medical orders for life sustaining treatment

1. Medical Orders for Life Sustaining Treatment A MOLST Demonstration Program Update July 23, 2009 Margaret Ann (Peg) Metzger, JD, MOLST Project Consultant 1 I�m here with Jena Adams, the MOLST Project Director. She�s a seasoned health program director and happily she�s on board to manage this project. We want to give you a progress report on a MOLST demonstration project, MOLST standing for medical orders for life-sustaining treatment. The demonstration area is centered on Worcester and the demonstration will be based on the POLST paradigm projects that exist in other states around the country. POLST, of course, is the acronym for physician�s orders for life-sustaining treatment. I expect many of you have some familiarity with the initiative. Today, I have two goals: To fill you in on the work that is being done on MOLST, and to make sure you know that we welcome your thoughts and your help on implementation issues in the hospice environment. I don�t expect we�ll have enough time to have detailed discussions now but I am happy to get your comments off-line and, if there is enough interest, to holding a separate meeting to get further input from hospice leaders. I�m here with Jena Adams, the MOLST Project Director. She�s a seasoned health program director and happily she�s on board to manage this project. We want to give you a progress report on a MOLST demonstration project, MOLST standing for medical orders for life-sustaining treatment. The demonstration area is centered on Worcester and the demonstration will be based on the POLST paradigm projects that exist in other states around the country. POLST, of course, is the acronym for physician�s orders for life-sustaining treatment. I expect many of you have some familiarity with the initiative. Today, I have two goals: To fill you in on the work that is being done on MOLST, and to make sure you know that we welcome your thoughts and your help on implementation issues in the hospice environment. I don�t expect we�ll have enough time to have detailed discussions now but I am happy to get your comments off-line and, if there is enough interest, to holding a separate meeting to get further input from hospice leaders.

2. 2 Impetus for the MOLST project came from the End of Life and Chronic Care Subcommittee of the Health Care Quality and Cost Council. Its 2008 Annual Report includes a recommendation to create a POLST-like demonstration project and then report on its evaluation, and the ultimate implementation of a POLST � like process statewide. There were actually 3 EoL provisions of Chapter 305 of the Acts of 2008 Section 41 mandated an Expert Panel on end of life care for patients with serious chronic illnesses. Hospice is well-represented by Rigney Cunningham and Diane Stringer, among others. Section 42 mandated a public awareness campaign about the importance of EoL care planning � work was done around National Healthcare Decisions Day on April 16th. Section 43 - We�re calling our program MOLST (medical orders) since non-physician advanced practitioners can also sign the orders.Impetus for the MOLST project came from the End of Life and Chronic Care Subcommittee of the Health Care Quality and Cost Council. Its 2008 Annual Report includes a recommendation to create a POLST-like demonstration project and then report on its evaluation, and the ultimate implementation of a POLST � like process statewide. There were actually 3 EoL provisions of Chapter 305 of the Acts of 2008 Section 41 mandated an Expert Panel on end of life care for patients with serious chronic illnesses. Hospice is well-represented by Rigney Cunningham and Diane Stringer, among others. Section 42 mandated a public awareness campaign about the importance of EoL care planning � work was done around National Healthcare Decisions Day on April 16th.

3. What is MOLST? 3 MOLST is a form that may be used as part of an advance care planning process to promote: Better clinical training about communication at the end of life; Conversations between clinicians and patients who are nearing the end of life about goals of care and treatment preferences; and Standardized documentation of patient preferences with certain actionable medical orders that can be transferred and honored across treatment sites MOLST is both process and form � it will involve substantial clinician education and patient outreach in an effort to promote Conversations and standardized documentation that can be actionable across treatment settings as patients transfer. Please note that we are still working on the best way to describe who should consider using MOLST is � who is appropriate based on their current situation and the medical facts? This is critical because the form, including the orders in Sections A, B, and C are intended to be effective immediately and are not hypothetical or theoretical. Of course, the �who� question is as much art form as science. We think of people who: Have serious life-limiting conditions Chronic progressive disease Life-threatening injuries Serious illness Are medically frail Tool: Whose doctors wouldn�t be surprised if they died within a year MOLST is only for a person who, based on their current condition, is ready to accept that the orders could be honored that very same day. N No one is required to sign a MOLST form and, If signed, MOLST can be used either to limit or to encourage specific types of medically-indicated treatments. MOLST is both process and form � it will involve substantial clinician education and patient outreach in an effort to promote Conversations and standardized documentation that can be actionable across treatment settings as patients transfer.

