Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST), by Dr. Amy Sanderson.
Hello, my name is Amy Sanderson, and I'm an Assistant in Critical Care Medicine at Boston
Children's Hospital.
Today I'm going to be speaking to you about Massachusetts Medical Orders for Life-Sustaining
Treatment, also known as MOLST.
Specifically, I'll be talking about concerns regarding the current state of advance care
planning for children with life-threatening diseases, what MOLST is, and why the change.
Concerns Regarding Advance Care Planning.
Optimal care for children with life-threatening conditions requires effective advance care
planning.
Parents of critically ill children believe that it is important to have honest and direct
communication with health care providers, as information given by the clinical team
may influence their end-of-life decision making.
Furthermore, among adults, advance care planning has been associated with end-of-life care
consistent with patient preferences as well as a better rating of the dying experience.
However, advance care discussions often happen late in the course of illness, and resuscitation
status orders are frequently placed in the medical record near the time of death.
Communication during advance care discussions has been reported as suboptimal, and many
times there is parental dissatisfaction with the process.
In fact, parental perception of poor communication styles and insufficient transfer of information
have led to poor quality of care ratings.
Studies have shown that common barriers to pediatric palliative care and advance care
discussions include uncertain prognosis, differences between clinician and patient or parent understanding
of prognosis, the patient or parent is not ready to acknowledge an incurable condition,
language barriers, time constraints, and conflicts within the family.
Recommendations to overcome these barriers include interdisciplinary collaboration to
optimize care and increase clinician education, such as more formal courses in pediatric palliative
care, communication training, and hospice rotations.
Another recommendation is to discuss palliative care in advance of critical illness because
talking about treatment preferences earlier in the disease course may improve the patient
and parents' ability to make these decisions later on.
Furthermore, we really should integrate palliative and curative therapies.
A dichotomous model that compels one to choose between curative therapies and treatment directed
toward comfort is likely to be frustrating to pediatric health care providers, patients,
and their parents.
And finally, it may be helpful to accept prognostic uncertainty because it is an inherent part
of medical care.
An uncertain prognosis can create opportunities for enhanced communication.
Now we are briefly going to talk about Do-Not-Resuscitate orders because they can be an important part
of advance care planning and discussions.
DNR orders were developed as a means of inducing an informed decision by the patient on what
procedures would not be implemented at the time of cardiac arrest.
Indeed, the publication of the first DNR orders in the literature marked a significant transition
in the delivery of medical care.
Rather than initiating a therapeutic intervention, this was the first order prohibiting a specific
medical therapy.
The DNR order alone is insufficient for optimal advance care planning.
Why is that?
Most patients and families need time to deal with the reality of approaching death.
It is not recommended to use DNR orders to introduce dying.
Furthermore, if clinicians discuss resuscitation status before understanding the patient or
parents' overall goals of care, then the DNR discussion becomes a substitute for talking
about overall goals of care.
The problem with this is that confusion may arise if treatment preferences are not known
but rather inferred from a DNR order.
Clinicians may incorrectly assume that a patient who agrees to a DNR order would also prefer
to forgo other medical therapies.
Although patients who decline CPR may choose to decline other medical interventions, the
DNR order is not intended to limit any therapies other than those that attempt to reverse a
cardiopulmonary arrest.
However, studies have shown that there is substantial variability in the interpretation
of a DNR order.
In theory, many clinicians believe that a DNR order should guide therapeutic decisions
only during a cardiopulmonary arrest.
Yet in reality, care may change beyond resuscitative interventions.
These challenges surrounding treatment preferences for patients with advanced illness led to
the development of the MOLST form.
Introduction to the MOLST Form.
The Commonwealth of Massachusetts recognized that there was a need to standardize the way
in which patient preferences are communicated.
Specifically, MOLST is a medical order form that converts a patient's treatment preferences
into medical orders.
Why is MOLST important to our patients?
Because MOLST is honored across all treatment settings.
And because understanding treatment preferences is especially important for patients who have
progressive life-limiting illnesses.
Why change to the MOLST?
It's more comprehensive than the Comfort Care DNR form.
It includes other life sustaining treatment options in addition to resuscitation.
There is less risk for misinterpretation of a patient's wishes.
And it is a standardized medical order that crosses the continuum of care.
MOLST forms are not the same as advanced directives.
Why not?
Well, because advance directives are legal, not medical documents.
Remember MOLST is an active medical order.
Also, advance directives go into effect only after a patient is incapable of making his
or her own medical decisions.
Treatment preferences that are documented on a MOLST form are made by a person who is
still capable of making medical decisions.
MOLST forms are not the same as living wills either.
Living wills are written documentation of a person's preferences.
They are used to guide surrogates and clinicians if a person loses capacity to make medical
decisions.
A living will is not legally binding in Massachusetts.
It is important to talk to all patients older than 18 years of age about signing a health
care proxy.
Before talking about MOLST, it is important to determine if a patient may be suitable
for a MOLST form based on his or her current medical condition.
One should consider patients with advancing illness due to a serious medical condition,
patients who have a DNR order, and patients who have a pre-existing MOLST form but current
treatment preferences are not accurately reflected.
So when introducing the option of MOLST, engage in discussions with the patient, the patient
representative, and other loved ones about the patient's condition, prognosis, values,
and goals of care.
Clinicians should explore expectations and hopes for treatment, especially what would
be acceptable and unacceptable outcomes of treatment.
Clarify that MOLST is a voluntary way to document and communicate preferences about life-sustaining
treatments.
Using the MOLST form.
Now we're going to talk about some of the specifics of filling out a MOLST form.
On page one, fill in sections A, B, and C to reflect treatment preferences then instruct
the patient or patient representative to fill in section D completely.
Fill in section E yourself.
It is important to not only fill in the date you signed the form but also to document the
time.
All medical orders must be dated and timed.
Fill in optional information as instructed at the bottom of page one if appropriate for
the patient.
For section F on page two, explain the uses, benefits, and burdens of each treatment and
mark the treatment preferences or mark undecided or did not discuss.
Instruct the patient or patient representative to fill in section G completely and fill in
Section H yourself.
Don't forget to document the date and time that the form was signed.
Physicians, Nurse Practitioners, and Physician's assistants can fill out and sign a MOLST form
with a patient.
Once again, patients who might be suitable for MOLST include those of any age with advanced
illness, including but not limited to life threatening illnesses, chronic progressive
diseases, medical frailty, and any patient suitable for considering DNR orders.
When you encounter a patient with the MOLST form, honor the form as you would honor any
other medical order.
Alert appropriate clinicians about the existence and contents of the MOLST form and contact
the clinician who signed the patient's MOLST for more information if needed.
Here are some points to remember after a MOLST form is signed.
The original MOLST form stays with the patient.
The MOLST form should be placed where it can be easily located such as on the refrigerator
or at the bedside.
The form should go with the patient to all care settings and during any trips or appointments
outside the home.
Family and caregivers should be informed about the MOLST form, its contents, and where to
find it.
Copies of the MOLST form are valid.
All of the patient's health care providers should have an updated copy.
MOLST forms should be updated any time there's a significant change in the patient's health
status, level of care, goals of care, or treatment preferences and patients can ask to change
or void their MOLST form at any time.
Any change to the MOLST form requires the form to be voided and a new form filled out.
To void a MOLST form, write "VOID" across pages one and two of the form.
Instruct the patient that all copies of the outdated form must be destroyed and create
a new MOLST form if the patient desires it.
For more information about MOLST please visit the Massachusetts MOLST website.
Thank you very much for your interest in the Massachusetts MOLST initiative.
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