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| 2020 Impact of eMOLST During COVID-19 |
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Patricia A. Bomba, MD, MACP, FRCP
MOLST & eMOLST Program Director
The value of Advance Care Planning, MOLST and particularly eMOLST was recognized during the COVID-19 crisis. Providers from across the US came to NYC during the crisis and were able to effectively use eMOLST. Long time eMOLST users were able to use data to improve patient care by responding to patients who requested new discussions and reach out to those at highest risk from complications from COVID. An article published in NEJM Catalyst describes the experience at Mount Sinai Health System: Baharlou, S, Orem, K, Kelley, A, Aldridge, M, and Popp, B. Rapid Implementation of eMOLST Order Completion and Electronic Registry to Facilitate Advance Care Planning: MOLST Documentation Using Telehealth in the Covid-19 Pandemic. NEJM Catalyst, November 3, 2020.
As the COVID-19 crisis surged in New York in the spring, there was a significant increase in eMOLST interest from health systems across the state. With the growing use of telemedicine and the added pressure on end-of-life discussions during COVID-19, eMOLST enrollment and utilization grew dramatically.
As of December 11, there are more than 55,000 providers enrolled in eMOLST, with a 22% increase this year. There are approximately 58,000 patients with a median age of 85 in the registry, with an impressive 43% increase (2019 vs. 2020) and continued growth each quarter. Approximately 20% of the medical orders were revised during COVID, primarily focused on Resuscitation, Respiratory Support and Hospitalization.
Users are distributed statewide with a particularly heavy concentration in downstate New York (NYC, Lower Hudson Valley & Long Island) that enrolled during the peak of the crisis. As the number of new COVID cases continues to rise, we are collaborating with health systems and providers across the state to accelerate eMOLST implementation.
Work on eMOLST enhancements were delayed by prioritizing and meeting the unexpected needs of COVID-19. Nonetheless, we were able to accomplish several additional enhancements and projects. We launched voluntary eMOLST security improvements and incorporated multi-factor authentication for eMOLST “super administrators.” To ensure compliance with NY Public Health Law, all three eMOLST sites (production, test & training) were successfully updated and launched at midnight on June 17, 2020 and the role of thousands of PAs were revised to “Form Signers” in accordance with individual health system policies and procedures. Required coding for a streamlined MOLST Chart Documentation Form (CDF) is done and ready for testing in 2021. Planned work on meeting legal compliance with an anticipated revised MOLST form was delayed by COVID-19.
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| Featured Resource: PEG Tube Guidelines |
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The Percutaneous Endoscopic Gastrostomy (PEG) Tubes Guidelines for Adults developed in 2004 are reviewed biannually by a panel of experts to support thoughtful MOLST discussions and shared medical decision making based on current disease-specific medical evidence and ethical-legal requirements.
The Guidelines aim to provide data, information and tools to physicians, NPs, PAs, other clinicians, patients, families, health care agents, and surrogates to help fully inform the evaluation and shared decision-making process around the use of tube feeding/PEG placement for the adult population, including persons with developmental disabilities, given the health status, prognosis, values, beliefs and goals for care of the individual.
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| FAQ: Who can witness a MOLST?
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Two witnesses on the MOLST form serve as witnesses to the discussion. The physician, NP or PA who has the authority and accountability for shared decision-making for life-sustaining treatment (incudes DNR) and signs the MOLST serves as a witness. The second witness may be a family member or another clinician who was present during the discussion. The names of the witnesses should be printed legibly. In contrast, it is not simply witnessing a signature, as with a health care proxy.
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| eMOLST Champion: All eMOLST Users |
Given this extraordinary challenging year, we honor each provider enrolled in eMOLST as eMOLST champions. More than 55,000 providers are enrolled in eMOLST. Nearly 10,000 new users were enrolled by healthcare systems this year as a result of the COVID-19 crisis. Many have emerged as eMOLST champions in other systems where they also practice encouraging eMOLST adoption. These eMOLST users recognize the value of eMOLST in caring for 1) patients screened appropriate for MOLST, 2) patients with a MOLST who wish to review and update medical orders given the public health emergency, and 3) patients whose clinical status rapidly deteriorates and are appropriate for MOLST.
Champions are people who fight or argue for a cause that they believe in, either for themselves or on behalf of someone else. Champions are hardworking, mentally tough, overcome adversity, have character, are consistent, demonstrate courage, always do their best. All eMOLST users are dedicated to their profession, value teamwork, and put in extra effort. In training eMOLST users, they desire to be the best and use a “best practice” solution.
Champions are heroes, as defined by Christopher Reeves, “A hero is an individual who finds strength to persevere in spite of overwhelming obstacles.” Champions perform under pressure, can adapt and compartmentalize life, and never quit. We extend special thanks to all eMOLST users who care for patients with advanced illness and advanced frailty. We also give thanks to all health care workers who have exemplified extraordinary heroism this year.
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| 2020 Impact of MOLST During COVID-19 |
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Patricia A. Bomba, MD, MACP, FRCP
MOLST & eMOLST Program Director
Effective sustainable implementation of the MOLST program requires a multidimensional approach. Patient and family education, engagement and empowerment and provider training are critical to ensure effective, well informed shared decision-making.
MOLST.org and CompassionAndSupport.org: New Webpages
The redesigned sister websites serve to educate patients, families, decisionmakers and professionals. A new section guidance on COVID-19 was quickly added to support providers when COVID was surging in NY. Additional pages were added and/or revised; for example 8 new web pages in the MOLST form section with up-to-date references on medical orders found on the DOH MOLST form.
ECHO MOLST + ECHO eMOLST
ECHO MOLST + eMOLST was successful in meeting its aims to provide sustainable MOLST provider education and to improve the quality of thoughtful end-of-life discussions and documentation to ensure patient preferences are honored. The goals of the clinic series were updated to reflect the pandemic, as accurate documentation of these preferences is critical amidst the rapidly changing situation with COVID-19.
To date, ECHO MOLST + eMOLST has provided end-of-life education to 826 participants from 116 health care organizations across NYS. Data collected from each clinic series shows improvement in knowledge and attitude. More than 93% of participants are directly involved in patient care, suggesting quality improvement in skills and patient care through education are immediate.
Feeding Tube Guidelines
The review and revision of the PEG Tube Guidelines was completed in early first quarter. The feeding tube guidelines were created in 2004 to support the MOLST program. The guidelines are reviewed biannually to reflect new research and best practices in an effort to reduce regional variations in care. Updated information is posted to MOLST.org.
MOLST Team
The MOLST Executive Committee is assessing the current and future structure of the MOLST Team. The revised structure supports our purpose and goals, including advancing eMOLST implementation by recognizing eMOLST as “best practice.”
A comprehensive document is being created for NY MOLST that includes an overview, purpose, goals, a 1-page outline of Individual and Association Member Benefits and Responsibilities that will be used for recruiting, onboarding and mentoring new members. Committee chair(s) are working on committee purpose, proposed members, 2021-2022 projects that will be presented and discussed at the Strategic Planning Meeting scheduled in January 2021.
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