Medical Orders For Life-Sustaining Treatment Research Articles

Implementing the MOLST (medical orders for life-sustaining treatments): Challenges faced by nursing home staff

This study examined how the Medical Orders for Life-sustaining Treatment (MOLST) is implemented in two nursing homes in Massachusetts; one had primarily long-term care residents and high hospice utilization, the other had low hospice utilization and a high proportion of post-acute care residents. Qualitative in-person interviews with 21 staff members who had a role implementing the MOLST explored their experiences using the form in their daily work routines. Staff at both nursing homes described benefits of the MOLST such as providing guidance for staff and family. Yet, they also gave detailed accounts of challenges they face in implementing the form. They reported problems with the form itself such as confusing language and conflicting categories as well as a set of procedural challenges that undermined the timely completion of the form. The nursing home with more post-acute care residents faced more challenges with transferability of the MOLST to and from hospitals.

Improving the Validity of MOLST (MA Medical Orders for Life-Sustaining Treatment) Documentation for Patients Discharged from Solid Oncology and Palliative Care Teams with Physician Assistants (FR419C)

Improving the Validity of MOLST (MA Medical Orders for Life-Sustaining Treatment) Documentation for Patients Discharged from Solid Oncology and Palliative Care Teams with Physician Assistants (FR419C)

NCBC Guide to Completing the POLST Form

POLST (Physician Orders for Life-Sustaining Treatment) is an actionable medical order signed by a qualified clinician that authorizes medical treatments that a patient chooses to receive or not receive at the end of life. POLST is a portable document that travels with the patient and applies across multiple health care settings, including hospitals and long-term care facilities. When health care providers see the POLST form, they are expected to implement its instructions just as they would if ordered to do so by a qualified clinician. There are other documents that, despite having different names, serve the same function. These include MOLST (Medical Orders for Life-Sustaining Treatment) and POST (Physician Orders for Scope of Treatment).

Electronic medical orders for life-sustaining treatment (eMOLST) in new york state: Length of stay, direct costs

Electronic medical orders for life-sustaining treatment (eMOLST) in new york state: Length of stay, direct costs

Increasing Advance Care Planning Completion at an Academic Internal Medicine Outpatient Clinic

BackgroundWe sought to increase advance care planning (ACP) completion at an academic internal medicine clinic through an electronic health record. MeasuresNumber of eligible patients who completed a form of ACP. InterventionMultidisciplinary team approach with engagement from providers and clinic staff; implemented informational letter and appropriate forms to eligible patients before appointment; informational video and provider reminders at time of appointment. OutcomesOf 480 eligible patients, 327 (68%) completed one or more forms of ACP or had a discussion with their provider. Discussed but not completed was highest (53%). The three types of ACP completed were 1) a state-formatted advance directive form (47%), 2) Medical Orders for Life-Sustaining Treatment (45%), and 3) power of attorney designation (8%). ConclusionsImplementation of a multi-disciplinary approach can facilitate ACP. However, challenges still arise because in more than half of the cases, advance care efforts led only to a discussion.

Maryland's Medical Orders for Life-Sustaining Treatment Form Use: Reports of a Statewide Survey.

Advance directives (ADs) and Physicians Orders for Life-Sustaining Treatment (POLST) orders perform different but complementary functions in documenting a patient's treatment preferences and translating them into actionable orders that change in keeping with the patient's evolving clinical picture. Maryland's Medical Orders for Life-Sustaining Treatment (MOLST) form developed through a stakeholder-driven process that deviates from other POLST forms. While a patient or surrogate can decline discussing MOLST orders with a clinician, clinicians must write MOLST orders for certain patients (e.g., those admitted to a nursing home (NH), assisted living facility (ALF), hospice, home health (HH) agency, or dialysis center, discharged from a hospital to any of these facilities, or transferred between hospitals). To gather data on Maryland MOLST form use to evaluate performance and inform future research and practice. Chart reviews (CRs). MOLST forms and patient data collected from Maryland hospitals (adult nonpsych, nontrauma, nonobstetric patients), NHs, ALFs, hospices, HH agencies, and dialysis centers. Facility demographic tool and CR tools. A total of 1959 CRs were received from 137 facilities, including 2064 MOLST forms. Most patients required to have MOLST orders had them (84%); fewer had ADs (47%). Few patients or surrogates declined discussing MOLST orders (1%). Few MOLST orders were written based on medical ineffectiveness criteria defined in Maryland law (<1%). MOLST form completion error rates ranged from 1% to 3%. Non-white patients were about twice as likely to have a MOLST "Attempt CPR" order (62%) as white patients (32%). MOLST error rates are relatively low and consistent with other research. Areas for improvement include selecting one order option where required, avoiding contradictions between Page 1 and 2 orders, offering MOLST Page 2 options if relevant, and documenting in the medical record a summary of the discussion informing MOLST orders.

