1. Medical Orders for Life Sustaining Treatment (MOLST) Promoting communication and respect for end of life care choices across the continuum of care

2. Purpose of MOLST?  To provide a mechanism to communicate patient preferences and appropriate life sustaining medical interventions for end of life treatment across care sectors.  Turns patient / substitute decision maker treatment preferences and advance care directives / plans into medical orders

3. What is MOLST?  A medical order which must be signed by a doctor involved in providing care to the patient  Complements, but does not replace advance care planning discussion and documentation  Provides clinical direction about CPR response and other invasive life sustaining treatment choices

4. MOLST is for….  Seriously ill patients with advanced chronic, progressive disease/s  Terminally ill patients  Patients with advanced frailty  MOLST is primarily recommended for patients who might reasonably be expected to die within the next year

5. MOLST patient population  ‘Would you be surprised if the patient were to die in the next year or month or days?’ (Joanne Lynn 2005)  If you would not be surprised, what treatment is appropriate for their clinical condition/s which will support the patient?

6. Distinctive colour for easy identification Standardised colour will facilitate easy form identification across care services and during transfer process Provides clinical guidance for life sustaining treatment in both urgent and non urgent situations Unless it is the patient’s preference use of the MOLST form is not appropriate for person’s with stable medical or functionality problems who have many years of life expectancy

7. MOLST medical summary Diagnosis and co morbidity Co morbidity is increasingly the biggest predictive indicatory of mortality Summary of prognostic indicators observed over the past 6 months Identification of advance care planning discussion and document location Medical advice re hospital based life sustaining treatment Substitute decision maker identification documented

8. MOLST medical orders Attempt CPR supports discussion re success rate of CPR Accept natural dying reinforces that dying is anticipated Clear instructions on when to transfer to hospital and use of critical care services Goals of antibiotic therapy clarified. Options other then IV administration are identified and opens up discussion opportunities Identification of artificial feeding and fluids as medical treatment, promoting further discussion opportunities Consent for treatment documented. MO ordering treatment identified Any section not completed implies full medical treatment for that option

9. Where’s the evidence?  http://www.ohsu.edu/polst/resources/research+referen ces.htm http://www.ohsu.edu/polst/resources/research+referen ces.htm http://www.ohsu.edu/polst/resources/research+referen ces.htm  POLST form associated with lower use of invasive life sustaining treatments at end of life then traditional no CPR orders  97% of completed POLST forms had information on when to transfer the Resident to hospital  Journal of American Geriatrics Society 2010 July Vol 58 Issue 7: 1249-1255