4. 4 The multiple pathways and complex transfer patterns are well known to you. This is a slide from Dominique Kim�s presentation to the MA Health Data Consortium�s Care Transitions Seminar. The need to communicate across these settings is a prime reason for implementing MOLST. Ideally, the conversations can build from one to the next. And MOLST is designed to allow that to happen. In each of these settings and with any emergency transfer along the way � it can be enormously helpful for both patients/families and providers if providers can get a snapshot indicating whether there are orders, whether there have been discussions, and what the patient�s preferences are with respect to care at the end of lifeThe multiple pathways and complex transfer patterns are well known to you. This is a slide from Dominique Kim�s presentation to the MA Health Data Consortium�s Care Transitions Seminar. The need to communicate across these settings is a prime reason for implementing MOLST. Ideally, the conversations can build from one to the next. And MOLST is designed to allow that to happen. In each of these settings and with any emergency transfer along the way � it can be enormously helpful for both patients/families and providers if providers can get a snapshot indicating whether there are orders, whether there have been discussions, and what the patient�s preferences are with respect to care at the end of life

5. Premise of MOLST Individuals have the right to accept or refuse medically treatments (including life-sustaining treatments) or have a health care agent act on their behalf if they lack capacity MOLST can be used either to limit or to encourage specific types of medically indicated treatments 5 That�s because MOLST is based on the premise that individuals have the right to accept or refuse medically indicated treatments or to have a health care agent act on their behalf if the lack capacity. As, I�ve said, MOLST can be used either to limit or to authorize specific forms of treatmentThat�s because MOLST is based on the premise that individuals have the right to accept or refuse medically indicated treatments or to have a health care agent act on their behalf if the lack capacity. As, I�ve said, MOLST can be used either to limit or to authorize specific forms of treatment

6. Goals of MOLST Increase the likelihood that patients� preferences will be discussed, defined, documented in a standardized way and honored at the end of life Expand the tools available for advance care planning processes in MA Decrease public and private spending on unwanted treatments 6 MOLST is looking to achieve the ever elusive triple win � improved quality, reduced cost and increased patient and family satisfaction We believe that the provider training required to make this a reality will ultimately improve provider comfort and proficiency in having discussions about dying and care at the end of life care. MOLST is looking to achieve the ever elusive triple win � improved quality, reduced cost and increased patient and family satisfaction We believe that the provider training required to make this a reality will ultimately improve provider comfort and proficiency in having discussions about dying and care at the end of life care.

7. Origins of POLST Development began in Oregon in 1991; Oregon POLST form released for use in 1995 National POLST Paradigm Initiative Task Force formed in 2004 to facilitate the creation of POLST Paradigm programs in every state (see www.polst.org) POLST Paradigm programs exist in all or parts of more than 20 U.S. states. 7 POLST was first developed in the early 90s in Oregon West Virginia and Wisconsin were also early adopters Programs that had been established by 2002 coalesced to create the National POLST Paradigm Initiative Task Force in 2004 to facilitate creation of POLST Paradigm programs in every statePOLST was first developed in the early 90s in Oregon West Virginia and Wisconsin were also early adopters Programs that had been established by 2002 coalesced to create the National POLST Paradigm Initiative Task Force in 2004 to facilitate creation of POLST Paradigm programs in every state

8. MOLST Organizational StructureCoordinated by UMass Medical School, Commonwealth Medicine* Process of developing MOLST started in October, 2008 . With coordination from Commonwealth Medicine, many committees and workgroups has been working under the leadership of Andy Epstein, representing the Department of Public Health and Ruth Palombo, representing the Executive Office of Elder Affairs Worcester was selected as the demonstration area Key institutions involved in planning have included: Commonwealth Medicine MA EOHHS Division of Health Care Finance & Policy, Department of Public Health and Executive Office of Elder Affairs MassHealth � appreciate their financial investment in getting this project underway Hospice and Palliative Care Federation of Massachusetts MA Health Data Consortium MA Senior Care Foundation Partners Healthcare System UMass Memorial Medical Center UMass Medical School, Commonwealth Medicine and the School of Nursing Better Endings Partnership Others? Process of developing MOLST started in October, 2008 . With coordination from Commonwealth Medicine, many committees and workgroups has been working under the leadership of Andy Epstein, representing the Department of Public Health and Ruth Palombo, representing the Executive Office of Elder Affairs Worcester was selected as the demonstration area Key institutions involved in planning have included: Commonwealth Medicine MA EOHHS Division of Health Care Finance & Policy, Department of Public Health and Executive Office of Elder Affairs MassHealth � appreciate their financial investment in getting this project underway Hospice and Palliative Care Federation of Massachusetts MA Health Data Consortium MA Senior Care Foundation Partners Healthcare System UMass Memorial Medical Center UMass Medical School, Commonwealth Medicine and the School of Nursing Better Endings Partnership Others?

