Medical Orders for Life Sustaining Treatment (MOLST) Form [MOST/POLST/POST]

What is a Medical Orders for Life Sustaining Treatment (MOLST) Form [MOST/POLST/POST]? This form is a two page cheat sheet that provides medical orders for doctors in the event patients are too sick to speak for themselves. This is one of the key end-of-life planning documents. The MOLST form includes the documentation for a Do Not Resuscitate (DNR) Order. The presentation is an overview of the MOLST form, as well as the medical interventions included on the form.

1. Medical Orders for Life Sustaining Treatment (MOLST) Form [MOST/POLST/POST] Eleanor Tanno, M.D . www.advancedirectivemd.com Osner Lifelong Learning Institute- American University July 2022

2. Objectives Understand the difference between an Advance Directive and a MOLST form Overview of the medical interventions on the MOLST form How to complete a MOLST Do Not Resuscitate orders

3. Advance Care Planning: Two Key Documents Advance Care Planning Advance Directive Assigning Power of Attorney (POA) General Medical Wishes MOLST form Do Not Resuscitate (DNR) order (if you have one) Specific Medical Orders

4. Advance Directive Form State specific Does NOT need to be signed by physician OR attorney, just witnesses (most states) 2 parts Naming POA Documenting medical wishes “living will” Sometimes extra statements about organ donation, additional wishes

5. Persistent Vegetative State Uncommon Person is unconscious with no hope of regaining consciousness even with medical treatment Lack reproducible responses to visual, auditory, tactile, or noxious stimuli show no evidence of language comprehension or expression have bowel and bladder incontinence have variably preserved reflexes Most people who are on life support are just very sick with complicated underling medical issues, including older age

6. What is a MOLST form ? Form that provides medical orders for physicians to follow in case you are critically ill and not able to speak for yourself. MOLST = MOST = POLST = POST Only used if you are incapacitated Once completed, you can update at any time.

7. How is a MOLST Form different from an advance directive ? An advance directive is a general document to communicate your medical wishes MOLST form differs in that it lists 8 very specific life sustaining medical orders MOLST form is intended for patients with advanced age or advanced illness

8. Who completes the MOLST form ? completed between the patient and their physician after a discussion. In some states, can be completed with a Nurse Practitioner or Physician Assistant. Can be between POA and physician Generally, completed closer to end-of-life, but can be done any time

9. What are the medical interventions on the MOLST that I will need to think about ? There are 8 life sustaining interventions on the MOLST form. Cardiopulmonary resuscitation (CPR) Ventilation Antibiotics Blood transfusion Artificial nutrition Hospital transfer Medical workup Dialysis

10. Feeling overwhelmed? Don’t! It’s basically a multiple choice document And, you complete this with your doctor!

11. MOLST: Basically a multiple choice test A. Do the least medical intervention, focus on comfort , allow natural outcomes B. Do some less invasive medical intervention such as oral rather than IV meds C. Do everything in the medical arsenal to prolong my life, even if it will not cure my condition and may cause discomfort D. Do C as above, but with a Time Limit in case things are looking futile

12. 1. Blood Transfusion would you accept a blood transfusion to save your life or to make you feel substantially better?

13. 2. Hospital Transfer   One of the easiest and hardest to understand One scenario where it makes sense

14. 3. Medical Workup Do you want doctors to look for the underlying cause of your sickness?

15. 4. Antibiotics None vs oral vs intravenous (IV)

16. 5. Dialysis Kidneys act as a filter for blood Every day, your kidneys filter 180 liters of blood your entire blood volume gets filtered approximately 20 to 25 times each day! If you would like dialysis, would you just want it short term in case your kidneys recover on their own, or indefinitely if your kidneys fail? Note: death from kidney failure is generally a peaceful death.

17. 6. Artificial Hydration/Nutrition  IV fluids are given through a standard IV in your arm A rtificial nutrition through a feeding tube IV (temporary), nasal tube or surgically inserted into stomach (long term or permanent) Near the end of life, if you are not conscious, you are not hungry or thirsty.

