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MOLST Implementation

MOLST Implementation. Jack Schwartz, Esquire Damien Doyle, MD, CMD, FAAFP Marian Grant, DNP, RN, CRNP, ACHPN Tricia Tomsko Nay, MD, CMD, CHCQM, FAAFP, FAIHQ, FAAHPM. Case #1. 38-year-man who injured his knee. Being discharged from the hospital to rehab. Healthy, no medications.

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MOLST Implementation

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  1. MOLST Implementation Jack Schwartz, Esquire Damien Doyle, MD, CMD, FAAFP Marian Grant, DNP, RN, CRNP, ACHPN Tricia Tomsko Nay, MD, CMD, CHCQM, FAAFP, FAIHQ, FAAHPM

  2. Case #1 • 38-year-man who injured his knee. • Being discharged from the hospital to rehab. • Healthy, no medications. • On discharge, the doctor asks about his code status.

  3. Case #1: Take Home Message • Discuss code status and other relevant issues from page two of the Maryland MOLST form.

  4. Case #2 • 68-year-old woman who visits her physician’s office for a leg wound. • PHM: Diabetes, hypertension, and peripheral vascular disease. • Doctor orders home health. • No Maryland MOLST form on file.

  5. Case #2 • Doctor brings up CPR, but patient cuts him off and says, “Don’t speak of such things.” • Doctor rephrases question, but she says, “I understand what the form is for, but I will not talk about these things.” • Doctor respects her right to decline to discuss the topic.

  6. Case #2 • Doctor explains that when no limitations are put on CPR and other life-sustaining treatments, that she will receive medically indicated treatments in most circumstances.

  7. Case #2: Take Home Message • Respect a patient or authorized decision maker’s right to decline to discuss an issue. • Whenever possible, inform the patient or ADM that not making a decision generally means that all medically indicated interventions will be done.

  8. Case #3 • 75-year-old woman who fell at home >>> hip fracture >>> ORIF >>> transferring to a nursing home for rehab. • Planning to return home. • Makes her own decisions. • Nurse practitioner at nursing home realizes there is no Maryland MOLST form from the hospital.

  9. Case #3 • If my heart stops of I stop breathing, “Do everything that you can.” • Use a ventilator if it is needed at any time. • I hated the hospital. Never send me back to a hospital. • I want medical tests to be done if needed. • I want any kinds of antibiotics that are recommended.

  10. Case #3: Take Home Message • Clarify general statements. • Address conflicting wishes immediately.

  11. Case #3 • During rehab, the patient has a stroke with right sided hemiplegia. • Now plans to stay in nursing home for long-term care. • Physician readdresses code status and life-sustaining treatments.

  12. Case #3 • If my heart stops or I stop breathing, “Allow God to take me.” • Never use a machine to treat me or keep me alive. • I only want to go to the hospital if I have severe pain or symptoms you can’t treat in the nursing home. • I only want medical tests if needed for symptomatic treatment or comfort.

  13. Case #3 • I want antibiotics I can take by mouth if I am in pain from an infection. • I never want any artificially administered fluids or nutrition, even for a short trial.

  14. Case #3: Take Home Message • Clarify general statements. • Reassess the goals of care when there is a change in condition. • A patient has the right to change his or her mind.

  15. Case #4 • 100-year-old man with end-stage dementia who lives with his daughter and son-in-law. • 24-hour private duty caregivers. • Being admitted to hospice.

  16. Case #4 • No Maryland MOLST form. • Two certs of incapacity. • Two certs of end-stage condition.

  17. Case #4 • Advance directive: If I am in an end-stage condition, do not resuscitate me . . . Do not give me any artificial feeding or hydration, including tube feedings. • His daughter is his health care agent.

  18. Case #4 • Daughter says he is a DNR-B and wants to begin artificial feeding and hydration. • She says that nine years ago, her father meant if he was going to die in a day or two, not to feed him artificially. • The hospice nurse thinks he will live for a few months.

  19. Case #4: Take Home Message • Honor the patient’s known wishes. • The health care agent cannot override the patient’s advance directive. • The Health Care Decisions Act affords the practitioner immunity for good faith efforts to comply with the act.

  20. For More Information marylandmolst.org MarylandMOLST@dhmh.state.md.us

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