by Patricia A. Bomba, MD, MACP & Michael Paulsen, Esq.

Senator Kemp Hannon has introduced a new bill (S7713) that would address a key concern with legislation that enables nurse practitioners (NPs) to execute medical orders not to resuscitate and other orders pertaining to withholding and/or withdrawing life-sustaining treatment, which goes into effect on May 28, 2018 (“NP DNR Bill”). Despite the overall support of the NP DNR Bill, many physicians, NPs, nursing homes and health systems were concerned that the legislation did not align the new role of NPs with existing laws governing health care proxies (HCPs), and, as a result, would not extend the authority of NPs to perform capacity determinations and execute DNR and other medical orders for individuals who have designated a HCP.

The new bill directly addresses this concern and would align existing HCP laws with the NP DNR Bill. The bill would authorize NPs making determinations of capacity for purposes of executing or implementing a HCP, issue orders not to resuscitate, and issue other orders pertaining to withholding and/or withdrawing life-sustaining treatment and provide appropriate notification of the capacity determination, as well as recovery and documentation of capacity. Importantly, the bill would take effect on the same date as the NP DNR Bill, which will limit both practitioner and patient confusion regarding the new role of NPs regarding medical orders like DNR and MOLST.

In order to determine capacity for a patient with developmental disabilities, the NP must: (a) be employed by a DDSO; or (b) have been employed for at least 2 years in a facility or program operated, licensed or authorized by OPWDD; or (c) have been approved by the commissioner of OPWDD as either possessing specialized training or have 3 years experience in providing services to individuals with DD. This aligns with current SCPA 1750-b that either the attending physician or the concurring physician or licensed psychologist must meet these requirements.

Similar to the attending physician, if an attending nurse practitioner of a patient in a general hospital or mental hygiene facility determines that a patient lacks capacity because of mental illness, the attending physician or attending nurse practitioner who makes the determination must be, or must consult, with a qualified psychiatrist or qualified psychiatric NP.

Increasingly, NPs are the primary care provider of choice for many New Yorkers, often serving as the attending health care provider for patients in long-term care, rural and urban areas of the state. We commend Senator Hannon for working to ensure that more New Yorkers will benefit from conversations between patients and their NPs regarding advance directives and thoughtful MOLST discussions.

Dr. Kim Petrone, a physician at St. Ann’s Community in Rochester, NY, shares her perspectives on the advantages of eMOLST. St. Ann’s Community was the first nursing home in the state to implement eMOLST at a time when the nursing home still had paper medical records. eMOLST is now fully integrated into their EMR. Dr. Pettrone shares, “eMOLST is easy to use, prevents medical errors and helps providers understand the ethical and legal requirements for withholding and withdrawing life-sustaining treatment. The law is structured to make sure decisions are person-centered.”

eMOLST improves quality, patient safety and legal outcomes. By ensuring 100% accuracy of MOLST orders, EMS and other clinicians can ensure patient preferences for care and treatment are followed in an emergency. Users recognize the value of accessibility to the MOLST orders and documentation of the discussion and ethical legal requirements for MOLST discussions. Based on a real patient case, access to eMOLST in the ER avoided transport from a critical access to a university hospital and unwanted intubation and mechanical ventilation. An eMOLST cost avoidance study affirmed the value equation.

by Patricia A. Bomba, MD, MACP

It was a pleasure joining with colleagues Meredith A. MacKenzie, PhD, RN, CRNP, CNE, Esther Smith-Howell, PhD, RN, and Salimah H. Meghani, PhD, MBE, RN, FAAN to conduct a systematic review and evaluate the published literature on the outcomes of the Respecting Choices and derivative models. In this review, we utilizing criteria developed by the Cochrane Collaborative. The article, Respecting Choices and Related Models of Advance Care Planning: A Systematic Review of Published Evidence was published in the American Journal of Hospice and Palliative Medicine.

Respecting Choices is a well-known model of advance care planning that aims to assist individuals consider, choose, and communicate their personal preferences to health-care providers.

Eighteen articles from 16 studies were included, of which 9 were randomized controlled trials, 6 were observational, and 1 was a pre–posttest study. Only 2 specifically included a minority population (African American). Fourteen were conducted in the United States, primarily in the Wisconsin/Minnesota region (n = 8). Seven studies examined the Respecting Choices model, whereas 9 examined derivative models. There was significant heterogeneity of outcomes examined.

We found that there is a low level of evidence that Respecting Choices and derivative models increase the incidence and prevalence of Advance Directive and Physician Orders for Life-Sustaining Treatment (POLST) completion. There is a high level of evidence that Respecting Choices and derivative models increase patient–surrogate congruence in Caucasian populations. The evidence is mixed, inconclusive, and too poor in quality to determine whether Respecting Choices and derivative models change the consistency of treatment with wishes and overall health-care utilization at the EOL. Based on our review, we urge further studies, particularly with minority populations and focused on preference-congruent treatment and health-care utilization outcomes.

Similar studies should be conducted on other models of advance care planning that focus on the population health approach recommended by the 2014 IOM report, Dying in America. Review of the evidence showed living wills do not work, because it is simply not possible for people to anticipate their future decisions about life-sustaining treatment with any degree of accuracy. Rather, it is recommended that:

• All individuals 18 years of age and older should focus on discussion of values, beliefs and goals for care and identification of the legally designated health care agent.

• Seriously ill people appropriate for medical orders should be offered the opportunity to have a thoughtful discussion and complete a POLST Paradigm form – in New York, the MOLST.