1. Teresa Guarino University of Rhode Island College of Nursing Graduation Spring 2014

2.  Medical Orders for Life Sustaining Treatment  A set of medical orders which MUST be honored in all healthcare settings, that specifies what types of medical treatment a patient wishes to receive or not to receive toward the end of life.  The form is intended to be filled out in the primary care office by a physician, registered nurse practitioner, or a physician's assistant, and signed by them as well as the patient or surrogate.

4.  To educate nurses throughout Rhode Island so that they will be prepared to honor the MOLST  Enhance the nurses role as patient advocate.

5. The 1990 Federal Patient Self Determination Act The National POLST Paradigm originated in Oregon in 1991 as leading medical ethicists discovered that patient preferences for end-of-life care were not consistently honored. Among the first states to develop POLST Programs following Oregon were New York, Pennsylvania, Washington, West Virginia, and Wisconsin.

6.  According to an article found in the Cleveland Clinic Journal of Medicine titled “POLST: An Improvement Over traditional Advance Directives,” preferences for care at the end of life are not consistently followed. (Bomba, Kemp, & Black, 2013, p. 458)  The Catholic Health Association of the United States found that patients with a POLST are more likely to have expressed more detailed life-sustaining preferences, and these preferences are honored because a medical order is already present. (Tuohey & Hodges, 2011, p. 61)

7.  The Catholic Health Association of the United states also found that:  96% of the hospice staff interviewed described the POLST as an effective tool for initiating conversations about care preferences  97% of hospice staff stated that the POLST prevented burdensome resuscitation  The POLST more accurately conveys end-of-life preferences and yields higher adherence by medical professionals (Tuohey & Hodges, 2011)

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11. As of January 1, 2014, Rhode Island has officially joined the POLST paradigm by endorsing the MOLST as a legal document that must be honored. The following facilities are required to accept, update, and offer qualified patients the opportunity to complete a MOLST form during the admission process: A nursing facility, An assisted living residence A hospice A kidney dialysis center A home health agency

12. A hospital must Accept and update if appropriate, a completed MOLST form Offer each qualified patient the opportunity to complete a MOLST form during the inpatient stay. The MOLST must also be honored by emergency medical personnel

13. Ensure patient preferences are honored Improve quality of care Communicate the wishes of a patient as they move from one care setting to another. Prevent unwanted or medically ineffective treatment Reduce patient and family suffering Give seriously ill patients more control over their end of life care

14.  Seriously ill with a life limiting advanced illness  Medically frail with limited life expectancy, regardless of age  Frail and weak persons who have excessive difficulty with performing activities of daily living  Individuals living in a nursing home or hospice  Individuals who are afraid of losing the capacity to make their own decisions in the near future

15. MOLSTAD Who completes the form Physician or Advance Practice nurse with the patient Patient, often with a lawyer or social worker Time frame Current careFuture care Who The seriously illAll adults Portability Provider and patient responsibility Patient and family responsibility Periodic review of form Provider responsibilityPatient and family responsibility Health care agent/ surrogate role Able to engage in discussion to compose form with physician if patient lacks capacity. Cannot complete Emergency Situation Medical order that must be honored, starting with EMT’s Cannot be interpreted or followed by HCP’s in an emergency situation.

17. Section A: Cardiopulmonary Resuscitation (person has no pulse and is not breathing) Check either  Attempt resuscitation  Do not attempt resucitation (DNR) Specifies no defibrillator will be used if DNR is checked

18. Section B: Medical Intervention Person has a pulse AND/OR is breathing Check Either  Comfort Measure only  Limited Additional Interventions  Full treatment

19. Section C: Transfer to Hospital Check  Do not transfer to hospital for medical interventions  Transfer to hospital if comfort measures cannot be met in current location

20. Section D: Artificial Nutrition Check  No artificial nutrition  Defined trial period of artificial nutrition  Long term artificial nutrition if needed  Artificial nutrition until not beneficial or burden to patient Section E: Artificial Hydration Check  No artifical hydration  Defined trial period of artificial hydration  Long term artificial hydration if needed  Artificial hydration until not beneficial or burden to patient

21. Section F: Advanced Directive (if any) Check all that have been completed  Durable Power of Health Care  Health Care Proxy  Living Will  Documentation of oral advance directive Check who these have been discussed with  Patient  Health care decision maker  Parent/ guardian of minor  Court appointed guardian  Other __________

