Compassion & Choices » MOLST

Choosing Options for Life-Sustaining Care: Advance Directive Will Ensure Your Wishes Are Followed

Sonja — Thu, 10 Jan 2013 00:37:58 +0000

The Chicago Tribune
January 9, 2012

Mr. J. had an implantable cardioverter defibrillator (ICD) for advanced heart failure. Having survived one episode of cardiac arrest, in which he nearly died, he was at high risk for another episode caused by a rapid, unorganized heart rhythm called ventricular fibrillation. Should this happen, the ICD would shock his heart back into normal rhythm. But at his daughter’s wedding, the ICD fired nine times. Each time, it saved his life, but the painful episodes terrified him, and he asked that the ICD be turned off.

Dr. Eva Chittenden, associate director of palliative care at Harvard-affiliated Massachusetts General Hospital, met with Mr. J. to explore his decision further. He stated that he’d already been hospitalized five times within 12 months, and he felt this took too much time away from his family.

They discussed his personal values and what action he’d want taken if his heart stopped, and the ICD was no longer there to revive him.

After long talks with Dr. Chittenden and his family, Mr. J. chose a “Do Not Attempt Resuscitation/Do Not Intubate (DNAR/DNI)” order. The decision meant he could continue seeing his cardiologist and other doctors, remain on his medications, and return to the hospital for intravenous diuretics. But he would not be revived if his heart stopped.

Doctors wish all their patients would make their preferences known in advance, like Mr. J. did.

“A talk with your doctor about your life goals, and what kind of medical care can help you attain these goals, is an extremely important part of health care for anyone with a chronic illness such as heart failure,” says Dr. Chittenden.

Providing an advance directive tells your doctors and emergency physicians what level of care you want, should you not be able to speak for yourself. It reflects your innermost values, especially what trade-offs you’re willing to make to stay alive. If length of life is most important to you, you may be willing to accept more technology than if quality of life and being at home are your primary desires,” Dr. Chittenden explains.

“Discussing these wishes and decisions with those closest to you is equally important, because one of them may need to make decisions for you in the event of an emergency,” she adds.

In addition to an advance directive, there are two measures you can take to ensure your wishes are respected:

1. HEALTH CARE PROXY

It’s important to designate a surrogate decision maker who’ll have the legal authority to make medical decisions for you, if you’re unable to make them for yourself. The situation may be temporary–when you’re under anesthesia, for example–or permanent. The person you choose might be a spouse, child, or trusted friend.

“Having a legal medical surrogate is very important, because if two family members disagree about what should be done for you, the legal surrogate has the final say,” says Dr. Chittenden.

In many states, all you need to do is ask your doctor’s office for a form, complete it, and have it witnessed by two people. In other states, you may need the assistance of a lawyer or notary. Ask your doctor’s office for direction.

2. A NEW TYPE OF LIVING WILL

Thirty-four states have adopted legislation encouraging people with life-limiting illness to fill out a form with their physician that directs their care in a medical emergency or other situation in which they’re unable to make decisions for themselves. It’s called a Medical Orders for Life-Sustaining Treatment (MOLST) form (or POLST, for Physician’s Orders). It’s more specific than a living will, which is often too vague to direct care in a meaningful way.

The MOLST form may document your preferences only about resuscitation, or it may also specify your wishes regarding hospitalization, dialysis, artificial nutrition, or hydration. The form serves as a medical order if an ambulance is called to your home or if you are hospitalized away from home. It should be completed with your physician following a discussion on the goals of your care. You may change your decision at any time and replace the form with an updated one.

DON’T WAIT UNTIL IT’S TOO LATE

Advance planning should be done while you are able to make and articulate your decisions. “You may never need these documents, but if you do, your wishes for life-sustaining care are more likely to be respected,” says Dr. Chittenden.

Care at the End of Life

Sonja — Mon, 26 Nov 2012 23:50:15 +0000

The New York Times
November 24, 2012

Three years ago, at the height of the debate over health care reform, there was an uproar over a voluntary provision that encouraged doctors to discuss with Medicare patients the kinds of treatments they would want as they neared the end of life. That thoughtful provision was left out of the final bill after right-wing commentators and Republican politicians denounced it falsely as a step toward euthanasia and “death panels.”

Fortunately, advance planning for end-of-life decisions has been going on for years and is continuing to spread despite the demagogy on the issue in 2009. There is good evidence that, done properly, it can greatly increase the likelihood that patients will get the care they really want. And, as a secondary benefit, their choices may help reduce the cost of health care as well.

Many people sign living wills that specify the care they want as death nears and powers of attorney that authorize relatives or trusted surrogates to make decisions if they become incapacitated. Those standard devices have been greatly improved in recent years by adding medical orders signed by a doctor — known as Physician Orders for Life Sustaining Treatment, or POLST — to ensure that a patient’s wishes are followed, and not misplaced or too vague for family members to be sure what a comatose patient would want.

Fifteen states, including New York, have already enacted laws or regulations to authorize use of these forms. Similar efforts are under development in another 28 states. The laws generally allow medical institutions to decide whether to offer the forms and always allow patients and families to decide voluntarily whether to use them.

With these physician orders, the doctor, or in some states a nurse practitioner or physician assistant, leads conversations with patients, family members and surrogates to determine whether a patient with advanced illness wants aggressive life-sustaining treatment, a limited intervention or simply palliative or hospice care.