Decisions by Default: Incomplete and Contradictory MOLST in Emergency Care

ObjectivesWhat patients intend when they make health care choices and whether they understand the meaning of orders for life-sustaining treatment forms is not well understood. The purpose of this study was to analyze the directives from a sample of emergency department (ED) patients' MOLST forms. ProceduresMOLST forms that accompanied 100 patients who were transported to an ED were collected and their contents analyzed. Data categories included age, gender, if the patient completed the form for themselves, medical orders for life-sustaining treatment including intubation, ventilation, artificial nutrition, artificial fluids or other treatment, and wishes for future hospitalization or transfer. Frequencies of variables were calculated and the associations between them were determined using chi-square. An a priori list of combinations of medical orders that were contradictory was developed. Contradictions with Orders for CPR (cardiopulmonary resuscitation) included the choice of one or more of the following: Comfort care; Limited intervention; Do Not Intubate; No rehospitalization; No IV (intravenous) fluids; and No antibiotics. Contradictions with DNR orders included the choice of one or more of the following: Intubation; No limitation on interventions. Contradictions with orders for Comfort Care were as follows: Send to the hospital; Trial period of IV fluids; Antibiotics. The frequencies of coexisting but contradictory medical orders were calculated using crosstabs. Free text responses to the “other instructions” section were submitted to content analysis. ResultsSixty-nine percent of forms reviewed had at least one section left blank. Inconsistencies were found in patient wishes among a subset (14%) of patients, wherein their desire for “comfort measures only” seemed contradicted by a desire to be sent to the hospital, receive IV fluids, and/or receive antibiotics. ConclusionsPatients and proxies may believe that making choices and documenting some, but not all, of their wishes on the MOLST form is sufficient for directing their end-of-life care. The result of making some, but not all, choices may result in patients receiving undesired, extraordinary, or invasive care.

Survey on Clinician Perceptions and Practices Regarding Goals of Care Conversations.

Early conversations between clinicians and patients about goals of care may improve patients' quality of life and prevent nonbeneficial care near the end of life, but these conversations are limited in frequency and scope. To address this issue, clinicians are increasingly asked to use standardized medical order forms, like the Medical Orders for Life-Sustaining Treatment (MOLST), to document end-of-life conversations and to help ensure that patients' wishes are realized. In kind, the Centers for Medicare and Medicaid Services recently decided to reimburse physicians as well as nurse practitioners and physician assistants for these conversations. To explore physicians' and advanced practitioners' (APs') attitudes and behaviors around initiating and documenting goals of care conversations and to identify targets for improvement. Online survey administered between October 1, 2014 and February 20, 2015. Physicians (n = 2492) and APs (n = 336) at an urban academic medical center. Clinicians' perceptions and self-reported behaviors regarding goals of care conversations and the Massachusetts MOLST form. We found that 44.0% of physicians and 33.0% of APs reported that they discussed goals of care with all patients with serious, life-limiting illness (p < 0.001). APs were more likely than physicians to report awareness of MOLST forms (55.1% vs. 45.1%, p < 0.001) but less likely to feel comfortable making recommendations on end-of-life care (25.3% vs. 41.0% recommending against resuscitation, p < 0.001; 35.1% vs. 55.7% recommending for resuscitation, p < 0.001). These findings suggest the need to educate physicians and empower APs to facilitate goals of care conversations and use standardized forms, as well as an opportunity for interdisciplinary collaboration.

