This past month Ithaca College’s Gerontology Institute and Care Compass Network hosted a full-day event focused on the significance and use of eMOLST when documenting patients’ end-of-life preferences as medical orders. Care Compass Network invited nationally recognized palliative care and end-of-life expert, Dr. Patricia Bomba Vice President and Medical Director of Geriatrics with Excellus BlueCross BlueShield (BCBS), to speak with healthcare professionals from the Southern Tier.
Dr. Bomba is revered by many medical professionals as the MOLST and eMOLST guru. She has made it her mission to make sure that every older person in the final stage of life has the ability to make their wishes known when it comes to their desires for level of care and quality of life.
MOLST stands for Medical Orders for Life Sustaining Treatment. The paper version is presented as a bright pink form and is only appropriate for people who are seriously ill or near the end of life. MOLST is not n advance directive, but it initiates a discussion which follows a nationally recognized 8-step Protocol. MOLST completion is based on a thoughtful conversation or a series of conversations between the patient and their physician about their health status, prognosis and goals for care in addition to what medical interventions can and cannot accomplish at this stage of their life and their medical condition. After the conversation, the physician completes the MOLST form that must travel with the patient and must be honored by all medical professionals, including emergency medical services (EMS) in the community.
eMOLST is the electronic version of this process and has many benefits. There are often flaws and failure in the paper world which make it difficult for the MOLST forms to be completed properly. eMOLST also guarantees that these orders will be accessible from any care setting that has internet access. This is important especially in cases when the printed MOLST is not available. The eMOLST also allows for easier editing as patients’ preferences and goals change over time. The eMOLST system has special prompts and programming to prevent medical errors and reduce gaps in information. Including the family in the process helps to nearly eliminate confusion nd family conflict related to the patient’s goals and preferences.
Dr. Bomba’s talk covered many aspects of advanced care planning including reasons why these conversations are so important. She highlighted the fact that implementing eMOLST gives medical professionals the opportunity to improve quality of care and patient safety while also reducing unwanted hospitalizations. Above all else, she stressed the importance of giving patients choices based on their personal values, beliefs, and goals for care that will improve their quality of life and reduce suffering. During her presentation, Dr. Bomba stressed “eMOLST [is] not just about IT integration, it starts with culture change.”
The UHS Palliative Care team and eMOLST task force shared their experience as a case study for undergoing a year-long implementation process. They took a leadership role in the community and initiated eMOLST use within two of their inpatient hospitals, their nursing home and their outpatient palliative care work. Today the health system is pursing implementation with two other inpatient facilities and numerous primary and specialty care practices. The UHS team walked through the phases of their process including the challenges they faced along the way. Overall, they were very pleased with the support of their team and colleagues, and stressed that the diverse disciplinary attributes of their team were instrumental in being able to make progress.
The eMOLST project at UHS was identified as a key priority by Rajesh Dave, MD, CMO, Kay Boland, RN, SVP CNO & COO, and Nancy Rongo, RN, VP & CQO. Kris Marks, LCSW-R, OSW-C, the administrative director for palliative care at UHS, led the project team. The project team also included representation from numerous clinical disciplines including hospitalists, palliative care, nursing, social work, intensive care, the emergency department, anesthesiology, surgery, the nursing home, legal, performance improvement, and outpatient practices. The clinical representatives are joined on the team by key personnel from IT, clinical systems, quality, education, and risk management.
In particular, Jeff Gray, MD, the UHS hospitalist program director, saw the benefit of eMOLST and championed the effort encouraging his entire team to come on board. He also diligently attended virtually all project team meetings and encouraged his physician colleagues from across the health system to be accountable for these critical end-of-life discussions. In the hospital setting, a hospitalist might have the best opportunity to discuss advance care planning and end-of-life preferences with a patient and their family. The care givers in their unit can facilitate the conversations but the physician is required to confirm the discussion, answer any questions that the patient or family might still have, and sign all the MOLST orders, whether they’re completed in eMOLST or on paper.
Following the UHS case study presentation, Katie Orem, MPH, eMOLST Administrator for NYS and the Geriatrics and Palliative Care Program Manager at Excellus BCBS, and Dr. Bomba walked participants through a mock eMOLST demonstration, entering data for a hypothetical patient. They shared different scenarios and answered questions concerning interpretation of terminology and addressed both best practices and recommendations for compliance with applicable public health laws. They also pointed out that once the eMOLST is completed, it can hen be printed on pink paper so that hard copies are available for the patient to have with them and at home.
Dr. David Evelyn, Vice President of Medical Affairs at Cayuga Medical Center (CMC) attended the workshop with a group of colleagues. He shared that they registered for the event because “we are interested in ways we might get our community using the eMOLST system as a way of communicating end-of-life preferences as medical orders and ensuring accessibility across all care settings.” Dr. Evelyn stressed that community participation is key because the emergency room is a difficult place to have discussions about end-of-life preferences. He agrees with Dr. Bomba that they conversation needs to occur early on – at the point that a patient is either newly diagnosed with a terminal illness or presenting symptoms of a complicated medical condition that compromises their quality of life. “We’d like to see the eMOLST being used in physician offices and long-term care facilities in our community,” Dr. Evelyn shared. “Ideally, patients should already be in the eMOLST system before they even arrive at the hospital.”
Like UHS, CMC has plans to lead a community-based effort to implement eMOLST throughout Ithaca and surrounding areas where their patients are served. They are in the pre-planning stages, putting together a project team with the goal to begin meeting as a group in the late winter or early spring.
The Gerontology Institute offers ongoing programs and workshops throughout the year through the Finger Lakes Geriatric Education Center. Many programs and workshops are free and open to the public.