1. MOLST Implementation Jack Schwartz, Esquire Damien Doyle, MD, CMD, FAAFP Marian Grant, DNP, RN, CRNP, ACHPN Tricia Tomsko Nay, MD, CMD, CHCQM, FAAFP, FAIHQ, FAAHPM

2. Case #1 38-year-man who injured his knee. Being discharged from the hospital to rehab. Healthy, no medications. On discharge, the doctor asks about his code status. 2

3. Case #1: Take Home Message Discuss code status and other relevant issues from page two of the Maryland MOLST form. 3

4. Case #2 68-year-old woman who visits her physician’s office for a leg wound. PHM: Diabetes, hypertension, and peripheral vascular disease. Doctor orders home health. No Maryland MOLST form on file. 4

5. Case #2 Doctor brings up CPR, but patient cuts him off and says, “Don’t speak of such things.” Doctor rephrases question, but she says, “I understand what the form is for, but I will not talk about these things.” Doctor respects her right to decline to discuss the topic. 5

6. Case #2 Doctor explains that when no limitations are put on CPR and other life-sustaining treatments, that she will receive medically indicated treatments in most circumstances. 6

7. Case #2: Take Home Message Respect a patient or authorized decision maker’s right to decline to discuss an issue. Whenever possible, inform the patient or ADM that not making a decision generally means that all medically indicated interventions will be done. 7

8. Case #3 75-year-old woman who fell at home >>> hip fracture >>> ORIF >>> transferring to a nursing home for rehab. Planning to return home. Makes her own decisions. Nurse practitioner at nursing home realizes there is no Maryland MOLST form from the hospital. 8

9. Case #3 If my heart stops of I stop breathing, “Do everything that you can.” Use a ventilator if it is needed at any time. I hated the hospital. Never send me back to a hospital. I want medical tests to be done if needed. I want any kinds of antibiotics that are recommended. 9

10. Case #3: Take Home Message Clarify general statements. Address conflicting wishes immediately. 10

11. Case #3 During rehab, the patient has a stroke with right sided hemiplegia. Now plans to stay in nursing home for long- term care. Physician readdresses code status and life- sustaining treatments. 11

12. Case #3 If my heart stops or I stop breathing, “Allow God to take me.” Never use a machine to treat me or keep me alive. I only want to go to the hospital if I have severe pain or symptoms you can’t treat in the nursing home. I only want medical tests if needed for symptomatic treatment or comfort. 12

13. Case #3 I want antibiotics I can take by mouth if I am in pain from an infection. I never want any artificially administered fluids or nutrition, even for a short trial. 13

14. Case #3: Take Home Message Clarify general statements. Reassess the goals of care when there is a change in condition. A patient has the right to change his or her mind. 14

15. Case #4 100-year-old man with end-stage dementia who lives with his daughter and son-in-law. 24-hour private duty caregivers. Being admitted to hospice. 15

16. Case #4 No Maryland MOLST form. Two certs of incapacity. Two certs of end-stage condition. 16

17. Case #4 Advance directive: If I am in an end-stage condition, do not resuscitate me... Do not give me any artificial feeding or hydration, including tube feedings. His daughter is his health care agent. 17

18. Case #4 Daughter says he is a DNR-B and wants to begin artificial feeding and hydration. She says that nine years ago, her father meant if he was going to die in a day or two, not to feed him artificially. The hospice nurse thinks he will live for a few months. 18

19. Case #4: Take Home Message Honor the patient’s known wishes. The health care agent cannot override the patient’s advance directive. The Health Care Decisions Act affords the practitioner immunity for good faith efforts to comply with the act. 19

20. For More Information marylandmolst.org MarylandMOLST@dhmh.state.md.us 20