1. Ohio MOLST Initiative Jeff Kaufhold, MD FACP Chair, Grandview Bioethics Advisory Committee Aug 2012

2. Summary Definition of MOLST and alternatives Current process for establishing limits on end of life care in Ohio Advantages of evolving to MOLST Use of MOLST in other states Links and further education

3. MOLST POLST Physicians Order regarding Life Sustaining Treatment MOLST Medical order regarding Life Sustaining Treatment MOST Medical Order for Scope of Treatment POST Physician Order for Scope of Treatment.

4. MOLST Doctors order regarding patients wishes to have or to forego resuscitation in the event of a cardiac or respiratory arrest. Guides healthcare providers and families on what treatments the patient wants to have, or wishes NOT to have Can include other life sustaining treatment directives such as feeding tubes, dialysis, organ donation, and donation of remains for medical education/study

5. Ohio Patient Self Determination – National PSDA Law passed 1990 – Went into effect Dec 1991 – Ohio DNR rules went into effect 1999 A person, in consultation with a physician, certified nurse practitioner or clinical nurse specialist, may seek a DNR order. There are currently two types of DNR orders: 1) "DNR Comfort Care," and 2) "DNR Comfort Care - Arrest." Upon the issuance of either order, standard forms of identification are provided for in OAC rule 3701-62-04. Supported by Ohio Revised Code Sections 2133.21 through 2133.26. – Is not clear on use of intubation and mechanical ventilation. – Required hospitals to come up with policies and procedures to operationalize how they would honor patients wishes at the end of life.

6. The Ohio Law on DNR-CC Creates a portable DNR FormID bracelet Wallet card Description of Components of CPR Stipulates what will NOT be done if pt is DNR Provides protection from liability Ohio Revised Code Sections 2133.21 through 2133.26, 1999

8. Ohio DNR in Practice How do we implement the Ohio DNR order in the Hospital?

10. Identification of Patient wishes to be DNR in EPIC Premier Hospital Network

11. Identification of Patient wishes to be DNR in EPIC Kettering Health Network

12. Process for establishing DNR in EPIC Order Set or enter DNR or “level of care” in new order section.

13. Process for establishing DNR status in EPIC Importance of adding the DNR status to the Problem list and PMHx

14. Ohio MOLST Initiative How do we evolve from the DNR law to MOLST? Advantages from our experience with the DNR law, recognizing its shortcomings – Statewide recognition regardless of setting of care – More comprehensive outline of patient wishes regarding specific treatments – Ability to benefit from the experience of other states with POLST Difficulties: Legislative Inertia, Need for healthcare worker and public education.

15. Ohio MOLST Initiative Need for healthcare worker and public education is still great, as evidenced by: Oregon experience that 10 % of POLST forms are invalid due to improperly completed/ lack of physician signature or date. Resuscitation of residents with DNR orders in LTCFs.

16. Resuscitation of Residents with DNR orders in LTCFs Measured the frequency of EMS calls to ECFs for patients with DNR orders Calls392 DNR 139 (35%) Resus. Attempted29 (21%) Becker Yeargen et al. Prehospital Emergency Care 2003: 7: 303-6.

17. Ohio MOLST Initiative What are the advantages of MOLST paradigm?

18. Ohio MOLST Initiative Most patients with chronic illness think about end of life wishes and fears. Preserves patient autonomy by answering questions about DNR status, Return to hospital, use of ICU, and symptom management. Helps guide discussion with the family

19. National POLST Programs Oregon program in effect since 1995 – Includes a statewide directory which maintains a repository of patients with a POLST SUPPORT study published 1995 Washington State program 2000, the Department of Health administers it and is able to update and change the form/ implementation without going back to the legislature

20. National POLST Programs Utah Life with Dignity Act July 2010, updated 2012 North Carolina MOST act 2007 Montana 2009 has policy that ECFs must establish POLST with 100 % of residents (not all get DNR order but all must have discussion)

21. National POLST Paradigm Programs March 2012 POLST.org

22. How do we move Ohio from pink to Purple? Ohio MOLST activity started in 2005, to begin working on updates to the DNR rules. MOLST legislation stalled Local community action to establish standard of care in the community Purpose of our meeting today!

23. Ohio MOLST form Notice the red print. The Ohio DNR form is the officially recognized form.

24. Resources WWW.POLST.ORG Youtube has educational videos for Physicians and healthcare workers, as well as patient information. (just type POLST in the search) Ohio Hospice and Palliative Care organization OHPCO.org