Conversations about advance care planning are not easy. Family members want the best for their loved ones but talking about end-of-life circumstances is often uncomfortable and therefore, avoided.
Sometimes, well-trained and thoughtful providers initiate these conversations with patients, especially with those who are seriously ill. They will talk about Actionable Medical Orders which guide medical professionals’ actions when it comes to life sustaining treatments. One order that many people are familiar with is the Do Not Resuscitate Order – or more commonly known as “DNR”. New York’s MOLST (Medical Order for Life-Sustaining Treatment) is a form that puts into writing a patient’s orders regarding resuscitation (such as DNR) as well as many other items pertinent to end-of-life care. eMOLST, a new electronic version of New York’s MOLST, is a tool that guides medical professionals through the MOLST process and ensures that these orders are always completed correctly. This process makes certain that patient safety and quality care are maintained while honoring their wishes. The eMOLST information is accessible 24/7 in New York’s statewide registry.
UHS Hospitals, a Care Compass Network partner, has implemented a protocol for incorporating the MOLST discussion and eMOLST system into their work with patients and families. Kris Marks, LCSW-R, OSW-C, Social Worker and Administrative Director of Palliative Care at UHS Hospitals, partnered with Katie Orem, MPH, New York’s eMOLST Administrator and the Geriatrics and Palliative Care Program Manager at Excellus BlueCross BlueShield.
Together, they planned an interactive training session for UHS Hospitals practitioners, led by Patricia Bomba, MD, MACP, who championed the creation of New York’s MOLST program. the training helped guide medical professionals through the nationally recognized 8-step Protocol for having end-of-life conversations with patients and families. They reviewed with participants all of the necessary clinical, ethical, and legal documentation in the eMOLST system.
“It’s a medical order that can be confusing and complicated,” shared Marks. “Understanding the patient’s preferences requires a conversation.” She added, at UHS Hospitals, in addition to the inpatient medical providers, it is also possible that the Palliative Care Team can be consulted for a patient who has been admitted and might be facing the reality that they are near the end of life. The palliative consult must come from a physician. If the initial MOLST discussion occurs with a nurse practitioner or social worker, a physician is also required to confirm the conversation and then sign the orders in the eMOLST system.
Physicians and their team members complete the MOLST discussion and the eMOLST document with the patient or their designated health care agent (or surrogate, if necessary). Family members are typically encouraged to attend the discussion when possible. If unable to attend family and loved ones need to be aware of the discussion and patient preferences. Patients are then instructed to keep the MOLST or printed eMOLST somewhere visible in their homes such as on the refrigerator or the nightstand (this is where EMS will look). It must go with the patient whenever they leave their home. The document has two pages of medical orders and two pages of blank space available for review/renew. The medical orders address instructions for resuscitation, intubation, hospitalization, artificial nutrition & hydration, antibiotics and general guidelines for treatment. There is also a section titled “Other Instructions” where directions on dialysis, transfusions, and trial periods for certain interventions can be captured.
The paper version of the MOLST is a bright pink form that can’t be missed. Hospitals, nursing homes and physician offices are also instructed to print the eMOLST form on bright pink paper so it stands out and is easily identifiable, just like the paper MOLST.
The electronic version of this form was designed to be sure there are no misunderstandings or errors in completion. Sometimes the paper forms will have more than one box checked in an area, or they’re mission some key information that should have been written in. In other examples, the paper version might have certain indicators crossed off after being in the home for a period of time. MOLST forms with errors like this cannot be honored. When the orders are completed in eMOLST there are no errors, discrepancies, or mission information. The eMOLST system has embedded logic to ensure that two boxes for the same question cannot both be checked. It also prevents clinicians from making incompatible orders such as allowing CPR and a do not intubate (DNI). Similarly, information that’s sometimes missing on paper forms, such as the authorizing physician’s printed name, license number and phone number, is always populated in the eMOLST version. The eMOLST also makes the information available across multiple platforms, accessible from many hospitals, nursing homes, specialty practices, or urgent care facilities. The system and technology is consistent across New York State. When a patient is visiting the Greater Binghamton area from another part of the state, their eMOLST orders can always be retrieved electronically.
Katie Orem is the eMOLST Administrator for New York State and recognizes the significant role the eMOLST system can play in honoring a patient’s wishes. Katie said, “eMOLST is a game-changer. No other state in the country has a system like ours. We keep the patient at the center of the process and ensure that conversations start with their goals and proceed logically through the medical orders and then address the legal documentation. Keeping the patient and their goals as the focus of the conversation brings peace of mind to both family members and professionals who are caring for the person.”
Whether a patient is looking at a year-long journey with a terminal illness or faced with only weeks ahead, palliative care professionals believe the conversations are delicate and unique to each patient and family. For this reason, it’s important to make sure that the healthcare providers they trust most are prepared to share this information the best way that they can. Sometimes this might mean that the primary care provider is talking to them about eMOLST while in other cases it might be a specialty care physician. In any scenario, it was Dr. Bomba’s intention that the patient’s goals be the highest priority and that their preferences are honored throughout the process.
Dr. Bomba said, “eMOLST is designed in a way to support both the clinicians leading these discussions and the patients and their family members participating in them. Patient’s goals and preferences are the focus of the process. Patients and family members can be assured that when their physician is using eMOLST, everything is done legally and that their orders are always accessible. Taking the time to have open and hones end-of-life discussions and document them appropriately in eMOLST is the peak of professionalism.”
Care Compass Network will be hosting an eMOLST education session which will be lead by Dr. Bomba on Wednesday, February 7th at Ithaca College. Click here for additional information on the eMOLST session.