MOLST
JUNE 2020
Expanded Authority for Physician Assistants Beginning June 17, 2020

Effective June 17, 2020, licensed physician assistants (PAs) will be permitted to authorize orders to withhold and/or withdraw life-sustaining treatment for the first time in New York State, as a result of legislation signed by Governor Cuomo in 2019. As Maureen Regan, PAC, MBA, FACHE, DFAAPA, President of the New York State Society of Physician Assistants explains, “This has been a long time coming and is a win for palliative care in NYS, patients and their families. As PAs continue to practice on the frontlines of serious illness patient care in this state, this statute enhances the ability of PAs to provide the essential continuity of care for their patients and caregivers. It further ensures their participation in best practices in shared medical decision-making that address patients’ goals of care.” The expanded authority of PAs to participate in the MOLST process will help ease the burden on physicians and nurse practitioners (NPs) to ensure thoughtful MOLST discussions are offered to all appropriate patients and current MOLST orders are reviewed and renewed considering COVID-19. For more information, read the March 2020 MOLST Update.

In addition to being permitted to authorize orders to withhold and/or withdraw life-sustaining treatment, PAs will be accountable for additional legal and ethical requirements that currently only physicians and nurse practitioners are responsible for today (i.e. attending capacity determination, clinical standards, etc. as outlined on DOH MOLST Checklists 1-5 as well as the Minor Patient’s Checklist). These changes to public health law (PHL) will impact all orders to withhold/withdraw life-sustaining treatment in NYS documented in eMOLST, on MOLST forms and non-hospital DNRs. eMOLST will be updated on June 17, 2020 and PAs will have additional privileges enabled in accordance with changes in PHL and compliance with health system P&Ps where they practice. Additional details can be found here.

PAs, like NPs, can follow the MOLST process and sign MOLST/eMOLST for patients with Intellectual/Developmental (I/DD) who have capacity and those who lack capacity but have a health care proxy. However, ONLY a physician is accountable for ensuring the Surrogate Court Procedures Act (SCPA) 1750-b process is followed prior to the physician signing MOLST orders for individuals with I/DD who lack capacity and do not have a valid health care proxy. Similar to the changes that went into effect for NPs in 2018 and 2019, PAs will not be able to authorize MOLST orders under the 1750-b process. The SCPA 1750-b was not revised and the OPWDD Checklist will not change.

The process begins with conversations with your health care provider, family members and trusted friends. Once you identify the person you’d like to serve as your health care agent, you document it by completing a health care proxy form.

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, within scope of practice, develop a systematic approach to end-of-life discussions that worked for physicians prior to MOLST. Having a standardized approach to thoughtful MOLST discussions can help ensure best practices in shared medical decision-making.

The impending expanded authority for PAs, the NP changes that went into effect in 2018 and 2019 and the omnipresent influx of new clinicians entering the healthcare system highlights the need for a sustainable platform for education on end-of-life care. ECHO MOLST: Honoring Patient Preferences at End-of-Life provides valuable education to fulfill the demand for professional training and assistance on advance care planning, MOLST, and eMOLST. As a bonus, the ECHO model was fundamentally created around remote collaboration and is designed to shine in this new era of social distancing. For more information on ECHO MOLST as a proven education model on end-of-life care, please read the February 2020 MOLST Update.

Featured Resource: Web Page & Tables Outlining MOLST Authority of PAs Under New York State Public Health Law

A new web page on MOLST.org has been created in response to the new law that will permit licensed physician assistants (PAs) to authorize orders to withhold and/or withdraw life-sustaining treatment. View Authority of Physician Assistants as of June 17, 2020 for more information.

Two tables at the bottom of the web page clarify New York State Public Health Law and the Physician Assistant authority to do capacity and concurrent capacity determination, as well as participate in the MOLST process and sign MOLST orders.

Please share this web page with colleagues to explain the authority and accountability of Physician Assistants under New York State Public Health Law.

FAQ: Can a PA witness a Health Care Proxy created for an individual with I/DD?

Individuals residing in a facility (operated or certified by OPWDD) can execute a HCP if he or she can understand that they are delegating the authority to make health care decisions to another person.

To be valid, the HCP must be signed and dated by the person with I/DD and must be signed by two adult witnesses. The agent cannot be a witness. If the individual resides in an OPWDD facility, at least one witness must not be affiliated with the facility. The other witness must be a NYS licensed physician, NP, PA (as of June 17, 2020) or clinical psychologist who:
1. is employed by the DDSO for at least 1 year; or
2. has been employed in an OPWDD facility for at least 2 years; or
3. has specialized training in I/DD and at least 2 years’ experience treating persons with DD; or
4. has at least 3 years of experience treating persons with DD.

eMOLST Implementation at Mount Sinai Health System

Mount Sinai Health System, combining the Icahn School of Medicine at Mount Sinai and eight hospital campuses throughout the New York metropolitan area, had worked through the later half of 2019 preparing for a phased rollout of eMOLST in 2020. Dr. Cardinale Smith led the overall initiative, Dr. Beth Popp led the educational components, Mark Liu managed the roll out, and Anand Ramaswamy pursued integration with their primary EMR (Epic) and enrolled key users in their “phase 1” group (oncology and supportive oncology).

Simultaneously, MSHS’s Mount Sinai South Nassau site, formerly known as South Nassau Communities Hospital, had started their own eMOLST implementation prior to the completion of their integration into the Mount Sinai Health System and had launched eMOLST hospital-wide in 2019. Their clinical project champion, Dr. Indra Daniels, led the implementation efforts and the hospital had started using eMOLST with a phased approach. The palliative care department was the first group to launch and by the end of the year several hundred clinical users representing disciplines across the hospital were enrolled, including all residents.

