Post on 23-Dec-2015
MMedical edical OOrders for rders for LLife-ife-SSustaining ustaining TTreatmentsreatments
MOLST Staff EducationMOLST Staff Education
Patricia A. Bomba M.D., F.A.C.P.Vice President and Medical Director, Geriatrics
Excellus BlueCross BlueShieldExcellus BlueCross BlueShield
A Community-wide End-of-life/Palliative Care Initiative project
ObjectivesObjectives
• Background
• Oregon POLST
• Rochester MOLST
• Values, Goals, Expectations
• Implementation & Education
• Questions
www.compassionandsupport.org
Evolving RealitiesEvolving 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”
Gaps and Quality IssuesGaps and Quality Issues
““Approaching Death: Approaching Death:
Improving Care at the End-of-LifeImproving Care at the End-of-Life””
location of death
pain management
treatment preferences
hospice admissions
Institute of Medicine Report, 1997
Community-wide End-of-life/Community-wide End-of-life/Palliative Care InitiativePalliative Care Initiative
Advance Care PlanningAdvance Care Planning – Community Conversations on Compassionate Care
Honoring PreferencesHonoring Preferences– Medical Orders for Life-Sustaining Treatment (MOLST)
Pain Management and Palliative CarePain Management and Palliative Care– Community Principles of Pain Management– CompassionNet
Education and CommunicationEducation and Communication – Education for Physicians on End-of-life Care (EPEC)– Community web site: www.compassionandsupport.org
Rockland
Niagara Orleans
Erie
Onondaga
Jefferson
ChautauquaSteuben
Cayuga
Orange
MonroeWayne
Genesee
St. Lawrence
Allegany
Wyoming
Cattaraugus
Ontario Seneca
Livingston
Schuyler
Chemung
Cort land
Oswego
Lewis
Madison
Chenango
Delaware
Franklin
Otsego
Sullivan
Essex
Clinton
AlbanySchoharie
Greene
Washington
Rensselaer
Saratoga
Warren
Schenectady
Columbia
UlsterDutchess
Putnam
Westchester
SuffolkNassau
Fulton
Montgomery
Herkimer
Hamilton
Oneida
Tioga
Broome
Oneonta
Watertown
Poughkeepsie
Amsterdam
Binghamton
Elmira
Albany
Rome
Ut ica
Plat tsburgh
Syracuse
AuburnBuffalo
Rochester
Jamestown
Hornell
Ithaca
Batavia
Malone
Potsdam
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Tompkins
GeneseeCentral
Southern Tier Tri-Cities
Watertown
North Country
Utica-Rome
Rochester region
Southern Tier region
Syracuse region
Utica region
Yates
Western
Western region
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* EPEC* EPEC
* ACP/CCCC* ACP/CCCC
* MOLST* MOLST
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* CPPM* CPPM
Rockland
Niagara Orleans
Erie
Onondaga
Jefferson
ChautauquaSteuben
Cayuga
Orange
MonroeWayne
Genesee
St. Lawrence
Allegany
Wyoming
Cattaraugus
Ontario Seneca
Livingston
Schuyler
Chemung
Cort land
Oswego
Lewis
Madison
Chenango
Delaware
Franklin
Otsego
Sullivan
Essex
Clinton
AlbanySchoharie
Greene
Washington
Rensselaer
Saratoga
Warren
Schenectady
Columbia
UlsterDutchess
Putnam
Westchester
SuffolkNassau
Fulton
Montgomery
Herkimer
Hamilton
Oneida
Tioga
Broome
Oneonta
Watertown
Poughkeepsie
Amsterdam
Binghamton
Elmira
Albany
Rome
Ut ica
Plat tsburgh
Syracuse
AuburnBuffalo
Rochester
Jamestown
Hornell
Ithaca
Batavia
Malone
Potsdam
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Tompkins
GeneseeCentral
Southern Tier Tri-Cities
Watertown
North Country
Utica-Rome
Rochester region
Southern Tier region
Syracuse region
Utica region
Yates
Western
Western region
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* MOLST* MOLST
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Advance Care Planning: A GiftAdvance Care Planning: A Gift
Clarify values, beliefs
Choose a spokesperson
Understand life-sustaining treatments
Practical issuesCompassion and Supportat the End of Life
Advance Care DirectivesAdvance Care Directives
For All AdultsFor All Adults
Health Care Proxy Form
Living Will
Organ Donation (optional)
For Those Who Are For Those Who Are Chronically Ill or Chronically Ill or
Near the End of Their LivesNear the End of Their Lives
Nonhospital Do Not Resuscitate (DNR) Order
Medical Orders for Life Sustaining Treatment (MOLST) form
POLST in OregonPOLST 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
Philosophy of POLST 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
POLST in OregonPOLST 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
POLST ResearchPOLST 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
POLST ResearchPOLST 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
POLST : ResearchPOLST : 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)
POLST : ResearchPOLST : 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%
POLST : ResearchPOLST : 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)