9. Local Implementation Sites 9 Implementation sites have been identified Extensive input has and is being sought from both professional and consumer stakeholders as we: refine the essential features of the demonstration program for Worcester and create the actual form, as well as the training materials and the model protocols and policies for the various participating institutions Don�t expect to go live until the spring of 2010 in order to allow time for implementation and training Implementation sites have been identified Extensive input has and is being sought from both professional and consumer stakeholders as we: refine the essential features of the demonstration program for Worcester and create the actual form, as well as the training materials and the model protocols and policies for the various participating institutions Don�t expect to go live until the spring of 2010 in order to allow time for implementation and training

10. Environment for MOLST in MA Reliance on health care agents Living will-type documents not legally binding (but may serve as evidence of patient preferences if presented) Existence of out-of-hospital DNR protocol Much discomfort with bundling and labeling care as Comfort Measures Only, Limited Additional Interventions and Full Treatment Some desire to reserve MOLST for the sickest patients with advanced progressive disease or those at risk for losing capacity 10 Of course we need to recognize certain features of MA law and practice. We are one of only 3 states that doesn�t officially recognize living will type advance directives. As a result, clinicians expect to look to health care agents rather than documents. Second, MA has an out-of-hospital Do Not Resuscitate protocol known as CC/DNR, the acronym for Comfort Care/Do not Resuscitate. It involves a specific DPH sanctioned form that is completed by a clinician to verify the existence of a DNR order. The only basis on which first responders are authorized not to proceed with treatment is the existence of a competed CC/DNR verification form. The CC/DNR is not widely used because there was minimal publicity and training when the program was first developed and little since. However, among EMTs and those who use the CC/DNR Verification form, the idea of building on and improving it really resonated. They like the idea that MOLST will cover more types of treatments and can be honored across multiple treatment settings. During the course of many interviews, I encountered almost universal discomfort with bundling and labeling care as Comfort Measures Only, Limited Additional Interventions (or Limited Treatment), and Full Treatment Some reservations about allowing MOLST to be used for basically healthy individuals. Some desire to reserve MOLST for the sickest patients so clinicians can reasonably anticipate and adequately explain the likely disease trajectory or trajectoriesOf course we need to recognize certain features of MA law and practice. We are one of only 3 states that doesn�t officially recognize living will type advance directives. As a result, clinicians expect to look to health care agents rather than documents. Second, MA has an out-of-hospital Do Not Resuscitate protocol known as CC/DNR, the acronym for Comfort Care/Do not Resuscitate. It involves a specific DPH sanctioned form that is completed by a clinician to verify the existence of a DNR order. The only basis on which first responders are authorized not to proceed with treatment is the existence of a competed CC/DNR verification form. The CC/DNR is not widely used because there was minimal publicity and training when the program was first developed and little since. However, among EMTs and those who use the CC/DNR Verification form, the idea of building on and improving it really resonated. They like the idea that MOLST will cover more types of treatments and can be honored across multiple treatment settings. During the course of many interviews, I encountered almost universal discomfort with bundling and labeling care as Comfort Measures Only, Limited Additional Interventions (or Limited Treatment), and Full Treatment Some reservations about allowing MOLST to be used for basically healthy individuals. Some desire to reserve MOLST for the sickest patients so clinicians can reasonably anticipate and adequately explain the likely disease trajectory or trajectories

11. Features of MOLST in MA Clinician training will focus on the conversation before the form MOLST is most suitable for patients who are nearing the end of life due to a serious advancing medical condition, including, but not limited to: Life threatening disease Chronic progressive disease Acute injury Medical frailty 11 Again, still some question about exactly how to describe who MOLST is for. We are expecting to need extensive clinician training � both online and in-person and appreciate Susan Block�s suggestions for ways to create materials that accompany the forms that clinicians can use during their discussions with patients in ways that amplify and reinforce the training. Unlike a living will � MOLST will be completed based on the person�s current medical condition and will be effective immediately. It is not theoretical and its effectiveness is not dependent on loss of capacity Again, still some question about exactly how to describe who MOLST is for. We are expecting to need extensive clinician training � both online and in-person and appreciate Susan Block�s suggestions for ways to create materials that accompany the forms that clinicians can use during their discussions with patients in ways that amplify and reinforce the training. Unlike a living will � MOLST will be completed based on the person�s current medical condition and will be effective immediately. It is not theoretical and its effectiveness is not dependent on loss of capacity

