MOLST Program Overview for EMS Providers, First Responders, and other initial decision makers MOLST for EMS & First Responders, September 2010

How to Use this Presentation This PowerPoint presentation may be used as a companion to “Writing Your Final Chapter: Know Your Choices … Share Your Wishes” (Video 1) and or in lieu of “MOLST Comprehension Review” (Under Video Refresher). Use of both videos is preferred. The educator using this presentation should review materials from the CompassionAndSupport.org website including the videos mentioned above and NYS BEMS Policy Statement 10-05 dated 06/16/10 (supersedes & updates 99-10, 08-07) & the NYSDOH-5003 MOLST form MOLST is approved by NYSDOH as the only alternate form to the NYSDOH Non-Hospital DNR form for use in ALL settings statewide. All properly completed versions of the MOLST form must be honored. The educator should also be familiar with any local or regional protocols regarding DNR, MOLST, and advanced directives. Students should have a copy of the NYSDOH-5003 MOLST form and NYS BEMS Policy Statement 10-05 dated 06/16/10 to review during the presentation. MOLST for EMS & First Responders, September 2010

Objectives Review of out of hospital results Introduction to Medical Orders for Life Sustaining Treatment (MOLST) Validation and interpretation the MOLST Implementing the patient’s wishes DNR or resuscitation for initial providers Other patient care decisions for transport and ALS providers MOLST for EMS & First Responders, September 2010

Review of Out of Hospital CPR and AED Results What is our “save rate” for cardiac arrest? How do age and other health factors change that “save rate”? Are out of hospital cardiac arrests dignified? Are patient desires always able to be followed? Discuss each of the points with the students. The answers don’t need to be based on specific numbers. The likely consensus is that our “save rate” is poor. It is worse with the elderly and terminally ill. Out of Hospital Cardiac Arrests are chaotic and traumatic. Would you like to have a loved one die that way? The last question is open ended. Most have had the experience that they can’t follow everyone’s wishes. MOLST for EMS & First Responders, September 2010

Introduction to the Medical Orders for Life-Sustaining Treatment Approved for statewide use 7/7/08 Revised NYSDOH-5003 MOLST form, effective 6/1/10 User-friendly; Supplemental forms eliminated Approved by OMH 8/23/10 Approved by OPWDD: for patients with DD without ability to decide, the physician must follow special procedures and attach the appropriate legal requirements checklist MOLST Form is a physician’s medical order sheet Completed with the patient or patient’s designee and physician Provides explicit direction for CPR, mechanical ventilation, and other life sustaining treatments Reviewed with patient on a regular basis The form is the result of a lengthy discussion with the patient and/or medical decision-maker These are the essential points of the MOLST form and the process that leads to its completion. It is important for EMS providers to understand that the form is not taken lightly and it is designed to make EMS’s job easier. MOLST for EMS & First Responders, September 2010

DNRs vs. MOLST MOLST is pink, but a copy is acceptable MOLST goes across healthcare settings; the Non- Hospital DNR form is pre-hospital MOLST covers DNR, DNI and pulmonary failure, transfer orders and other LSTs. Non-hospital DNR only covers DNR order What are the differences and similarities between the standard one-page nonhospital DNR order and the MOLST form? The MOLST form (DOH-5003) is a bright pink multi-page form; however, a photocopy or facsimile of the original form is acceptable and legal. A Nonhospital Order Not to Resuscitate form (DOH-3474) is a single page form on white paper with black ink. The MOLST form is meant to be utilized by health care providers across the health care system. It is not limited to EMS agencies; it travels with the patient to different care settings. The Nonhospital Order Not to Resuscitate form is not intended for use in facilities. MOLST provides for end-of-life orders concerning resuscitation and intubation for Advanced EMTs when the patient is in full cardio-pulmonary arrest or has progressive or impending pulmonary failure without acute cardiopulmonary arrest. The Nonhospital Order Not to Resuscitate form (DOH-3474) only applies to patients in full cardio or pulmonary arrest. Both forms, the MOLST form and the Nonhospital Order Not to Resuscitate form (DOH-3474) must be authorized and signed by a physician. Unlike the Nonhospital Order Not to Resuscitate form, there are multiple patient orders contained on the MOLST form that are intended for other health care providers to follow in other health care settings such as the hospital or nursing home. The MOLST form gives prehospital care providers and agencies direction regarding the patient's end-of-life treatment orders in Section A (page 1) and Section E (page 2). See below. MOLST for EMS & First Responders, September 2010

