Massachusetts

1
Massachusetts Medical Orders for
Life-Sustaining Treatment
MOLST Overview for Health Professionals
2

• The MOLST project is a collaboration of the
• Massachusetts Department of Public Health
• Massachusetts Executive Office of Elder Affairs
  and
• Commonwealth Medicine at UMass Medical School

3
Presenters

• Christine McCluskey, RN, MPH
• Director, MOLST Expansion Project
• Commonwealth Medicine, UMass Medical School
• Mary Valliere, MD
• Medical Consultant, MOLST Expansion Project
• Jena Bauman Adams, MPH
• Training Consultant, MOLST Expansion Project
• Central Massachusetts Area Health Education
  Center

picture
4
Goals of the Presentation

• Provide basic information about MOLST
• Provide a recorded version of the MOLST Overview
  for Health Professionals that may be used for
  individual or group training
• Supplement the MOLST Overview for Health
  Professionals with responses to Frequently Asked
  Questions about its content

5
MOLST Overview for Health Professionals Documenti
ng and honoring patients preferences for
life-sustaining treatment
6
MOLST is

• A POLST paradigm program (more info at
  www.polst.org)
• A medical document that may be used in the
  context of advance care planning
• Suitable for patients of any age with an advanced
  illness
• Based on a patients current health status
• Valid medical orders for life-sustaining
  treatments
• A portable document that is valid across care
  settings

7
MOLST expands on the MA Comfort Care/DNR form
CC / DNR
M O L S T
The CC/DNR form remains valid in Massachusetts!
8
MOLST is not an Advance Directive

• Advance Directives are legal (not medical)
  documents.
• Advance Directives specify who (e.g. health
  care agent) or what (e.g. information on a living
  will) represents a persons preferences if the
  person loses capacity to make medical decisions.
• Advance Directives go into effect only after a
  patient is declared incapable of making their own
  medical decisions.

9
Advance Directives in Massachusetts

• The only legally authorized Advance Directive in
  Massachusetts is a health care proxy (HCP) form.
• Health care proxy forms specify who (the health
  care agent) represents an incapacitated patient
  during shared decision-making.

10
What about Living Wills?

• A living will is written documentation of a
  persons preferences to guide surrogates and
  clinicians if the person loses capacity to make
  medical decisions.
• Living wills are not legally binding in
  Massachusetts, but can be important sources of
  information about a persons preferences.

11
A Comparison of Forms
MOLST HEALTH CARE PROXY
Form type Medical document Legal document
Form users Patients of any age with advanced illness All adults (ages 18 and older) healthy or sick
Form contains Current medical orders about life-sustaining treatments Name of the persons appointed health care agent(s) for future shared decision-making
Form signer(s) The patient and clinician The person and two witnesses of their own choice
Or health care agent (only if the patient lacks
capacity)
12
Who signs the MOLST form?

• The patient or patients health care agent (only
  if the patient has been declared to lack
  capacity). If there is no agent, a guardian or
  the parent/guardian of a minor can sign to the
  extent permitted by Massachusetts law. Seek
  legal counsel about a guardians authority.
• and
• The clinician a physician, nurse practitioner
  or physician assistant, after goals of care
  discussions with the patient and his or her
  surrogates.

13
Which patients are suitable for MOLST?

• Patients of any age with an advanced illness
  including, but not limited to
• Life-threatening diseases
• Chronic progressive diseases
• Life-threatening injuries
• Medical frailty
• Any patient suitable for considering DNR
  orders

14
When a patient has a MOLST form

• Honor the MOLST form as you would honor other
  medical orders, until a physician, nurse
  practitioner or physician assistant can assess
  the clinical situation.
• Alert a clinician about the existence and
  contents of the MOLST form.
• Contact the clinician who signed the patients
  MOLST for more information if needed.

15
When a patient wants a MOLST form

• Alert a clinician when
• Any patient/health care agent asks about MOLST
• Any patient/health care agent expresses
  preferences about life-sustaining treatments
• Any patient may be suitable for MOLST
• Assist patients and families to get information
  they need for advance care planning especially
  the importance of completing a health care proxy
  form

16
Contents of the MOLST form

• Page 1 contains
• Section A CPR for a patient in cardiac or
  respiratory arrest
• Section B Ventilation for a patient in
  respiratory distress
• Section C Transfer to Hospital
• Section D Patient signature, printed name,
  phone , date
• Section E Clinician signature, printed name,
  phone , date
• Optional expiration date and other optional
  contact information
• Required for a valid page 1

17

• Page 2 contains
• Section F Preferences about treatments that may
  be appropriately offered in the future
  including
• Non-invasive ventilatory support Dialysis
  Artificial Nutrition Artificial Hydration and
  other treatment preferences.
• Includes Treatment Options Give treatment No
  treatment Short-term only Undecided Did not
  discuss
• REQUIRED FOR A VALID PAGE 2
• Section G Patient signature, print name,
  contact info, date
• Section H Clinician signature, print name,
  contact info, date

18
After the MOLST is signed

• The original MOLST form stays with the patient.
• The MOLST form should be placed where it can be
  easily located (e.g. on the refrigerator, at the
  bedside).
• The form should go with the patient to all care
  settings and during any trips/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 are valid make copies for
  all the patients health care providers and to
  put in the EHR.

19
Updating MOLST forms

• MOLST forms should be re-discussed with patients
  any time there is a significant change in the
  patients health status location or level of
  care goals of care or treatment wishes.
• Patients can ask to change or void their MOLST at
  any time (or request and receive previously
  refused medically-indicated treatment).
• Any change to the MOLST form requires the form to
  be voided and a new form created (and documented
  in the EHR)

20
Voiding the MOLST forms

• Write VOID across Page 1 and Page 2 of the
  form.
• Instruct the patient that all copies of the
  outdated form must be destroyed.
• Document updates to MOLST instructions in the EHR
  system.
• Create a new MOLST form if the patient desires
  it.

21
If you have further questions about MOLST in
Massachusetts, please review the MOLST website,
especially the FAQs and other information for
Health Professionals at www.molst-ma.org.