POLST Outcomes: POLST Outcomes: Completed ACD 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
Site of DeathSite 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
POLST Outcomes: POLST Outcomes: Site of Death Site of Death
Oregon residents who die in hospital
• 1980: 50%
• 1993: 35% (national average: 56%)
• 1999: 31% (lowest rate in the US)
Site of Death:Site of Death:National and State DataNational and State Data
Deaths at home
Deaths in a Hospital
Deaths in a NH
Oregon (Nat'l Benchmark) 35.10% 32.50% 32.40%
National Mean (Average) 24.90% 50.00% 25.10%
New York 21.20% 61.80% 17.00%
POLST is SpreadingPOLST is Spreading
Parts of:Parts of:
Georgia, Kansas,
Missouri, New Mexico,
Utah, Washington,
West Virginia,
Wisconsin, New York,
Pennsylvania
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From Oregon POLST to From Oregon POLST to Rochester MOLSTRochester MOLST
Medical Orders for Life-SustainingTreatment
MOLSTMOLST
• 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
MOLST vs. POLSTMOLST vs. POLST
POLSTPOLST– Proprietary about exact form– Mainly researched in LTC– Did not fit many New York
State criteria
MOLSTMOLST– Adapted to New York State law– Combines DNR, DNI and other
Life-Sustaining Treatments– Meets all regulatory
requirements
Pink MOLST FormPink 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
• PortablePortable: transfer PINKPINK across systems • AvailabilityAvailability: Original PINKPINK MOLST with the
patient; make copy to retain in the chart
Health Care Proxy/Living WillHealth Care Proxy/Living Willand MOLSTand MOLST
Health Care Proxy/Living WillHealth Care Proxy/Living Will – completed ahead of time– applies only when decision-making capacity is lost
MOLST MOLST – applies right now– not conditional on losing decision-making capacity– set of physician orders– may carry more weight in medical settings
What Does MOLST Replace?What Does MOLST Replace?
• Replaces previous DNR/DNI forms
• Old forms still valid
• It does NOTNOT replace NY State Health Care
Proxy forms (or a living will)
• Preferences for other life-sustaining therapies
DNR Order DNR Order State of New York
Department of Health
Nonhospital Order Not to Resuscitate (DNR Order)
Person's Name:___________________________________
Date of Birth: _____/_____/_____
Do not resuscitate the person named above.
Physician's Signature ____________________
Print Name _________________________
License Number ____________________
Date _____/_____/_____
It is the responsibility of the physician to determine, at least every 90 days, whether this order continues to be appropriate, and to indicate this by a note in the person's medical chart.
The issuance of a new form is NOT required, and under the law this order should be considered valid unless it is known that it has been revoked. This order remains valid and must be followed, even if it has not been reviewed within the 90 day period.
DOH-3474 (2/92)
It Does NOT
Replace the NYS
Nonhospital
Order Not to
Resuscitate form
(DNR Order)
Clarify Values and BeliefsClarify 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
Hope, Goals, ExpectationsHope, 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
Potential Goals of CarePotential 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
Multiple Goals of CareMultiple Goals of Care
• Multiple goals often apply simultaneously
• Goals are often contradictory
• Goals are sometimes unrealistic
• Certain goals may take priority over others
Goals May ChangeGoals May Change
• Some take precedence over others
• Gradual shift in focus of care
• Expected part of the continuum of medical care
7-Step Protocol7-Step Protocol
1. Create the right setting
2. Determine what the patient and family know
3. Explore what they are expecting or hoping for
7-Step Protocol7-Step Protocol
4. Suggest realistic goals
5. Respond empathetically
6. Make a plan and follow-through
7. Review and revise periodically
Reviewing goals,treatment prioritiesReviewing 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
MOLST: MOLST: Who Should Have One?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
MOLSTMOLST
• Implementation Issues– Development of policies and procedures
– Integration of Policies and Procedures across the continuum of care
– Discharge or Transfer
– Accountability
MOLSTMOLST
• Education– Staff
• Medical• Hospital • Long Term Care• EMS
– Community• Community Conversations on Compassionate Care
MOLST SummaryMOLST 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
MOLST SummaryMOLST 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)
ResourcesResources
• 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