When is it important for EMS Providers? In most situations, the form will just need to go with the patient to the hospital or back home Look for the form on the refrigerator, the back of the bedroom door, or in the patient’s chart When the patient has stopped breathing and lost a pulse, an EMS provider will need to locate the form, determine if it is valid, and follow the directions either to DNR or to CPR If the patient is critically ill, sections on “Life Sustaining Treatment” may apply MOLST should always be present with a patient The presence of a MOLST Form does not mean Do Not Resuscitate. The specific information about reading the form and how to follow it is on following slides. MOLST for EMS & First Responders, September 2010

MOLST Form Characteristics Original is a uniform “MOLST pink” and printed on heavy stock Do Not Resuscitate or Full CPR is on page 1 Other care decisions are documented on page 2 Can replace NYS DOH “Non-Hospital DNR Form” An “Non-Hospital DNR Form” is still valid if found Supplemental Documentation Form is no longer required For patients with DD without ability to decide, the physician must follow special procedures and attach the appropriate legal requirements checklist MOLST Form Although the original is pink, a photocopy or a fax copy would be valid This presentation focuses on the June 2010 version of the form. Previous versions of MOLST are still valid. The form can replace the Out of Hospital DNR in Monroe and Onondaga counties. In other counties, it is valid in hospitals and nursing homes, but a valid “Out of Hospital DNR Form” is required in other settings outside of the pilot counties. MOLST for EMS & First Responders, September 2010

Determine If It Is the Patient’s Form Check patient name and date of birth eMOLST Number (This is not an eMOLST Form) HIPAA permits disclosure of MOLST to other health care professionals & electronic registry as necessary for treatment This MOLST form has been approved by the NYSDOH for use in all settings MOLST Form A reasonable attempt must be made for verification MOLST for EMS & First Responders, September 2010

Section A: Resuscitation Instructions When the Patient Has No Pulse and/or Is Not Breathing CPR Order: Attempt Cardio-Pulmonary Resuscitation Defined; includes intubation DNR Order: Do Not Attempt Resuscitation (Allow Natural Death) DNR and DNI differ (DNI defined in section E) DNR does NOT mean “Do Not Treat” MOLST Form Section A Once the form has been determined to be valid, EMS providers need to follow the orders. First responders must be comfortable with determining the validity of the form and following the requests for DNR or Resuscitation THE Presence of a MOLST form does not mean DNR Presenters should be prepared for a thorough discussion of what is DNR. MOLST for EMS & First Responders, September 2010

Section B: Verify Consent Identify who made the decision. Verbal consent permissible; box should be checked. Two witnesses are always recommended; witness signatures are not required. The physician who signs the orders may be a witness. If it is documented that the attending physician witnessed the consent, the attending physician just needs to sign the order and does not need to sign a second time as a witness. MOLST Form Section B This section MUST be filled out in accordance with New York State law. A box should always be checked to indicate who consented to the decision, and the name of the decision-maker should be printed. If the signature line is left blank, the box for verbal consent should be checked. If the box for verbal consent is checked, the attending physician who signed the order should have witnessed the consent or two other adult witnesses should be indicated. Either the patient signature or an indication of verbal consent is sufficient There also needs to be a witnesses signature. If it is documented that the attending physician witnessed the consent, the attending physician just needs to sign the order and does not need to sign a second time as a witness. MOLST for EMS & First Responders, September 2010

Section C: Physician Signature In Section C, is there a physician signature and name? If there are signatures where appropriate in sections B and C, check the dates with the signatures MOLST Form Section C Section C - Physician Signature for Sections A and B This section MUST be signed by a physician. As with the Nonhospital Order Not to Resuscitate form (DOH 3474), the MOLST form is required to be reviewed by the physician periodically. However, both forms should be considered valid unless it is known that the medical order has been revoked. In rare cases, the physician may have provided verbal authorization for the form, but has not been able to sign it yet. In this case a record of a verbal order is appropriate, but EMS should make an effort to verify the validity of the form. MOLST for EMS & First Responders, September 2010

Section D: Advance Directives Health Care Proxy Living Will Organ Donation Documentation of Oral Advance Directive MOLST Form Section D This section contains multiple check boxes listing advanced directives for the patient. MOLST for EMS & First Responders, September 2010