18. 7. Ventilation Nasal cannula high flow mask CPAP  BiPAP intubation (sedated) Temporary vs Permanent If long term, will need a surgical placement of an airway

19. 8. Cardiopulmonary Resuscitation (CPR ) Heart is a pump that moves oxygenated blood to your body CPR performed when heart stops   Goal of CPR - restart your heart to get blood pumping again to your body. In the interim, chest compressions are used to manually move the chest to pump blood from the heart through the lungs to provide oxygenated blood to your body, most notably your brain. Electrical shocks are used in an attempt to restart the heart . If you do NOT want CPR performed, you need to have an easily accessible Do Not Resuscitate (DNR) order signed by a physician. By default, if you do not have a signed DNR order, CPR will be attempted by EMTs/paramedics.

20. Review State MOLST/MOST

21. I am ready to complete my MOLST. Now what ? Dedicated appointment with your primary care physician to review your choices. You may bring your POA if helpful You can also discuss your decisions with POA before or after your physician signs it.

22. What to do with your signed MOLST The form does not need to be notarized in most states . Disperse copies to PCP POA(s ) and back-up POA(s store a copy where it can be easily found in an urgent situation (NOT a safe)

23. What if I want to update my MOLST ? No problem! You just need the updated copy to be signed by your physician and make sure your POA(s) get an updated copy. If two copies appear later, your healthcare team will honor the most recent version.

24. Next Lecture Do Not Resuscitate (DNR) Order

25. What does it mean to be Do Not Resuscitate (DNR )? The more informative question is, what does it look like to be resuscitated?

26. Review of Cardiopulmonary Resuscitation (CPR) A resuscitation is attempted when there is no heart beat and the breathing is absent or irregular During CPR, regular compressions are applied to the chest to manually pump blood from the heart to the body . Electric shocks are administered at regular intervals to try to “jump start ” the heart. During a resuscitation, breathing tubes may be inserted into you to open the airway and medications may be used to control your heart .

27. What is the success rate of a resuscitation ? Success is defined as survival to leave the hospital Community setting - 10% In-Hospital setting - 25 % The odds are better depending on their age, overall health, and the underlying reason for the arrest

28. What is a Do Not Resuscitate (DNR) order ? medical order, signed by a physician (or nurse practitioner in some states), that instructs healthcare workers NOT to resuscitate a person who has had a cardiac arrest. The order must be chosen by the patient or, if applicable, their medical Power of Attorney (POA) If a person does not have a DNR order, by default, medical personnel, including paramedics, will always attempt a resuscitation .

29. Who should have a DNR order ? Personal decision, based on current health

30. How do I make a DNR order ? You create a DNR order with your physician, or nurse practitioner in some states. Schedule an appointment just to have this discussion and ask all your questions. Accomplished by signing the appropriate state form (MOLST)

31. DNR Order on MOLST Let’s look at the DNR order on the MOLST form

32. Where to store a DNR order? Copies to: Yourself – readily available in your home in case paramedics are called Consider medical bracelet/tag Your doctor Your medical power of attorney keep a copy with your estate documents Some states have a database where you can upload your advance directive and DNR order Always bring a copy of your DNR order with you when you go to the hospital.

33. How do paramedics and other healthcare workers know whether someone has a DNR order ? At the time of the arrest, the healthcare workers need to be presented with a signed DNR order to NOT attempt CPR. all patients admitted to the hospital are asked whether they have a DNR order and it is noted in their chart. For people who desire for their DNR order to be honored in a community setting (at their home, etc.), they must have the order prominently displayed so that it is known they have such an order. Some patients will order a DNR medical bracelet. A tattoo cannot act as a DNR order.

34. What if I want to revoke my DNR order ? Anytime! J ust tear it up or write “VOID” over it. Be sure all the copies are also destroyed and you update your medical power of attorney and other key people in your life .

35. Can my POA/family change my DNR order ? Generally, doctors try to follow the patient’s wishes Your family can revoke your DNR order, but if doctors really feel this is not your wish and not in your best interest, they can escalate the decision to a hospital Ethics Committee for further discussion.

36. Questions? Eleanor Tanno, M.D. www.advancedirectivemd.com