MOLST Quality Forums Next Steps for Statewide Expansion January 2008

1. MOLST Quality ForumsNext Steps for Statewide ExpansionJanuary 2008 Patricia Bomba, M.D., F.A.C.P. Vice President and Medical Director, Geriatrics Director, Education for Physicians on End-of-life Care Co-Director, Community-wide End-of-life/Palliative Care Initiative Chair, Monroe and Onondaga Counties MOLST Implementation Team Patricia.Bomba@lifethc.com A nonprofit independent licensee of the BlueCross BlueShield Association

2. MOLST Today • Consistent with New York State Law • Approved by NYSDOH for institutional use in ALL health care facilities throughout New York State • Approved by NYSDOH for use in the community as a nonhospital DNR and DNI in Monroe & Onondaga counties

3. Future of MOLST If the MOLST pilot is made permanent and expanded statewide, it could be used in the community as DNR and DNI throughout New York State.

4. MOLST Serves As “Clear and Convincing Evidence” MOLST can be used now ANYWHERE in New York State to provide “clear and convincing evidence” of a patient’s wishes regarding life-sustaining treatment.

5. Nonhospital DNR Law before MOLST(PHL § 2977) • Nonhospital DNR – Must be on “standard form” issued by the Department of Health (by contrast, hospital-based DNR order can be on any form) • “Standard form” – one page form with little detail beyond instruction not to resuscitate • Nonhospital DNR – Can be honored ONLY if patient is in FULL cardiopulmonary arrest • If patient is NOT in full cardiac or respiratory arrest, FULL treatment must be provided • DNI was NOTcovered in nonhospital DNR law

6. Permits NYS Department of Health to authorize MOLST form in lieu of Nonhospital DNR in Monroe and Onondaga Counties “Standard form” does NOT need to be used in pilot counties Dear Administrator Letter (DAL) of January 17, 2006 http://www.health.state.ny.us/professionals/nursing_home_administrator/docs/dcl_molst.pdf MOLST Pilot Project Legislation(PHL § 2977(13))

7. MOLST Pilot Project Legislation(PHL § 2977(13)) Regional Pilot in Monroe and Onondaga Counties, Approved by NYSDOH, October 2005 Unless further legislation extends the pilot, The expiration date will be June 30,2008

8. 2006 Amendment • DNI was not covered in Nonhospital DNR Law (Public Health Law § 2977) • Permits EMS to honor Do Not Intubate (DNI) instructions prior to full cardiopulmonary arrest in Monroe and Onondaga Counties during MOLST Pilot • Carve-out: Persons with MH and DD without capacity • DNR law for persons with MR/DD without capacity remains the same as it would be without MOLST

9. EMS in Pilot Counties • EMS personnel will follow orders on the MOLST form for individuals living in Monroe and Onondaga counties • Individuals living in Monroe and Onondaga counties: a completed MOLST form can replace the NYS Nonhospital DNR form • Individuals living outside Monroe and Onondaga counties: The NYS Nonhospital DNR form must be completed in addition to the MOLST

10. EMS Outside Pilot Counties MOLST provides “clear and convincing evidence” to EMS Medical Control outside Monroe and Onondaga counties.

11. Next Steps • SEMAC • Report to NYSDOH • Work with OMH and OMRDD • Statewide support • Legislation to amend PHL

12. THANK YOU Patricia.Bomba@lifethc.com Visit the MOLST Training Center at www.compassionandsupport.org