Section E: Treatment Guidelines New form separates treatment guidelines and future hospitalization/transfer MOLST Form Section E Section E - Orders for Other Life-Sustaining Treatment and Future Hospitalization When the Patient has a Pulse and the Patient is Still Breathing This section contains several parts containing treatment options that must be reviewed by prehospital care pro-viders and includes: Treatment Guidelines Comfort measures only Limited medical interventions No limitations Instructions for Intubation and Mechanical Ventilation Do Not Intubate (DNI) A trial period Intubation and mechanical ventilation Non-invasive ventilation (e.g. BIPAP) Intubation and long-term mechanical ventilation Future Hospitalization/Transfer Do not send to hospital unless pain or severe symptoms cannot otherwise be controlled Send to hospital if necessary, based on MOLST orders. Artificially Administered Fluids and Nutrition No feeding tube A trial period of feeding tube Long-term feeding tube No IV fluids A trial period of IV fluids Antibiotics Do not use antibiotics Limited use of antibiotics Use antibiotics Other Instructions (e.g. dialysis, transfusions) If any part of Section E is completed, additional consent and a physician signature, similar to Section B, must be documented at the end of this section. Sometimes two boxes will be checked in Section E. If the form was completed in the community (as opposed to a hospital or nursing home), a Public Health Law Surrogate may consent to a nonhospital DNR and/or DNI order, but may not consent to withholding other life-sustaining treat-ment unless the consent is based on clear and convincing evidence of the patient's wishes. For that reason, the box for "based on clear and convincing evidence of the patient's wishes" may be checked in addition to the box for "Public Health Law Surrogate." MOLST for EMS & First Responders, September 2010

Section E: Instructions for Intubation and Mechanical Ventilation DNI vs. a trial period vs. intubation & long-term mechanical ventilation DNI should not be checked if full CPR is checked in Section A EMS would be a trial period MOLST Form Section E MOLST for EMS & First Responders, September 2010

Section E: Future Hospitalization/Transfer Specific directions to EMS re: preferences for future hospitalization/transfer MOLST Form Section E It is important that EMS providers should be able to contact the physician on the form or medical control to clarify any of these situations. MOLST for EMS & First Responders, September 2010

Section E: Artificially Administered Fluids and Nutrition EMS would be a trial period of IV fluids MOLST Form Section E It is important that EMS providers should be able to contact the physician on the form or medical control to clarify any of these situations. MOLST for EMS & First Responders, September 2010

Section E: Antibiotics EMS is not able to give antibiotics MOLST Form Section E MOLST for EMS & First Responders, September 2010

Section E: Other Instructions Include “Other Instructions” about starting or stopping treatments discussed with the doctor or about treatments not otherwise listed (such as dialysis, transfusions, etc.) These may be relevant to EMS MOLST Form Section E MOLST for EMS & First Responders, September 2010

Section E: Consent for Life-Sustaining Treatment Orders Identify who made the decision Two witnesses are always recommended; witness signatures are not required The physician who signs the orders may be a witness. If it is documented that the attending physician witnessed the consent, the attending physician just needs to sign the order and does not need to sign a second time as a witness MOLST Form Section E MOLST for EMS & First Responders, September 2010

Section E: Physician Signature Physician signature, name and date/time for any of the orders in Section E This may be different from section C MOLST Form Section E MOLST for EMS & First Responders, September 2010

Section F: Review and Renewal of MOLST Orders on This MOLST Form No change Form voided, new form completed Form voided, no new form MOLST Form Section F MOLST for EMS & First Responders, September 2010

Liability Protection PHL § 2994-gg provides: "No person shall be subjected to criminal prosecution or civil liability, or be deemed to have engaged in unprofessional conduct, for honoring reasonably and in good faith pursuant to this section a nonhospital order not to resuscitate, for disregarding a nonhospital order pursuant to § 2994ee of this article, or for other actions taken reasonably and in good faith pursuant to this section." MOLST for EMS & First Responders, September 2010

Review of MOLST MOLST contains orders either for DNR OR Full Resuscitation MOLST may contain orders for other life sustaining treatments – either to give them or withhold them The form is completed based on the patient’s wishes and authorized by a physician If you have concerns with the content of the MOLST form, contact Medical Control, contact the signing physician and use your best judgment. MOLST for EMS & First Responders, September 2010

Additional Information www.CompassionAndSupport.org Contains videos with extensive background on the MOLST project and form utilization Educational and reference tools NYS BEMS Policy Statement 10-05 dated 06/16/10 (supersedes & updates 99-10, 08-07) NYSDOH-5003 MOLST form For changes or suggestions about this presentation, contact Paul Bishop at pbishop@monroecc.edu MOLST for EMS & First Responders, September 2010