family
Choose the right Health Care Agent
Discuss what is important to you
Understand life-sustaining treatment
Share copies of your directives
Review and Update
A Project of the Community-Wide End-of-life/Palliative Care Initiative
Medical Orders for Life-Sustaining Treatment
(MOLST) Program
 Improve the quality of care people
receive at the end of life
 effective communication of patient wishes
 documentation of medical orders on a
brightly colored pink form
 promise by health care professionals to
honor these wishes
 Complements the use of traditional
advance directives
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A Project of the Community-Wide End-of-life/Palliative Care Initiative
MOLST:
End-of-life Care Transitions Program
Hospital
LTC
Office
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A Project of the Community-Wide End-of-life/Palliative Care Initiative
History of MOLST Program
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Work initiated Fall 2001
Created November 2003
Adapted from Oregon’s POLST
Combines DNR, DNI, and other LST
Incorporates NYS law
Collaboration with NYSDOH – 3/04
Revised 10/05; Approved Inpatient DNR form
Legislation passed 2005;Community Pilot launched
Chapter Amendment passed 2006
Gov. Paterson signed bill 7/8/08
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MOLST consistent with PHL§2977(3)
Permanent change in EMS scope of practice
MOLST permanent and statewide
HEAL 5 grant includes eMOLST, 2008
DOH-5003 NYSDOH MOLST form, 6/10
FHCDA, effective June 1, 2010
eMOLST Preview: October 19, 2010
PCIA, effective February 9, 2011
PCAA, effective September 27, 2011
Hospice added to FHCDA, September 19, 2011
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© Patricia A. Bomba, M.D., F.A.C.P.
National POLST Paradigm Programs
*As of 2006
National POLST Paradigm Programs
*As of November 2013
Mature Programs
Endorsed Programs
Developing Programs
POLST-Like Programs
No Program (Contacts)
Reciprocity
Are advance directives and POLST Paradigm forms recognized?
 New York recognizes advance directives and
POLST Paradigm forms from other states
 Border states and POLST*
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Vermont: Yes
New Jersey: Yes
Pennsylvania: No statute or regulation
Massachusetts: Unclear
Connecticut: no POLST paradigm Program
 Other states
 Varies: check POLST.org
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*Sabatino, C.P., Karp, N. Improving Advanced Illness Care:
The Evolution of State POLST Programs.
AARP Public Policy Institute. Copyright 2011, AARP; updated 2012
Questions?
Thank You for Attending!
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