Medical Orders for Life Sustaining Treatment (MOLST) in

Massachusetts: An Overview

Greg Bird, RN, MS

What is MOLST?

• Written instructions on a medical order form about life-sustaining medical treatments from a clinician (MS, NP, PA) to other health professionals (e.g. nurses, EMTs).

• Based on the patient's own preferences. • A portable document that is honored by all health care professionals.

• Valid across all health care settings.

Original MOLST forms are created on hot pink-colored paper to maximize visibility and portability. Electronic, faxed and non-pink forms are also valid.

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What is MOLST?

MOLST is intended to honor the treatment preferences of

those with advanced progressive illness or frailty.

Original MOLST forms are created on hot pink-colored paper to maximize visibility and portability. Electronic, faxed and non-pink forms are also valid.

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Where Did MOLST Come From?

Recommendations from the Massachusetts

“Expert Panel on End-of-Life”1:

1.  The Commonwealth should launch a vigorous, high-visibility, and ongoing public awareness campaign about the value of advance care planning by January 1, 2012, in accordance with Massachusetts Acts of 2008, Chapter 305, Section 42.

2.  Full statewide implementation of MOLST should be achieved no later than January 1, 2014.

Note: All but 42 States have implemented, are implementing or have endorsed MOLST (or POLST).

1. Patient-Centered Care and Human Mortality : The Urgency of Health System Reforms to Ensure Respect for Patients’ Wishes and Accountability for Excellence In Care. Report and Recommendations of the Massachusetts Expert Panel on End-of-Life Care. October 2010. P.1.

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Launching MOLST in Hospitals

The Statewide expansion of MOLST began April, 2012 with the following direction:

1.  Every suitable patient will be offered the opportunity to utilize a MOLST form in concert with that patient’s clinician to communicate life sustaining treatment preferences across health care settings.

2.  Every emergency medical technician will receive MOLST training and be authorized to honor valid MOLST forms.

3.  Every major hospital system and health care plan will implement policies and procedures to facilitate the appropriate utilization of MOLST by clinicians and patients.

4.  Every clinician will seek to improve communications skills with patients nearing the end of life; have access to MOLST education; and be encouraged by professional organizations and regulatory bodies (e.g. Boards of Registration, Massachusetts Medical Society) to utilize MOLST correctly.

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67% of Massachusetts residents want to die at home…

…24% do.1

50% of terminally ill patients had an advance directive…

…24% of their physicians knew it.2

80% said that if seriously ill, they would want to talk to their doctor about end-of-life care…

…only 7% report having done so.3

Why is MOLST Important?

1.  Patient-Centered Care and Human Mortality : The Urgency of Health System Reforms to Ensure Respect for Patients’ Wishes and Accountability for Excellence In Care. Report and Recommendations of the Massachusetts Expert Panel on End-of-Life Care. October 2010. P.1.

2.  Advance Care Planning: Preferences for Care at the End of Life. U.S. Department of Health and Human Services. Public Health Service. Agency for Healthcare Research and Quality. 2003. http://www.ahrq.gov/research/endliferia/endria.htm

3.  Advance Care Planning: Preferences for Care at the End of Life. U.S. Department of Health and Human Services. Public Health Service. Agency for Healthcare Research and Quality. 2003. http://www.ahrq.gov/research/endliferia/endria.htm

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82% said it is important to have end-of-life wishes in writing…

…only 23% say they have done so.1

More than 80% said their loved ones “know exactly” or have a “good idea” of what their wishes would be if they were in a persistent coma…

…only 50% say they've talked to them about their preferences.2

Why is MOLST Important?

1.  Final Chapter: Californians’ Attitudes and Experiences with Death and Dying. Survey of Californians by the California HealthCare Foundation. February 2012

2.  Ibid. 7

of Californians say they would prefer a natural

death if they were severely ill…

66% 7% …say they would want everything done to prolong life. 2

1.  Patient-Centered Care and Human Mortality : The Urgency of Health System Reforms to Ensure Respect for Patients’ Wishes and Accountability for Excellence In Care. Report and Recommendations of the Massachusetts Expert Panel on End-of-Life Care. October 2010. P.1.

