Updates to the NYSDOH MOLST Form
The NYSDOH posted a revised MOLST form on 12/31/18. The revised MOLST form complies with changes in New York State Public Health Law (NYSPHL) with regards to the Authority of Nurse Practitioners. Please Note: the changes in NYSPHL do not amend the Surrogate Court Procedures Act (SCPA) 1750-b, which relates to individuals with developmental disabilities who lack the capacity to make their own health care decisions and do not have a health care proxy.

The revised MOLST form does not include suggested clinical edits gathered from to physicians, nurse practitioners, EMS and others who use the MOLST every day. Per NYSDOH, “we are working on the comments that we got from the RFI and are open to additional changes if all can agree.” Additional changes will result in another revised MOLST form estimated to be released in late 2019.

Given our limited budget and human resources, we will not be printing these “interim” MOLST forms at this time. In the meantime, we encourage you and your organizations to implement eMOLST in your setting and encourage use in the communities you serve. While you’re working on eMOLST implementation, you can print the MOLST form on pulsar pink paper.

While we will not be printing the interim MOLST form until the clinical changes are incorporated, we will be updating the Community Conversations on Compassionate Care Advance Care Planning Booklets to align with the changes in public health law that have occurred over the past year. Read more about the updates to the ACP Booklet and expected arrival in the FAQ.

Updates to NYS Public Health Law Affecting MOLST Discussions
Separately, on Sunday, February 3, 2019, Health Care Proxy Law was updated to include nurse practitioners in the process for determining capacity for patients who lack capacity and have a health care proxy with their health care agent making end-of-life decisions for them (this pathway is known as Checklist 2). Nurse practitioners can now determine both attending and concurring capacity for the general population of patients on Checklist 2. eMOLST was also updated accordingly at midnight on Sunday.

As the authority of NPs is further expanded, please remember that there are still special populations with different rules for concurring capacity determination on this pathway, including individuals who lack capacity due to mental illness (which requires a psychiatrist for concurring capacity) and individuals who lack capacity due to a developmental disability (which requires a physician or clinical psychologist with special training in DD).

If there are questions about the authority of NPs, please refer to our Featured Resource, the MOLST.org web page and table on this topic.

Lastly, MOLST is more than a form. Having a thoughtful MOLST discussion that ensures shared medical decision-making occurs is best done using a standardized approach. The 8-Step MOLST Protocol was developed in 2005 to help physicians, nurse practitioners, physician assistants and others who are engaged in end-of-life discussions use a systematic approach to these conversations.

The web page and reference table have been revised to reflect changes regarding NP’s authority to perform capacity determination and sign MOLST forms, as of 5/28/18 and 2/3/19.

The first table at the bottom of the web page clarifies current NYSPHL and the NP’s authority to do capacity and concurrent capacity determination and is accurate as of February 3, 2019. The second table clarifies current NYSPHL and the NP’s authority to participate in the MOLST process and sign MOLST orders. This table is accurate as of May 30, 2018. The 2018 amendments to the health care proxy law do not impact this table.

Special thanks to Robert Swidler, Esq., St. Peters Health Partners for creating the reference tables.

We are updating the Advance Care Planning Booklets to align with the changes in public health law that have occurred over the past year. We expect updated ACP Booklets will be available for ordering before National Healthcare Decisions Day (April 16).

To learn more about National Healthcare Decisions Day and the role we play in New York State, please consider joining the NHDD NYS Coalition. More details about the Coalition can be found here. Please email Meg.Greco@Excellus.com to be added to the NHDD NYS Coalition distribution list.

By Meg Greco, MPA
Geriatrics & Palliative Care Coordinator; ECHO MOLST Coordinator

The rumors are true! Coming off the heels of a successful run in Fall 2018, ECHO MOLST will be returning for another clinic series beginning March 7, 2019. Just like last time, 1-hour clinics will be held for 8 weeks on Thursdays at noon, skipping Thursday 4/4. Interested in getting in on the action? Email me at Meg.Greco@Excellus.com

What is Project ECHO? ECHO, which stands for Extension for Community Healthcare Outcomes, is an all-teach-all-learn telementoring model that uses case-based learning. Specialists at a “Hub” meet regularly with physicians, nurse practitioners and other clinicians at “Spokes” via videoconferencing to support in the delivery of specialty care services. To learn more about ECHO and its history, watch this short video by Project ECHO’s founder, Dr. Arora.

So how does this apply to MOLST? The aims of ECHO MOLST are to provide sustainable MOLST education and to improve the quality of thoughtful MOLST discussions and documentation to ensure patient preferences are honored. Our 1-hour video conferencing clinics begin with brief introductions and a short 15-minute didactic presented by subject matter expert Dr. Patricia Bomba. This is followed by a 35-40 minute real patient case presentation given by a spoke using a standard presentation form, Q&A and discussion. At the end of the clinic series, attendees will learn to identify MOLST-appropriate patients, utilize the 8-Step MOLST Protocol and NYSDOH Checklists to ensure accurate completion, and increase their comfort level with end-of-life conversations. Additionally, we offer free CME credits to attendees! Each ECHO MOLST clinic has been approved for 1.0 AMA PRA Category 1 Credit™. For more information on ECHO MOLST, including objectives and who should attend, view the flyer and web page.

I bet right now you’re thinking, “this is all too good to be true,” but we’ve got the numbers to prove that ECHO works! Data collected using a pre-test post-test method in Fall 2018 showed increases in overall MOLST knowledge. Before the clinic series, only 34% of respondents could correctly identify that MOLST is not an advance directive; after the clinic series, that number jumped to 72%. Similarly, we saw increases in respondents’ ability to recognize incompatible medical orders, and an increased familiarity with and use of the 8-Step MOLST Protocol. Respondents also recognized the importance of their own advance care planning, as attendee HCP completion rose from 58% to 63%.

Don’t miss out on this unique educational opportunity! Space in the ECHO MOLST clinic series is limited and spoke reservations will be taken on a first-come-first-serve basis. Attendees from the Fall 2018 clinic series are encouraged to re-enroll and to recruit colleagues to join them at their organization’s spoke. These case-based sessions will provide fresh and different learning opportunities for veterans and newcomers alike! Ready to get started? Don’t wait! Email me today at Meg.Greco@Excellus.com.