Physician / Medical Orders for Life Sustaining Treatment

In many hospitals, hospices, home care and nursing homes respecting a patient's dying wishes during the last weeks, days, hours or minutes for continuation or discontinuing any further care is often not known to family members, doctors or medical professionals. Oregon Health Science University (OHSU) which provides palliative care (Patients who are terminally ill, seriously ill or chronically ill offered the best delivered care and relief of suffering by medication or other means. 1 The patient's primary doctor works in partnership with patient's attending nurses, social workers and other health providers in palliative care environment, relieve pain and related symptoms of serious or terminal illness. 3) developed standardized Physician (or Medical) Orders for Life-Sustaining Treatment (POLST or MOLST): Details a dying patient's wishes for receiving or declining to receive further health care to sustain life. 2

Physician Orders for Life-Sustaining Treatment (POLST) printed on a bright colored (pink) medical form, distinguishable from other medical forms. The form contains specific instructions regarding how the patient should be provided with any medical interventions, including antibiotics and feeding procedures or full treatment including resuscitation attempts, at the end of their life. 4 The POLST signed by the patient's physician confirming (verbal communication) doctor's patient desired wishes regarding life-sustaining treatment for the patient health care providers. 5 "No witnessing or notarizing is required." 16 Suggest the patient health care facility and patient's family informed of the patient's wishes, preventing any future conflict. 15 The POLST form is attached to the patient's medical records in a hospital and nursing home(s). Whenever the patient is transferred to another medical facility the POLST document is recognized. 5 State laws that adapted (passed legislation) or recognized Physician Orders of Life - Sustaining Treatment specify their own descriptive out-line of the form. "Some places also use a bracelet (patient wears) to identify that POST form has been signed." 2 According to legislation passed in New York State, Medical Orders for Life-Sustaining Treatment includes information regarding: Intubation and mechanical ventilation, CPR (cardiopulmonary resuscitation), future hospitalization & transfer, and antibiotic treatment The MOLST provides specific information to Emergency Medical Services (EMS) personnel's how to treat or reframe from providing medical assistance, including "Do not Resuscitate" according to the patient's wishes. 10

The Medical Orders for Life-Sustaining Treatment (MOLST) recommended for chronic sick patients and terminally ill patients. 6 "Some programs allow the form to be used for minors who have advanced serious or terminal illness. Generally, the parents are entrusted by law as the surrogate." POLST is not recommended for patients who have many years of life expectancy despite stable medical or functionally disabling health concerns. 7 Mentally retarded, developmental disable or persons with mental illness, who have capacity (Affirmed by the patient physician and concurrent physician according to New York State Law) to make their own decisions, do qualify to complete a Medical Orders for Life - Sustaining Treatment document. 6 Also, care takers or clinicians should not recommend POLST to patients if they ask themselves this question and answered the question with a 'yes': Would I be surprised if the person died in the next year? The answer is Yes, I would be surprised. If the opposite answer is given, then POLST form is appropriate. 7

The Medical Orders for Life -Sustaining Treatment (MOLST) form should be completed entirely. The validity of the document is ascertained by a physician signature or some states recognize the signature of a physician assistant or nurse. "Any section not completed implies full treatment for that section". Section 'E' ('Other Instructions') under New York State Law regarding MOLST reference to starting / stopping treatment, not referenced to any other section: For Example 'Section E' regards ".... decisions about dialysis, implant able defibrillators, and the duration of time - limited trials". 7 According to New York State and Federal law the MOLST form should be reviewed and updated periodically by a physician, especially when a patient health improves or deteriorates, and the patient / resident treatment preference change. When the patient's care facility changes the MOLST document may need to be updated. Also, the MOLST form needs to reviewed or renewed specifically after certain number of days, when patients are staying in hospital, nursing home and non-hospital / community setting. 19