2.  The Final Chapter was developed by the California HealthCare Foundation in collaboration with the Coalition for Compassionate Care of California and Lake Research Partners. April 2012. www.chcf.org

Why is MOLST Important?

of Massachusetts residents have spoken with their physicians about their end-of-life preferences.1 17%

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“For patients near the end of life patterns of care vary

enormously by hospital in the Commonwealth, even

after adjusting for differences between

teaching and community hospitals, with no evidence

that this is based on differences in patient

preferences.”1

1. Patient-Centered Care and Human Mortality : The Urgency of Health System Reforms to Ensure Respect for Patients’ Wishes and Accountability for Excellence In Care. Report and Recommendations of the Massachusetts Expert Panel on End-of-Life Care. October 2010. P.1.

Massachusetts residents who are nearing the end of their lives often do not receive the care they want and need.1

Why is MOLST Important?

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1.  Tolle SW, Tilden VP, Dunn P, Nelson C. (1998). A Prospective Study of the Efficacy of the Physician Orders for Life Sustaining Treatment. Journal of the American Geriatrics Society, 46, (9), 1097-1102. 2.  Fromme EK, Bascom PB, Smith MD, Tolle SW, Hanson L, Hickam DH, Osborne ML. (2006). Survival, Mortality, and Location of Death for Patients Seen by a Hospital-Based Palliative Care Team. Journal of

Palliative Medicine, 9(4):903-911. 3.  Zhao Y, Encinosa W. The Costs of End-of-Life Hospitalizations, 2007. Statistical Brief #81, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. November 2009, revised April

2010. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb81.pdf (last accessed April 29, 2010).

32% Rate  of  In-­‐Hospital  Death  

for  SNF  pa6ents  Na6onal  Average1,2,3  

5% Rate  of  In-­‐Hospital  

Death  for  SNF  pa6ents  with  

MOLST  1,2,3  

Why is MOLST Important?

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Affect of MOLST in Wisconsin on Documented Preferences Not to Return to the Hospital for Acute Treatment.4

Pre-MOLST With MOLST

Use of MOLST resulted in a six-fold increase in documented preferences not

to return to the hospital for acute treatment

Prefer Not to Return

to the Hospital

Prefer Not to Return

to the Hospital

Source: Hammes BJ, Rooney BL, Gundrum JD. (July 2010 in press). A Comparative, Retrospective, Observational Study of the Prevalence, Availability, and Utility of Advance Care Plans in a County that Implemented an Advance Care Planning Micro-System. J Am Geriatrics Society.

Why is MOLST Important?

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…most are admitted to the hospital and many die there.1

75% of older Americans are seen in the Emergency

Department in last the 6 months of life,

50% in last month…

of Medicare beneficiaries who die each year consume

29% of total Medicare spending.2

5%

1. Smith AK, et al. Admitted To Hospital, And Many Die There Half Of Older Americans Seen In Emergency Department In Last Month Of Life; Most Admitted To Hospital, And Many Die There. Health Affairs.Vol. 31, no.6 (2012):1277-1285.

2. Hogan, C. et al: “Medicare Beneficiaries’ Cost of Care in the Last Year of Life.” Health Affairs 20:4, Jul/Aug 2001.

Why is MOLST Important?

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• MOLST helps medical staff respect patients' wishes in their final days.1

• MOLST help people avoid needless suffering from undertreated pain.

• MOLST helps avoid pointless and costly invasive tests and treatments, often in patients’ last days and hours.

• MOLST helps avoid treatment preferences or advance directives being ignored or overridden by healthcare professionals and others.

1.  California Healthcare Foundation: http://www.chcf.org/projects/2013/polst

Why is MOLST Important?

MOLST Helps Avoid Unwanted Care

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•  10,000 Boomers Turn Age 65 each day (and will for the next 18 years!).

•  The 79 million member Baby Boomer generation accounts for 26% of the total U.S. population.

•  Now just 13% of Americans are ages 65 and older; by 2030, it will be 18%.

The Grey Tsunami is upon us.

Why is MOLST Important?

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Annual Per Capita Health Care Cost Comparison of U.S. and Industrialized European Nations by Age Categories

U.S.

Healthcare Spending at End-of-Life

Source: Fischbeck, Paul. “US-Europe Comparisons of Health Risk for SpecificGender-Age Groups.” Carnegie Mellon University; September, 2009.

Unsustainable.

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MOLST Website – Great Resource

http://www.molst-ma.org/

Christine McCluskey MOLST Expansion Director Community Outreach Director Commonwealth Medicine Center for Health Policy and Research

I have an advance directive not because I have a serious illness, but because I have a family

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The  6th  Annual

National  Healthcare  Decisions  Day

to inspire, educate & empower the public & providers about the importance of advance care planning

A  Quick  Video!

“IMAGINE” http://www.nhdd.org/

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