Maryland's Medical Orders for Life-Sustaining Treatment Form Use: Reports of a Statewide Survey

Abstract

Abstract

Background:

Advance directives (ADs) and Physicians Orders for Life-Sustaining Treatment (POLST) orders perform different but complementary functions in documenting a patient's treatment preferences and translating them into actionable orders that change in keeping with the patient's evolving clinical picture. Maryland's Medical Orders for Life-Sustaining Treatment (MOLST) form developed through a stakeholder-driven process that deviates from other POLST forms. While a patient or surrogate can decline discussing MOLST orders with a clinician, clinicians must write MOLST orders for certain patients (e.g., those admitted to a nursing home (NH), assisted living facility (ALF), hospice, home health (HH) agency, or dialysis center, discharged from a hospital to any of these facilities, or transferred between hospitals).

Objective:

To gather data on Maryland MOLST form use to evaluate performance and inform future research and practice.

Design:

Chart reviews (CRs).

Setting/Subjects:

MOLST forms and patient data collected from Maryland hospitals (adult nonpsych, nontrauma, nonobstetric patients), NHs, ALFs, hospices, HH agencies, and dialysis centers.

Measurements:

Facility demographic tool and CR tools.

Results:

A total of 1959 CRs were received from 137 facilities, including 2064 MOLST forms. Most patients required to have MOLST orders had them (84%); fewer had ADs (47%). Few patients or surrogates declined discussing MOLST orders (1%). Few MOLST orders were written based on medical ineffectiveness criteria defined in Maryland law (<1%). MOLST form completion error rates ranged from 1% to 3%. Non-white patients were about twice as likely to have a MOLST “Attempt CPR” order (62%) as white patients (32%).

Conclusions:

MOLST error rates are relatively low and consistent with other research. Areas for improvement include selecting one order option where required, avoiding contradictions between Page 1 and 2 orders, offering MOLST Page 2 options if relevant, and documenting in the medical record a summary of the discussion informing MOLST orders.