1. Massachusetts Massachusetts Medical Orders for Medical Orders for Life-Sustaining Life-Sustaining Treatment Treatment “MOLST Overview for Health Professionals”

2. The MOLST project is a collaboration of the: Massachusetts Department of Public Health Massachusetts Executive Office of Elder Affairs and Commonwealth Medicine at UMass Medical School

3. Presenters Christine McCluskey, RN, MPH Director, MOLST Expansion Project Commonwealth Medicine, UMass Medical School Mary Valliere, MD Medical Consultant, MOLST Expansion Project Jena Bauman Adams, MPH Training Consultant, MOLST Expansion Project Central Massachusetts Area Health Education Center 3 picture

4. Goals of the Presentation  Provide basic information about MOLST  Provide a recorded version of the MOLST Overview for Health Professionals that may be used for individual or group training  Supplement the MOLST Overview for Health Professionals with responses to Frequently Asked Questions about its content 4

5. MOLST Overview for Health Professionals Documenting and honoring patients’ preferences for life-sustaining treatment

6. MOLST is… A “POLST paradigm” program (more info at www.polst.org)www.polst.org 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 6

7. MOLST expands on the MA Comfort Care/DNR form Documents that a medical order exists Always instructs DNR - not to use CPR Orders about CPR only Honored in outpatient settings by EMTs 7 Is a medical order form May instruct to use OR not use treatments Orders about several types of life-sustaining treatments Honored across settings by all health professionals CC / DNR MOLSTMOLST The CC/DNR form remains valid in Massachusetts!

8. MOLST is not an Advance Directive Advance Directives are legal (not medical) documents. Advance Directives specify who (e.g. health care agent) or what (e.g. information on a living will) represents a person’s preferences if the person loses capacity to make medical decisions. Advance Directives go into effect only after a patient is declared incapable of making their own medical decisions. 8

9. Advance Directives in Massachusetts The only legally authorized Advance Directive in Massachusetts is a health care proxy (HCP) form. Health care proxy forms specify who (the health care agent) represents an incapacitated patient during shared decision-making. 9

10. What about “Living Wills”? A “living will” is written documentation of a person’s preferences – to guide surrogates and clinicians if the person loses capacity to make medical decisions. Living wills are not legally binding in Massachusetts, but can be important sources of information about a person’s preferences. 10

11. A Comparison of Forms MOLSTHEALTH CARE PROXY Form typeMedical documentLegal document Form usersPatients of any age with advanced illness All adults (ages 18 and older) healthy or sick Form contains Current medical orders about life-sustaining treatments Name of the person’s appointed health care agent(s) for future shared decision-making Form signer(s) The patient* and clinicianThe person and two witnesses of their own choice 11 * Or health care agent (only if the patient lacks capacity)

12. Who signs the MOLST form? The patient or patient’s health care agent (only if the patient has been declared to lack capacity). If there is no agent, a guardian or the parent/guardian of a minor can sign to the extent permitted by Massachusetts law. Seek legal counsel about a guardian’s authority. and The clinician – a physician, nurse practitioner or physician assistant, after goals of care discussions with the patient and his or her surrogates. 12

13. 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 13

14. When a patient has a MOLST form Honor the MOLST form as you would honor other medical orders, until a physician, nurse practitioner or physician assistant can assess the clinical situation. Alert a clinician about the existence and contents of the MOLST form. Contact the clinician who signed the patient’s MOLST for more information if needed. 14

15. When a patient wants a MOLST form 1)Alert a clinician when: Any patient/health care agent asks about MOLST Any patient/health care agent expresses preferences about life-sustaining treatments Any patient may be suitable for MOLST 2)Assist patients and families to get information they need for advance care planning – especially the importance of completing a health care proxy form 15

16. Page 1 contains : Section A – CPR: for a patient in cardiac or respiratory arrest Section B – Ventilation: for a patient in respiratory distress Section C – Transfer to Hospital Section D – Patient signature, printed name, phone, date* Section E – Clinician signature, printed name, phone, date* Optional expiration date and other optional contact information * Required for a valid page 1 16 Contents of the MOLST form

17. Page 2 contains Section F – Preferences about treatments that may be appropriately offered in the future – including: Non-invasive ventilatory support; Dialysis; Artificial Nutrition; Artificial Hydration; and other treatment preferences. Includes Treatment Options: Give treatment; No treatment; Short-term only; Undecided; Did not discuss REQUIRED FOR A VALID PAGE 2 Section G – Patient signature, print name, contact info, date Section H – Clinician signature, print name, contact info, date 17

18. After the MOLST is signed The original MOLST form stays with the patient. The MOLST form should be placed where it can be easily located (e.g. on the refrigerator, at the bedside). The form should go with the patient to all care settings and during any trips/appointments outside the home. Family and caregivers should be informed about the MOLST form, its contents, and where to find it. Copies of the MOLST are valid; make copies for all the patient’s health care providers and to put in the EHR. 18

19. Updating MOLST forms MOLST forms should be re-discussed with patients any time there is a significant change in the patient’s health status; location or level of care; goals of care; or treatment wishes. Patients can ask to change or void their MOLST at any time (or request and receive previously refused medically- indicated treatment). Any change to the MOLST form requires the form to be voided and a new form created (and documented in the EHR) 19

20. Voiding the MOLST forms Write “VOID” across Page 1 and Page 2 of the form. Instruct the patient that all copies of the outdated form must be destroyed. Document updates to MOLST instructions in the EHR system. Create a new MOLST form if the patient desires it. 20

21. If you have further questions about MOLST in Massachusetts, please review the MOLST website, especially the FAQs and other information for Health Professionals at www.molst-ma.org. 21