Many States are recognizing the merits and passing legislation regarding Physician Orders for Life Sustaining Treatment. In July 2008, New York Governor David Paterson signed into law through - out the state Medical Order's for Life - Sustaining Treatment. 10 In New York State MOLST form is available from participating health care facilities. The Medical Orders for Life-Sustaining Treatment does not replace Health Care Proxy (According to New York State Law refers to usually a family member to make health care decisions, if the patient is incapacitated to do so 8) and Living Will (A person who is incapacity gave prior instructions regarding a course of treatment or forbidding treatment, including food and water. 9) traditional Advance Directives. 7 Forms of MOLST is available in most doctors' offices. 10 Since November 2007, fifteen states have passed legislation regarding Medical Orders for Life-Sustaining Treatment.11 In the State of Oregon over one million POLST forms have been distributed. 13 During 2008 POLST program was initiated in seven California communities: Alameda, Humboldt, Mendocino, Riverside, Santa Clara, Ventura and Yolo counties. Expected other communities in California will adopt the same practice. 17 In July 2008, California State Assembly passed legislation enabling patients who have terminal illness (a year or less life expectancy), made available Life Sustaining Treatment process. The legislative bill is awaiting California Governor Arnold Schwarzenegger signature for state approval. 18 States that have passed MOLST legislation, printed forms are available: http://www.ohsu.edu/ethics/polst/programs/sample-forms.htm

Physician Orders for Life-Sustaining Treatment effective in limiting unwanted treatment according to 1998 study by the Center of Ethics in Health Care of Oregon (one of the many states approved POLST) 12 The Physician Orders for Life-Sustaining Treatment recommended by the National Quality Forum ("NATIONAL QUALITY FORUM ENDORSES CONSENSUS STANDARDS FOR QUALITY OF HOSPITAL CARE" 20), noting that: "Compared with other advance directive programs, POLST more accurately conveys end-of-life preferences and yields higher adherence by medical professionals." 14

References:

1.) What is Palliative Care? - http://www.soros.org/Staging/initiatives/pdia/articles_publications/publications/memo/whatis

2.) A Potential Better Way to Ensure End-of-Life Care through Improved Medical Orders (POLST) - http://www.cancersupportivecare.com/polst.html

3.) get Palliative care-org - http://www.getpalliativecare.org/home/

4.) POLST - http://www.ohsu.edu/ethics/polst/developing/faqs.htm

5.) Research: Study Shows Oregon's Physician Orders for Life-Sustaining Treatment

(POST) Document Prevents Unwanted Interventions - http://www.abcd-caring.org/exchange/99jan/oregon.htm

6.) What is Medical Orders for Life-Sustaining Treatment (MOLST)? - http://www.health.state.ny.us/professionals/patients/patient_rights/molst/frequently_asked_questions.htm

7.) Frequently Asked Questions - http://www.ohsu.edu/ethics/polst/developing/faqs.htm#13

8.) WHAT IS A HEALTH CARE PROXY? - http://www.oag.state.ny.us/health/care_proxy.html

9.) Advance health care directive - http://en.wikipedia.org/wiki/Living_will

10.) Patients can now make life and death decisions - http://rochesterhomepage.net/content/fulltext/?cid=21161

11.) End of Life Care - http://www.wbur.org/news/2007/72128_20071107.asp

12.) ABCD Exchange: January 1999: Research - Oregon's Physician Orders for Life-Sustaining Treatment Document - http://www.mywhatever.com/cifwriter/content/19/abcd625.html

13.) A Better Way Coalition - LIFE ON YOUR OWN TERMS - http://www.abetterwaycoalition.org/resources/best-practice-research.htm

14.) Special Article: The POLST Paradigm: Respecting the Wishes of Patients and Families - http://www.annalsoflongtermcare.com/article/7708

15.) Medical Orders for Life Sustaining Treatment Guidebook - http://www.compassionandsupport.org/pdfs/professionals/training/MOLST_Booklet%20.pdf

16.) Physician Orders for Life-Sustaining Treatment (POLST) - http://www.candcofwa.org/polst.html

17.) E-news: End-of-life care issues - http://www.sachealthdecisions.org/newsletters/eol_0801.html

18.) Wolk bill to put patients in charge of end-of-life care decisions sent to Governor -http://californiachronicle.com/articles/68476

19.) Medical Orders for Life-Sustaining Treatment (MOLST) Frequently Asked Questions (FAQs) - http://www.stronghealth.com/services/palliative/documents/MOLSTFAQsFINAL092706.pdf

20.) NQF - http://www.qualityforum.org/