Communicating life-sustaining decisions
Date: October 14, 2011
Redonda Miller, Vice President for Medical Affairs, The Johns Hopkins Hospital
Regulations will be finalized over the next few months for a new law that will mandate that Maryland hospitals and medical facilities 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 legislation will give patients an opportunity to voice their health care preferences. Dome asked Redonda Miller to explain the impact of the new statute and the role physicians and nurse practitioners will play in its roll-out.
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 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 they’re in the hospital, but also in an outpatient setting. Similarly, if a patient comes to one of our hospitals with a MOLST, we must abide by it the minute they enter, 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 importantly, 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. Only a physician or nurse practitioner licensed by the state of Maryland can fill out a MOLST. It’s completed upon discharge for patients who will be transferred to another medical facility or health program. 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 have to generate the MOLST.
The patient or authorized decision maker must receive a copy of the completed MOLST within 48 hours of completion or sooner if the patient is discharged or transferred.
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 void a MOLST and create a new one. If a patient comes to the hospital with a MOLST that has limitations of care, such as “do not resuscitate,” we’ll enter that 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. 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.
Many states have adopted similar legislation that a workgroup of Maryland legislators has followed for years. In April, MOLST received unanimous support by the Maryland General Assembly.
Q. Where can staff learn more about MOLST?
A. The website for the Maryland Department of Health and Mental Hygiene has tip sheets and frequently asked questions, as well as a copy of the MOLST form. It’s a great place for anyone who will be writing these orders or explaining them to patients to find more information.
—Reported by Shannon Swiger