Medical Orders for Life Sustaining Treatment MOLST: State of the Nation and of Ohio

1. Medical Orders for Life Sustaining Treatment (MOLST):State of the Nation and of Ohio Doug Cluxton, MA, LPC V.P., Education Midwest Center for Home, Hospice & Palliative Care Education

3. Four Commons Expressions �No Heroics� �Don�t keep me alive if I am a vegetable� �Don�t keep me alive on machines� �If I am terminal, let me go�

4. Ohio's Two -Tiered DNR DNR- Comfort Care DNR- Comfort Care Arrest

5. Do Not Resuscitate � DNR in Ohio A source of confusion Improvements sought DNR Task Force formed 6/05

6. With DNR-CC, CPR (and any �component of CPR�) are withheld from the point of the order being written. With DNR-CC Arrest, if a �component of CPR� has been initiated as a part of medical treatment, it is withdrawn at the point of arrest. One way to think about the difference between DNR-CC and DNR-CC Arrest is by considering each from the standpoint of �withholding� compared with �withdrawing.� Remember that the patient with a DNR- CC Arrest can and likely will receive very aggressive treatment.One way to think about the difference between DNR-CC and DNR-CC Arrest is by considering each from the standpoint of �withholding� compared with �withdrawing.� Remember that the patient with a DNR- CC Arrest can and likely will receive very aggressive treatment.

7. It is important that the official state form not have alterations on it as this may affect immunity provisions and first-responders� compliance with the order. Must be accurately completed Name of signer must be printed also so contact is facilitatedIt is important that the official state form not have alterations on it as this may affect immunity provisions and first-responders� compliance with the order. Must be accurately completed Name of signer must be printed also so contact is facilitated

8. Case example Betty, resident in nursing facility, wants good medical management but does not want to �be shocked or put on one of those breathing machines.� Elects DNR-CC �Arrest Becomes ill with pneumonia

9. Case example, cont�d. Worsens>> Emergency Med Squad called Breathing begins to fail Betty is intubated and placed on ventilator Transported to Emerg. Dept. Family upset that �those heroic measures were done against her will!�

10. Case illustrates� Lack of understanding that DNR-CC Arrest can be intubated and have �heroics� until breathing or pulse stops EMS acted correctly per the current DNR- CC protocol but Betty�s wishes were not carried out What is needed to improve this picture???

11. Purpose of POLST To provide a mechanism to communicate patients� preferences for end-of-life treatment across treatment settings To improve implementation of advance care planning 11

14. In Ohio��MOLST Medical Orders for Life Sustaining Treatment Reflects that MDs and others would be able to write MOLST orders (PAs, APNs) Converts patient preferences into actionable medical orders Intended primarily for frail elders, residents of LTC, seriously ill, chronically ill

15. Highlights of Proposed Bill Creates MOLST Advisory Council to develop form & rules under ODH administration Permits physician, physician assistant, or advanced practice nurse to complete orders Specifies various sections to be included on form MOLST is voluntary Affords immunity to healthcare workers and portability across sites of care

16. Current Status of MOLST(as of Sept. 3, 2009) Previous bill, HB 601, introduced by sponsor, Rep. Lynn Wachtmann in late July, 2008 Had bipartisan support Series of hearings in November Amendments by Ohio Right to Life Bill �died� in House Health Committee

17. Current Status of MOLST(as of Sept. 3, 2009) Current bill, HB 241, sponsored by Rep. Nancy Garland, (D) 20th District Has been introduced in Health Committee Next Steps: Hearings will be scheduled Amendments? Moves to full House Will need bill in Senate

18. The Ask: To show your support of seriously ill Ohioans by cosponsoring MOLST legislation that would enable them to better articulate their healthcare wishes.

19. Back it up� Less than 50 percent of severely or terminally ill patients studied had an advance directive in their chart; of those with an advance directive, only 12 % had received input from physician (AHRQ, 2003) Currently, leading predictors of location of patient�s death are availability of open hospital beds and local physician practice habits, rather than patient choice (Last Acts, 2002;Dartmouth Atlas 2008) 70 percent of Americans wish to die at home; 24.9 realize this (Last Acts, 2002) Aggressive care results in worse patient quality of life, (JAMA, 2008)

20. Give a solution� When given full information about treatment options, patients typically choose the lowest-cost, least invasive treatment option End of life discussions lower rates of ventilation, resuscitation, ICU admission and are associated with early hospice admission and longer hospice stays are associated with higher patient quality of life; higher patient quality of life is associated with better caregiver bereavement adjustment (JAMA, 2008)

21. Ohio Hospice & Palliative Care Org. 555 Metro Place North, Suite 650 Dublin, Ohio 43017 1-800-776-9513 / 1-614-763-0036 1-614-763-0050 FAX info@ohpco.org www.ohpco.org doug@ohpco.org