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)

MOLSTMOLST

Values, Goals and Expectations

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

MOLSTMOLST

Implementation and Education

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

LTCLTC

OfficeOffice

Pre-HospitalPre-Hospital& Acute Care& Acute Care

MOLSTMOLST

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

MOLSTMOLST

QuestionsQuestions