Interactive Online Module Failed to Improve Sustained Knowledge of the Maryland Medical Orders for Life-Sustaining Treatment Form.

Legal documents similar to the Maryland Medical Orders for Life-Sustaining Treatment (MOLST) form requiring physician endorsement are increasingly used by critically ill patients. To evaluate whether an interactive, online training module on completion and interpretation of the MOLST form leads to a sustained increase in knowledge among house staff. Pre/post survey of 329 house staff at Johns Hopkins Hospital who admit and discharge patients between June 2014 and July 2015. House staff were encouraged to complete a voluntary, interactive, online educational module on completing and interpreting MOLST forms. Participants received $25 for accessing the module and $10 for completing each survey. The primary outcome was the change in the number of questions answered correctly on the post- versus presurvey comparing house staff who viewed the module for at least 20 minutes with house staff who never viewed or never completed the module. Overall, 329 (69%) house staff completed the knowledge assessment survey both before and after the module was available, and 201 (61%) of these house staff completed the voluntary module. The median score on the presurvey conducted in July and August of 2014 was 14 out of 21 (interquartile range [IQR] 12, 16). The median (IQR) score on the postsurvey conducted in May and June of 2015 was 15 out of 21 (13, 17). The median (IQR) change in score among those who spent at least 20 minutes completing the module was 1 question (-1, 3), and among those who never viewed or never completed the module it was also 1 (IQR -1, 2). The postsurvey was completed a median (IQR) of 59 (52, 62) days after viewing the module. After adjusting for years of postgraduate clinical training, self-reported baseline experience completing MOLST forms, and self-reported responsibility for discharging patients, viewing the module for at least 20 minutes was associated with a nonsignificant increase in score of 0.41 questions (95% confidence interval, -0.25, 1.06; P = 0.23). An interactive, online educational module had no effect on trainee knowledge of completing and interpreting MOLST forms approximately 2 months after completion. Information conveyed via online modules alone may have minimal sustained impact on house staff knowledge.

Have the Answers to Common Legal Questions Concerning Nutrition Support Changed Over the Past Decade? 10 Questions for 10 Years.

Clinical nutrition specialists (CNSs) are often confronted with technological, ethical, and legal questions, that is, what can be done technologically, what should be done ethically, and what must be done legally, which conflict at times. The conflict represents a "troubling trichotomy" as discussed in the lead article of this issue of Nutrition in Clinical Practice (NCP). During Clinical Nutrition Week in 2006, a symposium covering these 3 topics was presented, and later that year, an article covering the same topic was published in NCP In this article, we revisit several legal questions/issues that were raised 10 years ago and discuss current answers and approaches. Some of the answers remain unchanged. Other answers have been modified by additional legislation, court decisions, or regulations. In addition, new questions/issues have arisen. Some of the most common questions regarding nutrition support involve the following: liability, informed consent, medical decisional incapacity vs legal competence, advance directive specificity, surrogate decision making, physician orders for life-sustaining treatment and electronic medical orders for life-sustaining treatment, legal definition of death, patient vs family decision making, the noncompliant patient, and elder abuse obligations. In the current healthcare environment, these questions and issues are best addressed via a transdisciplinary team that focuses on function rather than form. The CNS can play a pivotal role in dealing with these challenges by applying the acronym ACT: being Accountable and Communicating with all stakeholders while actively participating as an integral part of the transdisciplinary Team.

Implementation of Medical Orders for Life-Sustaining Treatment.

When an outpatient in a northeastern cancer institute requested a Medical Orders for Life-Sustaining Treatment (MOLST) form, the state's approved resuscitation form in all settings, none were available. A project was undertaken to institute MOLST forms into policy and routine practice. Research supports early discussions of end-of-life care in patients with cancer and the use of MOLST as an effective tool. The purpose of this article is to discuss the initiation and facilitation of MOLST implementation into practice and policy at a cancer institute. Introducing, overcoming resistance to, piloting, and adopting MOLST in an oncology setting is reported and explained based on the three stages of Lewin's Theory of Planned Change. A small pilot of MOLST with palliative care providers demonstrated the feasibility and suitability of using MOLST in the oncology setting. MOLST was adopted into policy and routine practice at the cancer institute.