12. Features of MOLST in MA Form translates a person�s specific preferences for resuscitation, intubation and mechanical ventilation and hospitalization into: Actionable medical orders Based on the person�s current medical condition Effective immediately once signed and Honored by clinicians across treatment settings Use of the MOLST form does not depend on loss of decision-making capacity 12

13. Features of MOLST in MA (continued) Expands the scope and application of the CC/DNR verification protocol Assures that patients� preferences about other key interventions are documented and transmitted Periodic reviews/updates of the form are recommended Use of original form is encouraged, but copies are permitted 13 Expands the scope and application of the current CC/DNR form by covering more treatment options and applying in more treatment settings. We plan to devote the front page of the form to emergency issues of resuscitation, artificial ventilation and hospitalization. The EMTs won�t need to look beyond the first page. We rejected the bundling approach to types of treatment and instead focus on several key interventions that represent escalations in treatment. We couldn�t (and don�t want to ) address every possible intervention. We do want to distinguish between a willingness to try an intervention on a short-term basis and a willingness, for example, to live on a ventilator, indefinitely. Of course, what is considered short term will vary based on the situation. We want a form that can reflect whether there has been a discussion and whether the patient is undecided. The thought is that future conversations may be easier and more effective if the receiving clinician has some idea of where the patient left off. We understand that it is good practice to review forms when there are changes in condition or location but conclude that it is counterproductive to set a fixed date for a regular review and invalidate any form that has not been reviewed within that time frame. We know that limiting use to original forms was unsuccessful when required as part of the Comfort Care/Do Not Resuscitate verification protocol and that they changed to allow copies. Obviously some logistics to work out. We don�t expect to impose a mandatory review or expiration date. Expands the scope and application of the current CC/DNR form by covering more treatment options and applying in more treatment settings. We plan to devote the front page of the form to emergency issues of resuscitation, artificial ventilation and hospitalization. The EMTs won�t need to look beyond the first page. We rejected the bundling approach to types of treatment and instead focus on several key interventions that represent escalations in treatment. We couldn�t (and don�t want to ) address every possible intervention. We do want to distinguish between a willingness to try an intervention on a short-term basis and a willingness, for example, to live on a ventilator, indefinitely. Of course, what is considered short term will vary based on the situation. We want a form that can reflect whether there has been a discussion and whether the patient is undecided. The thought is that future conversations may be easier and more effective if the receiving clinician has some idea of where the patient left off. We understand that it is good practice to review forms when there are changes in condition or location but conclude that it is counterproductive to set a fixed date for a regular review and invalidate any form that has not been reviewed within that time frame. We know that limiting use to original forms was unsuccessful when required as part of the Comfort Care/Do Not Resuscitate verification protocol and that they changed to allow copies. Obviously some logistics to work out. We don�t expect to impose a mandatory review or expiration date.

14. Does MOLST eliminate the need to appoint a health care agent? NO Every MA resident over the age of 18 should: Sign a health care proxy form to appoint their health care agent Have conversations with their appointed agent about their preferences, should they lose capacity to make and communicate their own health care decisions 14 MOLST is an additional tool intended to promote conversations and expand the advance care planning options available to patients and families It does not change the recommendation that every MA resident over the age of 18 sign a health care proxy appointing a health care agent and follow-up with conversations with their appointed agent about their preferences if they can no longer make and communicate their own health care decisions. MOLST is a further step for a subset of the population.MOLST is an additional tool intended to promote conversations and expand the advance care planning options available to patients and families It does not change the recommendation that every MA resident over the age of 18 sign a health care proxy appointing a health care agent and follow-up with conversations with their appointed agent about their preferences if they can no longer make and communicate their own health care decisions. MOLST is a further step for a subset of the population.

15. Conclusion The current draft of the MOLST form has been approved for the demonstration program, but ongoing comments are welcome The final MOLST form will be based on extensive input from people with a wide variety of experiences and perspectives The Massachusetts MOLST form is tailored to our environment and needs in Massachusetts� Yet still conforms to the basis of the POLST Paradigm and can be recognized as �of a kind� with POLST/MOLST forms in other states 15 Let me turn the program over to Jena Adams, the MOLST Project Director. She�s going to talk with you about the planning that is being done with respect to evaluation of the MOLST project and also the commitment that Commonwealth Medicine is making to end-of-life care and to making sure there is a permanent home for MOLSTLet me turn the program over to Jena Adams, the MOLST Project Director. She�s going to talk with you about the planning that is being done with respect to evaluation of the MOLST project and also the commitment that Commonwealth Medicine is making to end-of-life care and to making sure there is a permanent home for MOLST