Friday, March 8, 2013

Understanding MOLST

As Massachusetts did not long ago, Connecticut soon will launch its MOLST program with a pilot project.

Don’t know what MOLST stands for? Maybe the following will help. It’s from Paul Drager, J.D., of MedEthics Consulting of New Britain, Connecticut:

 “Traditional advance care planning, including living wills and appointment of a health care representative can be a starting a point for end of life discussions. In particular, Medical Orders for Life-Sustaining Treatment or MOLST complement advance directives. Traditional advance directives look to the future, but they are not actionable medical orders.  They are appropriate for anyone of legal age regardless of their medical condition. MOLST, on the other hand, is aimed primarily at persons, regardless of age, at the end-of-life (seriously ill patients with life-limiting advanced illness; patients with advanced frailty; patients who may lose the capacity to make their own health care decisions in the next year; persons with strong preferences about current end-of-life care).  MOLST is intended to encourage and facilitate discussions between physician and patient at this point in a patient's healthcare continuum.

“Prognostication is often an issue.  The key question to be answered by any physician, with regard to MOLST, is: Would you be surprised if your patient were to die within the next year?  If the answer is "no" then the intimate and comprehensive discussion on end-of-life care needs to be initiated to clarify the patient's wishes.  For example, the New York State MOLST allows patients to indicate that they want all resuscitative measures, no resuscitative measures, or resuscitative measures to be undertaken on a time-limited basis.  Importantly, that document then becomes an actionable medical order which is to be followed, and accompanies patients across all healthcare settings.  Conceptually, MOLST is an out-of-hospital 'do not resuscitate' form and a medical order to be followed regardless of a patient's healthcare setting, but it is more.  It should be reviewed on a regular basis (about every 90 days, but failure to do so will not void it); healthcare providers still have an affirmative duty to make an assessment; and EMS personnel must honor it.

“The MOLST paradigm recognizes that healthcare for any given patient is a team effort.  While MOLST discussions can take place with members of the healthcare team, the order itself is signed by the physician (however, some states allow a PA or APRN to sign the order) AND the patient (or their surrogate). 

“Another key to MOLST is that it is patient centered rather than physician centered.  It encourages, and in some states now requires, that the difficult discussion takes place between the physician and the patient.  MOLST seeks to achieve patient preferences and goals in end-of-life care.  In doing so, the MOLST discussion provides context by discussing values, beliefs and goals of care; identifying core patient values and beliefs; determining goals of care; and documenting the conversation.

“It is noteworthy that in 1995, a study highlighted a disconnect between patient preferences concerning end-of-life care and the care provided by their physicians. The Study to Understand Prognosis and Preferences for Outcomes and Risks of Treatment (SUPPORT), was a multimillion dollar, multisite investigation of the process of dying in American hospitals, funded by the Robert Wood Johnson Foundation. The majority of physicians did not know if their patients had Advance Directives, or did not follow them.  Little has changed.

“There are still significant barriers concerning the Advance Directive discussion between patients and physicians.  Many physicians are overworked, lacking time for "discussion", and believe that their patients are not receptive to discussing Advance Directives.  This underscores the need to address patient barriers and encourage a change in medical culture to address emotional and personal patient issues so that their goals of care are met.”


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