Awareness of Medical Orders for Life-Sustaining Treatment and Non-Hospital, Do-Not-Resuscitate (DNR) Orders Among Primary Care Pediatricians (S782)

Awareness of Medical Orders for Life-Sustaining Treatment and Non-Hospital, Do-Not-Resuscitate (DNR) Orders Among Primary Care Pediatricians (S782)

Nephrologist-Facilitated Advance Care Planning for Hemodialysis Patients: A Quality Improvement Project.

The Renal Physicians Association's clinical practice guideline recommends that physicians address advance care planning with dialysis patients. However, data are lacking about how best to implement this recommendation. Quality improvement project. Nephrologists caring for patients treated with maintenance hemodialysis at 2 dialysis facilities identified patients who might benefit most from advance care planning using the "surprise" question ("Would I be surprised if this patient died in the next year?"). Patients identified with a "no" response to the surprise question were invited to participate in nephrologist-facilitated advance care planning, including completion of a Medical Orders for Life-Sustaining Treatment (MOLST) form. Change in MOLST completion rate and identification of preferences for limits on life-sustaining treatment. Pre- and postintervention code status, MOLST completion rate, and vital status at 1 year. Nephrologists answered "no" to the surprise question for 50 of 201 (25%) hemodialysis patients. Of these, 41 (82%) patients had a full-code status and 9 (18%) had a do-not-resuscitate (DNR) status. Encounters lasted 15 to 60 minutes. Following the encounter, 21 (42%) patients expressed preference for a DNR status and 29 (58%) maintained full-code status (P=0.001). The MOLST completion rate increased from 10% to 90%. One-year survival for patients whose nephrologists answered "no" to the surprise question was 58% compared to 92% for those with a "yes" answer (P<0.001). Sample size and possible nonrepresentative dialysis population. Nephrologist-facilitated advance care planning targeting hemodialysis patients with limited life expectancy led to significant changes in documented patient preferences for cardiopulmonary resuscitation and limits on life-sustaining treatment. These changes demonstrate the benefit of advance care planning with dialysis patients and likely reflect better understanding of end-of-life treatment options.

Novel legislation for pediatric advance directives: Surveys and focus groups capture parent and clinician perspectives

Background: Legislative measures increasingly require consideration of pediatric inpatients for Medical Orders for Life-Sustaining Treatment. Aim: To explore pediatric clinicians’ experiences with life-sustaining treatments prior to the Medical Orders for Life-Sustaining Treatment mandate and to describe clinician and family concerns and preferences regarding pediatric Medical Orders for Life-Sustaining Treatment. Design: Clinician surveys and clinician and parent focus groups. Setting/participants: Pediatric clinicians and parents from one of Maryland’s largest health systems. Results: Of 96 survey respondents, 72% were physicians and 28% were nurse practitioners. A total of 73% of physicians and 34% of nurse practitioners felt able to lead discussions about limiting therapies “most” or “all” of the time. A total of 75% of physicians and 37% of nurse practitioners led such a discussion in the prior year. A total of 55% of physicians and 96% of nurse practitioners had written no order to limit therapies in the past year. Only for children predicted to die within 30 days did >80% of clinicians agree that limitation discussions were warranted. A total of 100% of parent focus group participants, but 17% of physicians and 33% of nurse practitioners, thought that all pediatric inpatients warranted Medical Orders for Life-Sustaining Treatment discussions. Parents felt that universal Medical Orders for Life-Sustaining Treatment would decrease the stigma of limitation discussions. Participants believed that Medical Orders for Life-Sustaining Treatment would clarify decision making and increase utilization of palliative care. Medical Orders for Life-Sustaining Treatment communication skills training was recommended by all. Conclusion: A minority of clinicians, but all parents, support universal pediatric Medical Orders for Life-Sustaining Treatment. Immediately prior to the Medical Orders for Life-Sustaining Treatment mandate, many clinicians felt unprepared to lead limitation discussions, and few had written relevant orders in the prior year. Communication training is perceived essential to successful Medical Orders for Life-Sustaining Treatment conversations.

