By Patricia Bomba MD, MACP

My family has a Thanksgiving tradition dating back to 1992 that has nothing to do with food or football, but rather personal values and beliefs. It’s our annual family advance care planning discussion when we focus on what makes life worth living at this point in our lives. I encourage every family to embrace our Thanksgiving tradition. Our Thanksgiving and thoughtful MOLST discussions helped our family honor our mom’s wishes at the end of her life.

Advance care planning is a gift to yourself and your family. Choose the person you trust to make medical decisions if you lose the ability to make medical decisions and share your values, beliefs and what matters most with your family and loved ones.

Years ago my family started this tradition on Thanksgiving because it’s an American holiday that just about everyone celebrates, attracting family members from far and wide. While at first you might think it’s morbid to discuss such issues at a festive gathering, we’ve found sharing our wishes for end-of-life care actually brings us closer. We gain peace of mind knowing our own wishes will be understood and honored in the event we can’t speak for ourselves.

In our family, “No pumpkin pie, until you tell me how you want to live until you die.” After the dinner dishes are cleared, the adults in our family stay at the table and talk about what matters most in our lives. We review our advance directives to make sure they reflect our current feelings. We have blank forms handy in case new documents need to be completed and witnessed.

As a physician and health plan medical director with an expertise in geriatrics, palliative care and end-of-life issues, I’m especially passionate about advance care planning. I recommend that everyone 18 and older participate in these discussions and complete a Health Care Proxy. Everyone should share copies with their physician, lawyer and most importantly, loved ones.

Discussing and documenting each family member’s values and goals for their care at that point in time will save heartache and family turmoil in the future. Download a free step-by-step Advance Care Planning Booklet that helps guide the process and contains blank forms for the New York Health Care Proxy and explains MOLST at CompassionAndSupport.org

Conversations change lives! Start yours today! What better time to start a conversation than when your family gathers for the holidays.

Share the Bomba family tradition with your family. Download the Thanksgiving Story.

Start your discussion by sharing personal values, beliefs, life goals and what makes life worth living today. Let your loved ones know who will make medical decisions if you lose the ability to do so.

The health care proxy is a legal document that lets you name someone to make decisions about your medical care, including decisions about life-sustaining treatment. It is recommended for everyone 18 years and older. It only applies when a person is no longer is able to make medical decisions.

The MOLST contains specific and actionable medical orders that can be followed by EMS in an emergency and transition with a patient across health care settings. MOLST is for seriously ill persons who might die in the next year.

Last month we described the incredible efforts and successes of UHS in implementing eMOLST system-wide. UHS’s Palliative Care Team deserves special recognition as they have been spearheading this work across the organization. The UHS Palliative Care Team provides consults on an inpatient basis at UHS’s hospitals and provides outpatient visits for seriously ill patients, including patients from special populations such as individuals with intellectual/developmental disabilities, across the Southern Tier.

The team has practiced what they preach, being the first users at UHS to go live and supprting the launch of eMOLST across the UHS system. Kris Marks, LCSW-R, OSW-C palliative care program director said that “we consider eMOLST to be an invaluable tool for work with our most seriously ill patients.” Since launch just months ago UHS has completed eMOLSTs with more than 1000 patients.

Since the launch of eMOLST, UHS’s Palliative Care Team has also seen their outpatient services continue to grow, with key primary care and specialty practices – particularly pulmonology, oncology and cardiology – recognizing the value of connecting their seriously ill patients with palliative care experts. The UHS Palliative Care Team spends a few days per week in area primary care offices to ensure that visits are convenient for patients. The inpatient service is also busier than ever.

In addition to their routine palliative care work and the launch of the eMOLST project, the team has supported all other hospital departments in end-of-life discussions and eMOLST completion since launching system-wide in June 2017. Special support has been given to the surgical and procedural teams in supplementing their work with eMOLST conversations for appropriate patients. A new perioperative workflow tool was developed as a result of this work. UHS is the first health system to fully integrate eMOLST within their surgical and procedural services areas.

The UHS Palliative Care Team is led by medical director Carolyn Crispell, DO, and program director Kris Marks, LCSW-R, OSW-C. Kris has also served as the project manager for the eMOLST project system-wide. Maureen Daws, NP, PhD, Amy Alonzo, LMSW, Phil Dzwonczyk, MD, Emily Tier, LMSW, MPA, and Wendi Zuwiyya, NP are the core palliative care team members. Jeff Gray, MD, UHS’s hospitalist program director, is considered an honorary team member for the impressive work, focus, dedication and support that he has brought to palliative care and eMOLST organization-wide.

By Patricia Bomba MD, MACP

Since the implementation of New York’s Medical Orders for Life-Sustaining Treatment (MOLST) program began in 2004, the need for physician and clinician professional training on the correct process for completing the MOLST has been recognized. The first statewide MOLST Conference was held in 2005 to support New York State Department of Health (NYSDOH) approval of the use of the MOLST in all hospitals and nursing homes, as well as the 3-year legislative community pilot required to prove EMS could read and follow Do Not Resuscitate (DNR) and Do Not Intubate (DNI) orders on the MOLST. Regional MOLST Train-the-Trainers Conferences, webinars, specialized training focused on use of MOLST for Persons with developmental disabilities/intellectual disabilities, medical grand rounds, presentations and intensive MOLST pre-conferences at annual state professional association conferences have been held to meet the ongoing needs of current and new providers.

The demand for professional training and technical assistance for practice transformation focused on advance care planning, MOLST and eMOLST has grown exponentially. To meet the growing need as well as provide for sustainable advance care planning and MOLST/eMOLST training, several options have been explored. Project ECHO’s innovative approach will support the current and future needs of our clinicians and system leaders. Excellus BlueCross BlueShield is a partner with Project ECHO.

Project ECHO is a lifelong learning and guided practice model that revolutionizes medical education and exponentially increases workforce capacity to provide best-practice specialty care and reduce health disparities. The heart of the ECHO model™ is its hub-and-spoke knowledge-sharing networks, led by expert teams who use multi-point videoconferencing to conduct virtual clinics with community providers. In this way, primary care doctors, nurses, and other clinicians learn to provide excellent specialty care to patients in their own communities using an all-teach all-learn model.

Project ECHO links expert specialist teams at a “hub” with primary care clinicians and other professionals in local communities. Primary care clinicians, the “spokes” in the ECHO model, become part of a learning community, where they receive mentoring and feedback from specialists. Together, they manage patient cases so that patients get the care they need. Although the ECHO model makes use of telecommunications technology, it is different from telemedicine.

Our core team at Excellus BlueCross BlueShield, Katie Orem, Meg Greco and Dr. Pat Bomba, traveled to Albuquerque, New Mexico and attended a 3-day ECHO Immersion Training in October as an important first step in launching ECHO MOLST: Honoring End-of-life Preferences in 2018. Each of us has attended additional training and ECHO clinics since returning from New Mexico. We have begun discussions with the MOLST Team Executive Committee regarding logistics. We will use the New York MOLST Update to share our progress in organizing and launching ECHO MOLST.