As opposed to a health care directive, a medical order for life-sustaining treatment (MOLST) is a physician’s order that sets out a patient’s end of life treatment preferences. The MOLST order differs from a do not resuscitate order because it not only focuses on preventing resuscitation but also communicates affirmative orders as to all other possible interventions. The MOLST permits a patient, in consultation with medical personnel, to document his or her choices about the level of intervention they wish as they live out the final phase of their life.[1] The Maryland statute provides that the MOLST form shall be developed in consultation with the Office of the Attorney General and certain governmental agencies and physician groups. Nationally, a form was produced by the national POLST paradigm that evolved from the Oregon POLST task force. Oregon was the first state to implement a physician order for life sustaining treatment (“POLST”). Interestingly, the national POLST paradigm stresses the voluntary nature of these orders whereas the Maryland legislation mandates the completion of the MOLST form for each patient being admitted to a health care facility (assisted living program, home health agency services, hospice, hospital, kidney dialysis center, or a nursing home.) Maryland Code, Health-General § 5-608.1(c)(ii)(1).
The Maryland MOLST form specifies seven categories of treatment:
- CPR ( resuscitation) status – whether there should be resuscitation attempted in the event of cardiac and/or pulmonary arrest;
- whether artificial ventilation should be used and, if so, indefinitely or on a limited therapeutic trial;
- whether blood products can be given if medically indicated;
- if the patient permits transfer to a hospital and, if so, for only the limited purpose of treating severe pain or severe symptoms that cannot be controlled otherwise;
- whether medical tests to diagnose and/or treat a medical condition can be performed and, if so, whether there are limitations on those medical workups;
- whether antibiotics may be administered and, if so, for what purpose;
- whether artificially administered fluids and nutrition may be given and, if so, for what purpose; and
- whether dialysis may be given for end stage kidney disease and, if so, whether it should be for a limited time.
The order must be signed by a physician, nurse practitioner, or physician assistant and must indicate that the order was entered as a result of a discussion with and the informed consent of either the patient, the patient’s health care agent named in an advance directive, the patient’s guardian per a court order, the patient’s surrogate under the authority granted by the health care decisions act, or if the patient is a minor, the patient’s legal guardian. The MOLST also requires that information must be supplied whether the orders were based on advance directives or other legal authority.
Although the Maryland law requires that the MOLST be offered upon admission to a health care facility, it is, of course, always voluntary.
Obviously, the MOLST/POLST is appropriate as a tool for coordinating end of life care. As such, it is something that should be considered by a person at that stage of his or her life:
“The most frequently cited clinical standard for determining if a POLST form is appropriate for a patient is the “surprise” question. If a patient’s physician or other caregivers would not be surprised if the patient died within the next year, then that person should have a conversation, or a series of conversations, about end-of-life care and should consider completing a POLST form. It is important to note that this group is intended to include more than just those patients with an end stage medical condition or terminal condition. Persons who are of advanced age or considerably frailty, or both, may want to specify the level of care they prefer.
The POLST process allows each person to clarify their own goals regarding end-of-life care, given their current condition, and to receive guidance in translating those goals into medical orders addressing likely emergencies. For example, a very elderly patient who has requested a DNR order may choose to make it clear, through a POLST form, that except with regard to the DNR order, the patient prefers full intervention and treatment or, in other instances, more limited care. The POLST process increases the likelihood that each person will receive the desired care and not receive undesired care. It avoids the assumption that every person, regardless of frailty, wants aggressive treatment or, at the other extreme, that every person who appears to be in the final stages of life does not want any intervention at all.”[2]
[1] See Robert B. Wolf, Marilyn J. Maag, and Keith Bradoc Gallant, “The Physician Orders for Life Sustaining Treatment (POLST) Coming Soon to a Health Care Community Near You,” 40 ACTEC L.J. 57 (Spring 2014) for the origin and overview of these medical orders. Hereafter “Wolf, Maag & Gallant.”
[2] Wolf, Maag & Gallant, 40 ACTEC L.J. 64-65.