The health care professional then signs a single-page medical order telling emergency medical personnel and other health care providers what to do if the patient is incapacitated. In most states, the patient or surrogate must also sign the medical order to indicate informed consent. The orders are conspicuously highlighted in a patient’s electronic medical record and follow patients from one setting to another — such as a hospital emergency room or nursing home — so that any health professional handling the case will know what interventions the patient might want.

This comprehensive approach to end-of-life decisions started in Oregon in the early 1990s and is now used voluntarily by virtually all hospices and skilled nursing homes in that state. At least 50,000 Oregonians with advanced illness are covered by orders signed by a nurse or doctor. The program has provided care consistent with a patient’s wishes to limit treatment more than 90 percent of the time and has significantly reduced unwanted — and costly — hospitalizations, presumably reducing the overall cost of care.

The Oregon model has been adopted by the Gundersen Lutheran Health System in Wisconsin, where the forms now cover virtually all patients in facilities for long-term care or hospice care. Families are pleased and costs have come down. The Dartmouth Atlas of Health Care, which compares Medicare costs among various regions of the country, found that, in 2010, Gundersen was among the lowest-cost hospitals in the nation in treating patients at the end of life.

The Wisconsin Medical Society moved to organize voluntary pilot projects with doctors using Gundersen’s approach in other areas of the state. But the society backed down from using the physicians’ order forms because of opposition from the state’s Roman Catholic bishops, who contended that the orders might raise the risk of euthanasia. As a result, the pilot projects will only encourage healthy adults to do advance planning and create powers of attorney well before they face a medical crisis.

No matter what the death-panel fearmongers say, end-of-life conversations and medical orders detailing what care to provide increase the confidence of patients that they will get the care they really want. In some cases, that could well mean the request to be spared costly tests, procedures and heroic measures that provide no real medical benefit.

New end-of-life health care regulations to take effect

Sonja — Fri, 21 Oct 2011 18:41:28 +0000

Delmarvanow.com
October 10, 2011

SALISBURY — It is never easy to make end-of-life health care decisions for yourself or a loved one.

Health care professionals and lawmakers in Maryland have recognized the process and paperwork involved with medical treatment options is often cumbersome, confusing and overwhelming for many patients and their families.

In an effort to minimize concerns and streamline the decision-making process, a new regulation in Maryland, referred to as Maryland MOLST — Medical Orders for Life Sustaining Treatment — has been initiated to help guide patients and health care professionals through the process and ensure the patient’s wishes for medical care are carried out.

The law, scheduled to go into effect this year, requires a Maryland MOLST form be completed by or for all individuals admitted to nursing homes, assisted living facilities, hospices, home health agencies, and dialysis centers.

The MOLST form is intended to help physicians and other health care providers discuss and convey a patient’s wishes regarding cardiopulmonary resuscitation and other life-sustaining treatments.

MOLST orders should be completed for any person who wants to avoid or receive life-sustaining treatments; lives in a long-term care facility or requires long-term care services; or is at risk of dying within the next year.

“The MOLST form should prove to be beneficial to both patients and providers because it delivers specific orders for medical treatment and will be recognized in a variety of health care settings,” said Stephanie Mitchell, director of clinical operations at Peninsula Home Care.

“It will also help patients and decision makers understand life-sustaining treatments and discuss them with health care practitioners.”

Completion of the MOLST form will begin with a conversation between the patient and a qualified, trained health care professional.

The process allows any health care professional to define the patient’s goals for care, review possible treatment options on the MOLST form and ensure shared, informed medical decision-making.

All MOLST orders, however, must be signed by a Maryland licensed physician or nurse practitioner.

For more information on Maryland MOLST, visit www.peninsulahome care.com.

New law takes effect statewide for terminally ill

Sonja — Thu, 10 Feb 2011 21:10:00 +0000

By Julie Sherwood, staff writer
Messenger Post
Posted Feb 09, 2011

Finger Lakes, N.Y.-A new law in effect beginning today requires doctors and nurse practitioners to offer terminally-ill patients information and counseling concerning palliative care and end-of-life options.

“Typically, patients are only referred to hospice two or three weeks before their death,” stated
Dr. Patricia Bomba, vice president and medical director of geriatrics for Excellus BlueCross
BlueShield. “This new law requires physicians and nurse practitioners to discuss palliative care,
hospice and all their other options earlier in the course of the patient’s illness.”

The New York State’s Palliative Care Information Act encourages discussions between patient
and physician about the goals for care and also the need for a Medical Orders for Life-Sustaining
Treatment (MOLST) form, as well as ensures optimal relief of pain and other symptoms and a
timely referral to hospice.

More information, at CompassionAndSupport.org

Atul Gawande: How to Talk End-of-Life Care with a Dying Patient

Sonja — Thu, 21 Oct 2010 22:14:12 +0000

Compassion & Choices has long been a leader in the effort to empower patients to make their own end-of-life decisions. Five states now have expanded end-of-life choice, including New York and California.

In July, Dr. Atul Gawande published a much talked about article on aggressive medical interventions for dying patients–and how patients and doctors must work together to decide priorities for how and when to treat illnesses for those facing the end of life.

In October, Dr. Gawande discussed the four important points for doctors to discuss with terminally ill patients about their end-of-life care. Instead of pressing patients to make hard decisions, Gawande emphasizes the importance of asking questions about their hopes and fears.