Issue No. 646
Communicating Life-Sustaining Decisions
Date: July 5, 2013
State law now requires Maryland hospitals and medical facilities to document patient health care decisions in the form of a two-page paper medical order set, the Maryland Medical Orders for Life-Sustaining Treatment (MOLST). By stimulating discussion on important and difficult-to-discuss topics, such as artificial life support, the law will give patients an opportunity to voice their health care preferences. Redonda Miller explains the impact of the new statute and the role physicians and nurse practitioners will play in its rollout.
Q. How is a MOLST different from an advance directive?
A. A MOLST is meant to complement and supplement advance directives, but it’s not supposed to take the place of them. Putting patient preferences in an enduring medical order—a set of paper instructions to be carried out by the patient’s care team—ensures that their wishes will be carried out across the continuum of care. That means it’s not only valid while the patient is in the hospital, but also in an outpatient setting. Similarly, if a patient comes to one of the Johns Hopkins Health System’s hospitals with a MOLST, we must abide by it the minute he or she enters the hospital, even if the physician who signed it is not on our medical staff. Because it is a statewide initiative, this order goes beyond the confines of the hospital.
We also encourage patients to complete an advance directive and, perhaps even more important, put in writing who will make health care decisions for them should they be unable to speak for themselves.
Q. Who can complete a MOLST and when?
A. Anyone on the patient’s care team can help fill out the MOLST, but only a physician or nurse practitioner licensed by the state of Maryland can sign the order. It’s completed upon discharge for patients who will receive care from another medical facility or health care service, including nursing homes, assisted living programs, hospices, home health agencies and dialysis centers, or when a patient has chosen to have a limitation on life-sustaining treatments. For example, we’ll create a MOLST before a patient leaves our facilities to go to a nursing home, but if a nursing home is sending a patient to us for admission, then it will provide the MOLST order.
The patient or authorized decision-maker must receive a copy of the completed MOLST order form within 48 hours of completion or sooner if the patient is discharged or transferred.
Q. Are there situations when a patient does not need a MOLST?
A. The MOLST order form is not required if the patient is younger than 18 and is unlikely to require a life-sustaining treatment. A MOLST is also not needed for a patient whose primary diagnosis for the current treatment is a psychiatric disorder (except for dementia, delirium or mental disorders due to a medical condition) or whose primary diagnosis is related to a current pregnancy.
Q. What happens if a patient comes to our hospital with a MOLST?
A. If a patient comes to the hospital with a MOLST that has limitations on life-sustaining treatments, such as “do not resuscitate,” we’ll enter that information into our electronic medical record system. That way everyone on the health care team—the nurses, doctors and social workers—knows what the patient desires.
Q. How do you update or change a MOLST?
A. When patients come to our hospital with a MOLST, we’ll talk to them to make sure the document is current and still reflects their wishes. If their requests have changed, it’s very easy to draw a line through the MOLST form to void it and complete a new MOLST order form when a patient is being discharged.
Q. What prompted this legislation?
A. Prior to MOLST, health care providers used the Life-Sustaining Treatment Options form, which was only required in the nursing home setting. If patients were transferred from a nursing home to the hospital, the form didn’t always travel with them and their wishes weren’t always honored. The new law seeks to resolve that issue by requiring the MOLST to follow patients throughout transitions to different care facilities.
Q. Where can staff learn more about MOLST?
A. The Maryland Department of Health and Mental Hygiene has created a special website, marylandmolst.org, where patients and providers can find tip sheets and
frequently asked questions, as well as a MOLST form. See also www.insidehopkinsmedicine.org/MOLST.
—Reported by Shannon Swiger and Janet Anderson