Facilitating End-of-Life Decisions: Advance Directives & MOLST
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1 Facilitating End-of-Life Decisions: Advance Directives & MOLST Thaddeus Mason Pope, J.D., Ph.D. Wilmington VA Hospital September 30, DE end-of-life care 2. Advance directives 3. Problems with ADs 4. MOLST
2 End-of-Life Care in Delaware
3 Treatment is unwanted
4 71%: More important to enhance the quality of life... even if it means a shorter life. National Journal (Mar. 2011)
5 84% would trade length of life for quality of life Harms from unwanted treatment
6 1. Harm to Patient
7 2. Harm to Family
8 3. Harm to Others
9 4. Harm to Society
10
11 Patients without capacity Prospective Autonomy
12 Spouse Adult child Parent Adult sibling Advance Directives
13
14 Limits of (instructional) Advance Directives Not completed Not found Not informed Not clear
15 Not completed 30% 28%
16 Not found
17 65-76% of physicians whose patients have advance directives do not know they exist Individuals fail to make & distribute copies Primary agent Alternate agents Family members PCP Specialists Attorney Clergy Online registry Not informed
18
19 Not clear if, then Trigger terms vague Reasonable expectation of recovery 75% 51% 25% 10% Plus: prognosis uncertain
20 Preferences vague No ventilator Ever Even if temporary
21 More technology is the default Patient must opt out
22 MOLST MOLST Medical Order Life Sustaining Treatment
23 POLST Practitioner / Physician Order Life Sustaining Treatment POST Physician Order for Scope of Treatment MOST Medical... COLST Clinician... Life with Dignity Order
24 What is MOLST MOLST supplements AD Does not replace
25 Both Terminal illness Advanced chronic progressive illness Frailty
26 In last year of life Others who want to define care The present Here & now
27 Order for LST CATEGORIES OF LIFE SUSTAINING TREATMENTS JAGS 58: , A Comparison of Methods to Communicate Treatment Preferences in Nursing Facilities: Traditional Practices versus the Physicians Orders for Life-Sustaining Treatment (POLST) Program. Susan E. Hickman, PhD, Christine A. Nelson, PhD, RN, Nancy A Perrin, PhD, Alvin H Moss, MD, Bernard J Hammes, PhD, and Susan W. Tolle, MD.
28 blood transfusions
29
30 Can be completed by surrogate, if patient lacks capacity 70% patient 30% surrogate MOLST does not expire
31 Review with change in condition or location MOLST can be revised or revoked at any time History of MOLST
32 1991 PA - implementing 2011 NJ - implementing 2011 MD - implementing 2011
33 Del. Code 9706(h) added by H.B. 332 Nov. 1, 2002 Proposed PACD regulations Request for written materials and suggestions Nov. 26, 2002 Public hearing Comment period extended Dec. 31, 2002 End comment period
34 June 13, 2003 July 10, 2003 July 2005 Final regulations approved Regulations effective S.B. 195 amends 9706(h) re driver designation Mar. 15, 2011 Proposed regulations Apr. 1, 2011 Published
35 May 2011 Aug End comment period Final regulations MOLST status Provider education Public education Policy writing
36 Limited terminally ill permanently unconscious Not binding on VHA Compliance not specifically mandated, except by EMS But all HCP must honor decisions of the patient per DE HCDA & PSDA Stop completing orange PACD forms But honor them when presented
37 MOLST benefits 1. Bright color
38 Original MOLST printed on lilac card stock But a copy has the same force as original 2. Single page
39 3. More informed 4. Immediately actionable
40 Medical Order Life Sustaining Treatment No need to interpret advance directive No need to translate into orders 5. Easy to follow
41 6. Better honored Can follow Will follow
42 7. Portable Home Hospital LTC EMS 8. Broader than PACD
43 PACD MOLST 9. Proven Effective
44 Closes gap between what people want and what they get
45 2 roles Honor Complete Act in accordance with MOLST Write corresponding VHA orders Scan into EHR
46 Encourage Educate Write or review on discharge Thank you Thaddeus Mason Pope, J.D., Ph.D. Widener University School of Law 4601 Concord Pike, Room L325 Wilmington, Delaware T: F: E: W:
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