1. 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

2. Objectives Background Oregon POLST Rochester MOLST Values, Goals, Expectations Implementation & Education Questions www.compassionandsupport.org

3. 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”

4. 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

5. 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.orgwww.compassionandsupport.org

6. * * * * * * * * * * * * * EPEC * ACP/CCCC * MOLST * ** * CPPM

7. * MOLST * * *

8. Advance Care Planning: A Gift Clarify values, beliefs Choose a spokesperson Understand life- sustaining treatments Practical issues Compassion and Support at the End of Life

9. Advance Care Directives For All Adults Health Care Proxy Form Living Will Organ Donation (optional) For Those Who Are Chronically Ill or Near the End of Their Lives Nonhospital Do Not Resuscitate (DNR) Order Medical Orders for Life Sustaining Treatment (MOLST) form

10. 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

11. 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

12. 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

13. 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

14. 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 life- prolonging treatments

15. 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)

16. 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%

17. 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)

18. 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

19. 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

20. 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)

21. Site of Death: National and State Data

22. POLST is Spreading Parts of: Parts of: Georgia, Kansas, Missouri, New Mexico, Utah, Washington, West Virginia, Wisconsin, New York, Pennsylvania * * * * * * * * * * *

23. From Oregon POLST to Rochester MOLST Medical Orders for Life-Sustaining Treatment

24. MOLST Created by the Community- wide 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

25. MOLST vs. POLST POLST –Proprietary about exact form –Mainly researched in LTC –Did not fit many New York State criteriaMOLST –Adapted to New York State law –Combines DNR, DNI and other Life-Sustaining Treatments –Meets all regulatory requirements

26. Pink MOLST Form Consistent colorConsistent color: easily identifiable –facilitate appropriate care desired by patient AccuracyAccuracy: clear, unambiguous medical orders FlexibleFlexible: changes can be made sequentially –Does not need to be done with each admission PortablePINKPortable: transfer PINK across systems AvailabilityPINKAvailability: Original PINK MOLST with the patient; make copy to retain in the chart

27. Health Care Proxy/Living Will and MOLST Health Care Proxy/Living Will –completed ahead of time –applies only when decision-making capacity is lostMOLST –applies right now –not conditional on losing decision-making capacity –set of physician orders –may carry more weight in medical settings

28. What Does MOLST Replace? Replaces previous DNR/DNI forms Old forms still valid NOTIt does NOT replace NY State Health Care Proxy forms (or a living will) Preferences for other life-sustaining therapies

29. DNR Order It Does NOT Replace the NYS Nonhospital Order Not to Resuscitate form (DNR Order)

30. MOLST Values, Goals and Expectations

31. 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

32. 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

33. Potential Goals of Care Cure of disease Avoidance of premature death Maintenance or improvement in function Prolongation of life Relief of suffering Quality of life Staying in control A good death Support for families and loved ones

34. Multiple Goals of Care Multiple goals often apply simultaneously Goals are often contradictory Goals are sometimes unrealistic Certain goals may take priority over others

35. Goals May Change Some take precedence over others Gradual shift in focus of care Expected part of the continuum of medical care

36. 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

37. 7-Step Protocol 4. Suggest realistic goals 5. Respond empathetically 6. Make a plan and follow-through 7. Review and revise periodically

38. 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

39. MOLST Implementation and Education

40. 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

41. LTC Office Pre-Hospital & Acute Care MOLST

42. MOLST Implementation Issues –Development of policies and procedures –Integration of Policies and Procedures across the continuum of care –Discharge or Transfer –Accountability

43. MOLST Education –Staff Medical Hospital Long Term Care EMS –Community Community Conversations on Compassionate Care

44. 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

45. MOLST Summary “Portable” medical order form Travels with patient Can translate an advance directive into physician’s orders DOES NOTDOES NOT replace an advance care directive DOES NOTDOES NOT replace the NYS Nonhospital Order Not to Resuscitate form (DNR Order)

46. 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 –pink forms available from Health Plan …fax reorder form to 585- 238-4400

47. MOLST Questions