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Winter 2013
Medical Orders for Life-Sustaining Treatment (MOLST) Implementation at UMMC Karen Kaiser, PhD, RN, Clinical Practice Coordinator, Clinical Quality and Safety Diane Gregg, LCSW-C, MSSA, Director, Social Work & Human Services
The Maryland State Legislature passed a law to implement Medical Orders for Life-Sustaining Treatment (MOLST) to increase the likelihood that a patient’s wishes to receive or deny care are honored throughout the health care trajectory These orders do not expire and are portable. The Medical Center is expected to comply with MOLST, unless it is medically inappropriate. Health care providers must take a more active role in asking about and documenting admitted patients’ medical care wishes during hospitalization. Upon admission, all patients (including infants and children) will be screened for the presence of MOLST or similar documents (see Table 1). There is a new state form for MOLST, so it may be unfamiliar to patients. This process is similar to screening for and obtaining the Advance Directive (AD). Since most patients will have a discussion about MOLST during their hospital stay, it is important that patients and their families are prepared. Nurses should focus the patient education about MOLST on the talking points that are highlighted in Table 2. A new patient handout, “Ten Things Everyone Should Know About Maryland MOLST,” is a good resource for this discussion. Versions are available for the patient, as well as for the Authorized Decision Maker (ADM), in English and Spanish. Since the pediatric patient is unlikely to require MOLST, applicable children’s ADM education is deferred until closer to discharge after the primary team has determined that MOLST is applicable. The existing MOLST orders are transcribed into PowerChart/First Net by the primary team. Code status and treatment limitations orders are being updated to reflect MOLST options. Treatment limitations specify patient/ADM wishes regarding blood transfusions, antibiotics, fluids and nutrition, dialysis, medical workups, etc. Goals of care and treatment modifications may occur during a hospital stay based on the patient’s condition and the on-going dialogue with the patient or their ADM. The primary team reflects these changes by voiding existing MOLST documents. A progress note should document the discussion, as well as the revision of the code status and treatment limitations orders. The primary team may elect to complete MOLST on admission, but it must be completed before discharge for applicable patients. Patient legal exclusions from MOLST are listed in Table 3. The completion of MOLST also applies to patients discharged from and admitted to our hospitals on the University of Maryland Medical Center campus. For example, it applies to a Shock Trauma discharge that becomes a psychiatry admission, or a psychiatry discharge that is being admitted directly to a UMMC medicine unit and vice versa. Since MOLST must be signed by an attending physician or nurse practitioner licensed in the state of Maryland, all members of the health care team must be vigilant to ensure MOLST is completed before discharge for applicable patients. Patients/ADMs must receive a copy of MOLST as part of the discharge instructions. A copy of MOLST must accompany patients who are transported by ambulance in non-emergent conditions and sent to receiving inpatient and
outpatient health care facilities (see Table 4). Transport services may refuse to transport patients and facilities may refuse to accept patients without MOLST. Fines may be levied by the state of Maryland if MOLST is not completed for applicable patients. Some Maryland health care facilities have already implemented MOLST, so you will see these patients if they are treated at UMMC. Until the MOLST implementation occurs at UMMC in mid-March, you should honor the intent of the MOLST within our current documentation framework. Mandatory education in Healthstream for MOLST will begin in early March at UMMC. Outpatient areas should treat MOLST similar to an AD before and after the implementation. MOLST should be placed with an AD in the chart if the patient provides one, or complete one if patient requests or condition warrants. By working together, we can help our patients receive the care they desire. Further information about MOLST is available in the Summer 2012 edition of News & Views or at the following website: https//intra.umm.edu/ummc/molst. Table 1 Forms With Names Similar To MOLST ◗◗ ◗◗ ◗◗ ◗◗
Maryland EMS DNR (MIEMSS) order form Life-Sustaining Treatment form Physician’s Order for Life-Sustaining Treatment (POLST) Orders for Life-Sustaining Treatment (OLST)
Table 2 MOLST Patient Education Talking Points ◗◗ The intent is to make sure a patient’s wishes to receive or deny care are honored across health care settings in Maryland. ◗◗ The patient/ADM may take wishes expressed in an AD or living will and apply it to current and future situations. ◗◗ MOLST is a form that contains medical orders about life-supporting treatments. ◗◗ MOLST is developed with the patient’s physician or nurse practitioner. ◗◗ The orders are applicable in all Maryland health care settings such as hospitals, assisted living facilities, nursing homes, inpatient hospices, dialysis settings and home health care. ◗◗ The orders are enduring and don’t need to be re-written unless the situation changes. ◗◗ The patient/ADM can refuse to have a MOLST completed by talking with their doctor or nurse practitioner. continued on page 18.