Lessons learned from New York's community approach to advance care planning and MOLAT.

This article reviews the lessons learned from the development and implementation of New York's community approach to advance care planning (ACP) as a wellness initiative and the key components of the complementary programs: Community Conversations on Compassionate Care (CCCC) and Medical Orders for Life-Sustaining Treatment (MOLST). Shared, informed medical decision-making is a patient-centered process that is critical to ensuring patient preferences for care are honored at the end of life. Providers must be trained, qualified, and comfortable with the discussions needed for effective shared, informed medical decision-making. Development, implementation, outcomes, lessons learned and sustainability of the CCCC and MOLST programs highlight the success of a healthcare and community collaborative initiative focused on improving care at the end of life. Community data support the value of implementing the CCCC and New York's MOLST throughout the country.

Preparation for Frontline End-of-Life Care: Exploring the Perspectives of Paramedics and Emergency Medical Technicians

Prehospital emergency providers (emergency medical technicians [EMTs] and paramedics) who respond to emergency calls for patients near the end of life (EOL) make critical decisions in the field about initiating care and transport to an emergency department. To identify how a sample of prehospital providers learned about EOL care, their perceived confidence with and perspectives on improved preparation for such calls. This descriptive study used a cross-sectional survey design with mixed methods. One hundred seventy-eight prehospital providers (76 EMT-basics and 102 paramedics) from an emergency medical services agency participated. Multiple choice and open-ended survey questions addressed how they learned about EOL calls, their confidence with advance directives, and perspectives on improving care in the field. The response rate was 86%. Education about do-not-resuscitate (DNR) orders was formal (92%), experiential (77%), and self-directed (38%). Education about medical orders for life-sustaining treatment (MOLST) was formal (72%), experiential (67%), and self-directed (25%). Ninety-three percent were confident in upholding a DNR order, 87% were confident interpreting MOLST, and 87% were confident sorting out conflict between differing patient and family wishes. Qualitative data analysis yielded six themes on improving preparation of prehospital providers for EOL calls: (1) prehospital provider education; (2) public education; (3) educating health care providers on scope of practice; (4) conflict resolution skills; (5) handling emotional families; and (6) clarification of transfer protocols. These study results suggest the need for addressing the potential interrelationship between prehospital and EOL care through improved education and protocols for care in the field.

Improving MOLST Implementation in a PACE Program

Advanced care planning is an important part of caring for elderly patients with multiple medical conditions, such as patients that participate in PACE (Program of All-Inclusive Care for the Elderly) programs. Traditional DNR (Do-Not Resuscitate) forms are limited to specifying the patients' desire to be resuscitated or not resuscitated in the event that they stop breathing and their heart stops beating. The MOLST (Medical Orders for Life-Sustaining Treatment) form allows patients to express their specific wishes regarding resuscitation, medical interventions, antibiotic use, and artificial feeding and hydration.

Medical Orders for Life-Sustaining Treatment: Maryland Legislates Universal Consideration for Pediatric Inpatients (S709)

Medical Orders for Life-Sustaining Treatment: Maryland Legislates Universal Consideration for Pediatric Inpatients (S709)

Prehospital Providers’ Perceptions of Emergency Calls Near Life’s End

The nature of emergency end-of-life calls is changing as people live longer and die from chronic illnesses. This study explored prehospital providers' perceptions of (1) end-of-life 911 calls, (2) the signs and symptoms of dying, and (3) medical orders for life sustaining treatment (MOLST). The exploratory-descriptive pilot study was survey based and cross-sectional. Calls to nursing homes occur most often, (47.8% every shift). The MOLST was seen infrequently (57.9% rarely never). The most frequent signs and symptoms of dying were diagnosis (76%), hospice involvement (82%), apnea (75%), mottling (55%), and shortness of breath (48%). The MOLST identifies wishes about intubation (74%), resuscitation (74%), life-sustaining treatment (72%), and cardiopulmonary resuscitation (70%). Synergy exists between the fields of prehospital, hospice, and palliative medicine which offers potential for improved education and care.

Multiple Transitions, Because No Advance Directive

Multiple Transitions, Because No Advance Directive