Then COVID hit.

Mount Sinai Health System’s careful plans for a phased 2020 rollout were pivoted in the early days of the pandemic when the geriatrics and palliative care department, led by Dr. Shahla Baharlou and Dr. Beth Popp, along with the emergency medicine, critical care medicine, pulmonary medicine and Mount Sinai Visiting Doctors requested urgent eMOLST access for their respective departments. Leadership responded positively to the initiative and supported an accelerated rollout. Within days, hundreds more users gained access from all areas of the health system that requested it. Staff from the various departments involved worked evenings and weekends putting together the enrollment data necessary for bulk loading to the eMOLST system. The eMOLST team responded and loaded their clinical users on a Sunday afternoon followed by Anand and the MSHS IT team putting in extra hours to urgently support Single Sign On and Patient Context from the Epic environment for all staff who needed access. Four expedited training sessions on different MOLST topics were held via Zoom with accompanying eMOLST demonstrations for the teams who gained access. The hundreds of eMOLSTs that were completed were instantly accessible statewide via the eMOLST registry.

Through the pandemic the Mount Sinai South Nassau location kept their focus on expanding MOLST and eMOLST education through their participation in ECHO MOLST and ECHO eMOLST, along with continued use of the eMOLST system. ECHO MOLST was part of required end-of-life education for their residents of all disciplines. Dr. Daniels coordinated an impressive group of clinicians to participate in the weekly ECHO MOLST clinic series and they presented several time-sensitive cases, often relating to COVID-19, for statewide discussion. One particularly interesting case was presented by an interdisciplinary team from Anesthesiology and the Directors of Surgery and Urology. Mount Sinai South Nassau’s focus on the importance of goals for care discussions and eMOLST completion among all disciplines has driven engagement across the hospital.

We look forward to continuing to work with Mount Sinai Health System on eMOLST in 2020.

eMOLST During COVID-19

Katie Orem, MPH

Geriatrics & Palliative Care Program Manager
eMOLST Administrator for New York State
Excellus BlueCross BlueShield

With the growing use of telemedicine and the added pressure on end-of-life discussions during COVID-19, eMOLST enrollment and utilization has grown dramatically. There was a 28% increase in new eMOLST patients during the first quarter of 2020 vs. what we would have expected from prior years. We also saw a 25% increase in new patients in the first quarter of 2020 when compared with the last quarter of 2019. From a data perspective we remain on track for the second quarter to reflect similarly high utilization as the first quarter of 2020.

In addition to the influx of new patients to eMOLST we also saw a significant increase in eMOLST interest from health systems across the state, particularly in March as the COVID-19 crisis came to a head in New York. More than 5000 clinicians gained urgent access from across the state in a matter of weeks. These users were distributed statewide with a particularly heavy concentration in downstate New York (NYC, Lower Hudson Valley & Long Island).

Many downstate health systems, including Greater Hudson Valley Health System, NYU Langone Health, VNSNY, Maimonides Medical Center and Mount Sinai South Nassau, found great value in having implemented eMOLST well ahead of this crisis. NYU Langone Health, which implemented eMOLST in 2016, found that their EDs and ICUs were well-prepared with the eMOLST tool to both honor existing eMOLST orders and to offer new end-of-life discussions to appropriate patients during the crisis. This was critical as NYULH’s embedded workflow for these conversations ensured that many staff who typically don’t work in emergency or critical care settings (and some of whom came from outside NYS under emergency permissions) were guided through MOLST discussions using eMOLST. The common language provided in eMOLST also promoted consistency and accuracy in these conversations across a very large health system. For those patients who were able to leave the acute care setting with COVID-19, some of whom transitioned to other settings within NYULH, the eMOLST also offered continuity and coordination of care during a hectic time.

Several other large health systems in downstate New York gained urgent access to eMOLST during the heat of the crisis including Mount Sinai Health System and NewYork-Presbyterian. In an accompanying article in this newsletter we are highlighting the excellent work of Mount Sinai Health System in their quick response to accelerating their (otherwise carefully planned!) eMOLST rollout when faced with the COVID-19 crisis.

In the last several months we have also seen an uptick in review and renew discussions in eMOLST. While periodic review and renew of these medical orders is both legally required and clinically necessary to ensure they always match up with a patient’s current health status, prognosis and goals, the COVID-19 crisis brought a new urgency to these discussions. We recommend that physicians and NPs across the state continue to take the time to review MOLST decisions in light of COVID-19 as any patient who is appropriate for MOLST is also at the greatest risk of suffering the worst outcomes if infected with the virus that causes COVID-19. This becomes especially important for nursing home residents and residents in other congregate care settings as those settings continue to be ravaged by this disease. Organizations that have implemented eMOLST can parse their eMOLST datasets to identify patients who may be particularly vulnerable or whose choices may have been most likely to change during the COVID-19 crisis.

Physicians & NPs have found eMOLST is the easiest way to review and renew MOLST, as well as offer MOLST to appropriate patients. eMOLST ensures quality, accuracy, accessibility & reduces harm. The coding in eMOLST prevents incompatible orders and changes to the orders can be quickly implemented using a team-based approach as the patient’s health status, prognosis, and goals for care change. eMOLST has been recognized as best practice for having end-of-life discussions and documenting medical orders on a MOLST. The utility of eMOLST – both for health systems that have used it for years and as a new tool to leverage urgently in a time of crisis – have been highlighted during COVID-19.