Abstract
Objectives
What patients intend when they make health care choices and whether they understand
the meaning of orders for life-sustaining treatment forms is not well understood.
The purpose of this study was to analyze the directives from a sample of emergency
department (ED) patients' MOLST forms.
Procedures
MOLST forms that accompanied 100 patients who were transported to an ED were collected
and their contents analyzed. Data categories included age, gender, if the patient
completed the form for themselves, medical orders for life-sustaining treatment including
intubation, ventilation, artificial nutrition, artificial fluids or other treatment,
and wishes for future hospitalization or transfer. Frequencies of variables were calculated
and the associations between them were determined using chi-square. An a priori list
of combinations of medical orders that were contradictory was developed. Contradictions
with Orders for CPR (cardiopulmonary resuscitation) included the choice of one or
more of the following: Comfort care; Limited intervention; Do Not Intubate; No rehospitalization;
No IV (intravenous) fluids; and No antibiotics. Contradictions with DNR orders included
the choice of one or more of the following: Intubation; No limitation on interventions.
Contradictions with orders for Comfort Care were as follows: Send to the hospital;
Trial period of IV fluids; Antibiotics. The frequencies of coexisting but contradictory
medical orders were calculated using crosstabs. Free text responses to the “other
instructions” section were submitted to content analysis.
Results
Sixty-nine percent of forms reviewed had at least one section left blank. Inconsistencies
were found in patient wishes among a subset (14%) of patients, wherein their desire
for “comfort measures only” seemed contradicted by a desire to be sent to the hospital,
receive IV fluids, and/or receive antibiotics.
Conclusions
Patients and proxies may believe that making choices and documenting some, but not
all, of their wishes on the MOLST form is sufficient for directing their end-of-life
care. The result of making some, but not all, choices may result in patients receiving
undesired, extraordinary, or invasive care.
Keywords
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Article info
Publication history
Published online: September 27, 2016
Footnotes
The authors declare no conflicts of interest.
Identification
Copyright
© 2016 AMDA - The Society for Post-Acute and Long-Term Care Medicine.
ScienceDirect
Access this article on ScienceDirectLinked Article
- Response to Clemency et al: Significant Errors, Gaps in MOLST Process, and Opportunities for Improvement With eMOLSTJournal of the American Medical Directors AssociationVol. 18Issue 2
- PreviewWe appreciate the interest of Clemency et al and JAMDA in both the National Physician Orders for Life-Sustaining Treatment (POLST) Paradigm and New York's Medical Orders for Life-Sustaining Treatment (MOLST) Program. As we lead the MOLST Program in New York State, we recognize the challenges with paper completion of both the New York MOLST form and POLST Paradigm forms in other states. We also appreciate the authors' attempts to document errors in MOLST completion. Accurate documentation of the errors frequently found in paper completion of New York MOLST forms or POLST Paradigm forms reinforces the need for a standardized approach to end-of-life discussion.
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