22. Section G: Signature of MOLST-Qualified Health Care Provider (Physician, RNP, APRN, or PA) & Signature of patient, decision maker, parent or guardian of minor, or guardian

23. Once signed, the MOLST form will become a portable part of the medical record.  If at home, it should be put near the bed or on the refrigerator. This is so that it can be easily find my emergency medical personnel  If in a hospital, nursing home, or assisted living facility, it will be in your chart or file.  If you are moved between locations, your MOLST form will go with you.  This aides in addressing the issue of DNR/DNI orders not being transferred from facility to facility

24. An individual can change or void their MOLST at any point in time. It is a good idea to review the decisions made in the MOLST form with a HCP when any of the following occur One is transferred from one setting to another There is a change in overall health status If the individual’s or decision maker’s treatment preferences change for any reason

25.  Provide in-service or online education on the MOLST  Provide in-service education on how to discuss end-of-life care  Input the MOLST into the electronic charting system  Have the MOLST form available on every unit

26.  The MOLST is a set of portable medical orders defining end of life wishes  It is a RI law to Honor the MOLST  The form is printed on bright pink paper to make it identifiable  The MOLST does not replace an advance directive  MOLST does not require a loss of decision making capacity to go into effect  You do not have to be over 65 to have a MOLST  The MOLST is signed by a physician, NP, PA, or APRN along with the patient or surrogate Key Points to Remember

27. “Because my mom made her own decisions by filling out a POLST form, I didn’t have to guess about what she wanted. This was comforting for both her and our family.” — PW, Davis, California “When patients have a POLST form, we know exactly what treatments they want and don’t want. It clears up any confusion, and gives patients peace of mind.” — Steve Lai, MD, Santa Clara County, CA “For people who are as sick as Max and who have strong feelings about the treatments they want and don’t want, Advance Directives are not enough,” cautions Susan Tolle, M.D., director of the Center for Ethics in Health Care at Oregon Health & Science University.

29.  My faculty sponsor, Professor Carolyn Hames Associate Professor, URI College of Nursing Associate Director, University Honors Program Professor of Thanatology  Heather Beauchemin, DON  Karen Gobin

31. References Bomba, P. A., Kemp, M., & Black, J. S. (2013, June 11). POLST: An Improvement over traditional advance directives. Cleveland Clinic Journal of Medicine, 79(7), 457-464. http://dx.doi.org/10.3949/ccjm.79a.11098 Dunn, P. M., Tolle, S. W., Moss, A. H., & Black, J. S. (2008, September 5). The POLST Paradigm: Respecting the Wishes of Patients and Families. Annals of Long-Term Care, 9(), 33-40. Retrieved from http://www.annalsoflongtermcare.com/article/7708 Frequently Asked Questions on the New Jersey Goals of Care POLST form and pilot. (2013). Retrieved from http://www.goalsofcare.org/polst-faq/ McLean, M. R., & Coleman, G. D. (2012, November). POLST Supports Care in Context of ERDs. Catholic Health Association of the United States, 6(93), 58-65. Retrieved from http://www.chausa.org/publications/health-progress/article/november december-2012/polst-supports-care-in-context-of-erds Medical Ethics Advisor. (2013, April). Momentum to better respect patients’ end-of-life wishes “growing every day”. Medical Ethics Advisor, 29(4), 37-48. Retrieved from http://www.polst.org/wp-content/uploads/2013/07/MEA-April-2013-POLST.pdf Muller, L. S. (2012). POLST: Something New Has Been Added. Legal & Regulatory Issues, 17(2), 90-93. http://dx.doi.org/10.1097/NCM.0b013e318244c30d POLST: What It Is and What It Is Not. (2012). Retrieved from http://www.polst.org/polst-what-it-is-and-what-it-is-not/ Tuohey, J., & Hodges, M. O. (2011, March). End of Life: POLST Reflects Patient Wishes, Clinical Reality. Catholic Health Association of the United States, 2(92), 60-64. Retrieved from http://www.chausa.org/publications/health progress/article/march-april-2011/end-of-life-polst-re%EF%AC%82ects-patient-wishes-clinical-reality