MOLST, Health Care Proxy and Electronic Code Status Order

Goals of Education/ Implementation Instruct clinicians in use of standard tools to communicate patient preferences across settings of care: Health Care Proxy MOLST (Medical Orders for Life Sustaining Treatment) Electronic Code Status Order Code Status Displays in Header Order detail visible in the Legal Indicators Tab NEW Clinical Panel Code Status/Advance Directive Order detail pulls into P.DOC discharge referral

3/31/2017 Health Care Proxy A basic ethical and legal right of every patient is to be able to make decisions about their medical care. If a person is unable to communicate, it is important that someone who knows their values and preferences can make decisions for them. If “invoked”, the Health Care Agent is expected to follow the patient’s wishes and make decisions as the patient would make them. All adults, even healthy adults, are encouraged to choose a Health Care Agent. Health care problems may arise suddenly; having a surrogate decision maker provides an extra layer of security.

Invoking the Health Care Proxy (HCP) When the Health Care Proxy form is invoked by the provider, the agent becomes the legal decision maker. Provider must be sure he/ she is communicating with the legal decision maker before making code status decisions with that person.

Orders for Life-Sustaining Treatment What is MOLST? Medical 3/31/2017 MOLST is a medical order that documents a patient’s wishes regarding end of life care. The MOLST form can be used to refuse OR request treatment; the form is voluntary, is valid in any health care setting, and is appropriate independent of the patient’s decision-making abilities. In contrast, a Health Care Proxy is a legal document that names an agent to speak on behalf of a patient who no longer has decision-making capacity. Establishing a MOLST with a patient is a process, i.e., a conversation or several conversations with the patient, caregivers, health care agent, and family, resulting in the documentation of the patient’s medical choices on a standard, two-sided MOLST form. The first side includes medical orders including resuscitation, intubation and transfer to hospital; the second side allows for selected patient preferences including non-invasive ventilation, dialysis, artificial nutrition, artificial hydration and space to add free text preferences. MOLST allows patients to designate which medical interventions they want and which they would refuse, if they could not communicate directly with a care provider. When a patient presents to a healthcare setting with a MOLST, orders should be honored until a physician, nurse practitioner or physician assistant can assess the situation.

3/31/2017 MOLST is… A medical document that may be used in the context of advance care planning Suitable for patients of any age with an advanced illness Based on a patient’s current health status Valid medical orders for life-sustaining treatments A portable document that is valid across care settings MA MOLST Demonstration Project: http://www.molst-ma.org/ 6

Which patients are suitable for MOLST? 3/31/2017 Which patients are suitable for MOLST? Patients of any age with an advanced illness including, but not limited to: Life-threatening diseases Chronic progressive diseases Life-threatening injuries Medical frailty Any patient suitable for considering DNR orders MA MOLST Demonstration Project: http://www.molst-ma.org/ 7

MOLST form side 1: Medical Orders 3/31/2017 1) Side A is “orders”: CPR, Vent, Transfer 2) Gray section is for signatures – must be signed by patient and provider to be valid 3) HCP-Agent can place name in the “optional section” below the signatures

MOLST form side 2: Patient Preferences 3/31/2017 1) Side B is “patient preferences”: Dialysis, Artificial Nutrition, other preferences 2) Need to address short term 3) The two sides can be independent of each other. Possible to have only one side be used/ valid.

Key Workflow Decisions: Emergency Dept & Hospital 3/31/2017 Paper process in ED.  Electronic process in inpatient setting.   Code status orders will be standardized in Meditech 6.0 and a code status order will be required for every inpatient upon admission Meditech 6.0 code status/ limitations in care supersede the MOLST form in the inpatient setting

Electronic Code Status ORDER IN MEDITECH

Use the type ahead search to find Code Status order

Check Mark the Order > Next in the Footer

Complete the Required Fields

Advanced Directive Discussion and List by Priority Order Special Circumstances = If patient is not competent and has no surrogate decision maker, refer to End of Life policy for DNR ordering process.

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Code Status on the Current Orders Screen

Detail on Legal Indicators Tab and Code Status appears in the Header

NEW Code Status/Advance Directive Clinical Panel

Detail in Clinical Panel View

Order Detail pulls into Discharge Referral

Complete Required Fields

Detail on Legal Indicators Tab and Code Status appears in the Header

Detail on Advance Directive Clinical Panel

Order Detail pulled into Discharge Referral

Complete Required Fields

Detail on Legal Indicators Tab and Code Status appears in the Header

Detail on Advance Directive Clinical Panel

Order Detail pulled into Discharge Referral