Note: MOLST forms are specific to New York. Other states have slightly different forms,
though essentially have the same goals.
As part of the workup for our patients, especially those who are critically ill, it’s our responsibility as providers to ask about and respect their treatment goals. Sometimes, it’s a non-issue at the time, for example, a 60 year old being admitted for a moderate COPD exacerbation who is responding well to treatments but just isn’t quite ready to go home yet. But what if their COPD is compounded by multiple significant comorbidities, and they’re getting close to a trial of BiPAP?
Sometimes initiating the goals of care discussion can be very intimidating.
‘Are they going to think that we’ve given up on them?’
‘Are we jinxing them by asking about what they would want?’
‘What if I don’t know what their overall course will be?’
‘I don’t really know how to talk to them without making them upset…’
But let’s face it, the onus is on us to be our patient’s advocates. We need to know what they want and it’s important to take it a step further and document the conversation. Fortunately for us, the documentation part is relatively straight forward- just follow along with the MOLST form.
The MOLST Form (Medical Orders for Life Sustaining Treatment), is a form developed to make a patient’s wishes crystal clear. It’s valid both in hospital and out-of-hospital (which is super important….. in hospital DNR’s aren’t valid in the out-of-hospital environment, so EMS providers can’t honor them without contacting Medical Control for approval). It never expires, doesn’t need to be notarized, and classically is printed on fairly obnoxious pink paper to make it stand out in a chart or taped to someone’s refrigerator. The MOLST form can be adjusted over time- there’s two whole pages at the end that allow modifications to be made without having to fill out a new one. Best yet, it can be filled out in sections. For example, it’s possible that just the “Do not resuscitate” portion is filled out. You could also fill out the “Do not intubate” portion as well. For those patients who have expressed additional wishes, there are sections for what they prefer when it comes to feeding tubes, intravenous fluids, antibiotics, etc. There’s even a section that they can write in absolute specifics, for example they don’t want to go on dialysis.
Let’s go back to our COPD patient with lots of comorbidities, who is getting closer to BiPAP.
Maybe you want to start the conversation off with a quick recap of what has been done so far, and what the immediate next steps are. Perhaps then you transition by saying, “I’m not sure that we’re there yet, or that we’re ever going to get there, but I think we should talk about what you would want if you suddenly got really sick. Sometimes medical conditions change very quickly, and I would rather have this conversation when we have time and everyone is calm.” Maybe next you want to acknowledge the elephant in the room with, “These are really serious questions than can seem scary, but I want to make sure that if something changes, we respect your wishes.”
Depending upon what the clinical situation is, maybe now you transition into the DNR/DNI talk. My personal phrase tends to be, “If your heart were to stop beating, would you want us to attempt to resuscitate you, or would you want us to allow a natural death to occur?” Notice the word “attempt”. I think we do our patients a disservice when we present it as this idea that if you pick option A, we’re definitely going to get you back when this is not necessarily the case. Think about the medical dramas on TV… How often do the TV characters miraculously recover from a cardiac arrest? Way, way more often than reality. And for our patients and their families, that’s probably the only frame of reference that they have. Most of the general public has no idea what goes on when we code a patient…. The chest compressions, intubation, central lines….. whatever else. Part of these goals of care discussions involve us making sure our patients are making an informed decision, which likely isn’t in line with what they picture due to TV and movie portrayal.
After the DNR part, next often comes the DNI follow up. Again, depending on the situation, maybe we need to follow that part up with what the treatment plan is going to be from here. Perhaps you decide to present it as three paths. In Path A, we aggressively treat your medical condition, which likely involves procedures that could cause pain and limit your ability to communicate with your family. In Path B, we shift our focus to aggressively treating your symptoms and making you comfortable. In Path C, we continue what we’re doing now, but don’t escalate care. The conversation can go lots of ways but that’s a general framework you can use to figure out how to present huge decisions to your patients and their families. (It also goes along quite nicely with the Treatment Guidelines section of the MOLST form.)
Notice, the comfort care option isn’t phrased as “we either can do everything to try and save you, or do nothing.” In my opinion, that’s not really a fair thing to say to a patient. By not doing central lines, starting pressors, intubating, and whatever else…. It’s not that we’re giving up; we’re changing our focus to making sure whatever time the patient has left has the very best quality. We may also need to mention that we can’t predict exactly when death will occur if the comfort care option is selected- sometimes it’s minutes, days, or weeks away.
So now that we have a better idea of what the patient wants, I generally say, “I want to make sure that when I’m not your doctor anymore, I can still protect your wishes. To do that, there’s a form that we can fill out together, that makes all these things very clear in case something happens suddenly.” I also reiterate that the decisions aren’t set in stone, and can be adjusted if there is a change in clinical course.
In comes the MOLST form. To complete it, you need to be a licensed provider, so generally this involves an attending signing the form in two places. As a resident, you can act as one of the two witnesses- I generally try and have a family member act as at least one witness. A bit of an oddity to the form is that witnesses only write their names- no signatures are needed.
Once the form is completed and signed, I make a copy of it for the patient or their family, placing the original pink version in the chart. I also educate the patient and their family that when the patient leaves the hospital, the original pink copy always travels with them- it’s their safety blanket of sorts, and should be in a very obvious, well known location at home (I actually responded to a cardiac arrest as a paramedic and arrived to find a patient in bed with their MOLST form taped to the wall above their bed…. A job well done in my book).
The MOLST form, in all reality, should only take 5-10 minutes to complete, once the goals of care discussion has been done. Realistically, it often takes more time for someone to figure out their license number than to actually fill out the form. Most patients and their families really appreciate that their voices are being heard and advocated for, and your medicine colleagues will likely very much appreciate your attention to detail when you admit the patient. Most importantly, you’ve just given the patient a way to have their wishes protected not only during their hospital stay, but also if/when they go home.
Still have questions about goals of care discussions? I highly recommend a really fantastic article that recently came out in Annals of Emergency Medicine, which was written by a resident. Check it out at:
Wang DH. “Beyond Code Status: Palliative Care Begins in the Emergency Department.” Annals of Emergency Medicine 2017;69(4):437-443. PMID:28131488
Lauren Maloney is a third year resident and the Administrative Chief at Stony Brook.
@medic2erdoc