1. MOLST, Health Care Proxy and Electronic Code Status Order

2. Goals of Education/ Implementation
Instruct clinicians in use of standard tools to communicate patient preferences across settings of care:
Health Care Proxy
MOLST (Medical Orders for Life Sustaining Treatment)
Electronic Code Status Order
Code Status Displays in Header
Order detail visible in the Legal Indicators Tab
NEW Clinical Panel Code Status/Advance Directive
Order detail pulls into P.DOC discharge referral

3. 3/31/2017
Health Care Proxy
A basic ethical and legal right of every patient is to be able to make decisions about their medical care. If a person is unable to communicate, it is important that someone who knows their values and preferences can make decisions for them.
If “invoked”, the Health Care Agent is expected to follow the patient’s wishes and make decisions as the patient would make them.
All adults, even healthy adults, are encouraged to choose a Health Care Agent. Health care problems may arise suddenly; having a surrogate decision maker provides an extra layer of security.

4. Invoking the Health Care Proxy (HCP)
When the Health Care Proxy form is invoked by the provider, the agent becomes the legal decision maker.
Provider must be sure he/ she is communicating with the legal decision maker before making code status decisions with that person.

5. Orders for Life-Sustaining Treatment What is MOLST? Medical 3/31/2017
MOLST is a medical order that documents a patient’s wishes regarding end of life care. The MOLST form can be used to refuse OR request treatment; the form is voluntary, is valid in any health care setting, and is appropriate independent of the patient’s decision-making abilities. In contrast, a Health Care Proxy is a legal document that names an agent to speak on behalf of a patient who no longer has decision-making capacity.
Establishing a MOLST with a patient is a process, i.e., a conversation or several conversations with the patient, caregivers, health care agent, and family, resulting in the documentation of the patient’s medical choices on a standard, two-sided MOLST form. The first side includes medical orders including resuscitation, intubation and transfer to hospital; the second side allows for selected patient preferences including non-invasive ventilation, dialysis, artificial nutrition, artificial hydration and space to add free text preferences.
MOLST allows patients to designate which medical interventions they want and which they would refuse, if they could not communicate directly with a care provider.
When a patient presents to a healthcare setting with a MOLST, orders should be honored until a physician, nurse practitioner or physician assistant can assess the situation.

6. 3/31/2017
MOLST is…
A medical document that may be used in the context of advance care planning
Suitable for patients of any age with an advanced illness
Based on a patient’s current health status
Valid medical orders for life-sustaining treatments
A portable document that is valid across care settings
MA MOLST Demonstration Project: 6

7. Which patients are suitable for MOLST?
3/31/2017
Which patients are suitable for MOLST?
Patients of any age with an advanced illness including, but not limited to:
Life-threatening diseases
Chronic progressive diseases
Life-threatening injuries
Medical frailty
Any patient suitable for considering DNR orders
MA MOLST Demonstration Project: 7

8. MOLST form side 1: Medical Orders
3/31/2017
1) Side A is “orders”: CPR, Vent, Transfer
2) Gray section is for signatures – must be signed by patient and provider to be valid
3) HCP-Agent can place name in the “optional section” below the signatures

9. MOLST form side 2: Patient Preferences
3/31/2017
1) Side B is “patient preferences”: Dialysis, Artificial Nutrition, other preferences
2) Need to address short term
3) The two sides can be independent of each other. Possible to have only one side be used/ valid.

10. Key Workflow Decisions: Emergency Dept & Hospital
3/31/2017
Paper process in ED.  Electronic process in inpatient setting.  
Code status orders will be standardized in Meditech 6.0 and a code status order will be required for every inpatient upon admission
Meditech 6.0 code status/ limitations in care supersede the MOLST form in the inpatient setting

11. Electronic Code Status ORDER IN MEDITECH

13. Use the type ahead search to find Code Status order

14. Check Mark the Order > Next in the Footer

15. Complete the Required Fields

16. Advanced Directive Discussion and List by Priority Order
Special Circumstances = If patient is not competent and has no surrogate decision maker, refer to End of Life policy for DNR ordering process.

17. Enter your PIN and Save Selected

18. Code Status on the Current Orders Screen

19. Detail on Legal Indicators Tab and Code Status appears in the Header

20. NEW Code Status/Advance Directive Clinical Panel

21. Detail in Clinical Panel View

22. Order Detail pulls into Discharge Referral

24. Complete Required Fields

25. Detail on Legal Indicators Tab and Code Status appears in the Header

26. Detail on Advance Directive Clinical Panel

27. Order Detail pulled into Discharge Referral

29. Complete Required Fields

30. Detail on Legal Indicators Tab and Code Status appears in the Header

31. Detail on Advance Directive Clinical Panel

32. Order Detail pulled into Discharge Referral