We deeply appreciate the challenges our health care practitioners and all health care workers are facing during the COVID-19 pandemic.
COVID-19 is a severe respiratory illness caused by the virus named SARS-CoV-2. It is a novel virus, which means that no one in the world has antibodies to it because no one has ever been infected by it before. When the COVID-19 virus invades our body, we do not have antibodies. We do not have resistance from a previous exposure to rapidly create a defense against the virus. Because no one has antibodies, everyone is at risk for catching the virus, becoming ill, and spreading the virus so that it can infect those around you.
COVID-19 is not a common flu. COVID-19 is an order of magnitude worse than the flu. Influenza spreads from September through April in the U.S. Patients will require hospital treatment over the course of a few weeks rather than the 3-4 months of a typical flu season.
New York Governor Andrew Cuomo warns the COVID-19 pandemic may overwhelm the US healthcare system. Further, Gov. Cuomo predicts the spread of the virus in the US is an “impending catastrophe.” We share his concerns.
The health care system in Italy is failing because the health care system was overwhelmed by a flood of people requiring critical medical care, all arriving too close together in time. The intent of containment, mitigation strategies and “social distancing” is to “flatten the curve” and prevent the potential “wave” of patients and collapse of our health care system.
If our health care system fails, everyone will suffer. If the hospital is filled with COVID-19 patients, people with heart attacks, acute abdomens, fractured hips, and so on will not be able to be treated. Everyone is at risk if there is a systemic failure of our health care system, not just those with COVID-19.
If the “wave” hits, then physicians may be faced with “extraordinary” decisions based on distributive justice and not patient preferences and goals.
“The principles of humanitarianism explicitly require both saving lives and prevention and alleviation of human suffering as essential parts of a humanitarian healthcare response. The consequences of humanitarian crises vary greatly depending on the causes, location, and vulnerability of the population they affect, but the consequences often include extensive loss of life and physical, psychological, social, and spiritual suffering on a massive scale.” *
Coronavirus: Extraordinary Decisions For Italian Doctors – The Atlantic
Advance care planning conversations and health care proxy completion has never been more important for everyone 18 and older. Advance care planning conversations helps you to maintain control and achieve peace of mind for you and your family by reducing uncertainty, as well as to avoid confusion and conflict over your care.
“Social distancing” has brought some nuclear families together and separated others. Through the power of technology, these important advance care planning conversations can occur through phone and videoconferencing.
Know your choices. Share your wishes. Create certainty during uncertain times! Be sure your physician, NP, and PA have a copy of your current health care proxy in your medical record.
Advance Care Planning
Choose the Right Health Care Agent
Patients with advanced medical conditions and frailty, and individuals who are immunocompromised are at the highest risk. The fatality rate estimate currently is twenty times worse than the flu.
Vulnerable older adults who reside in nursing homes and assisted living are at particularly high risk. This also applies to individuals eligible for care in a nursing home who choose to live at home and receive long-term care services.
Patients with advanced medical conditions and frailty are appropriate for MOLST and should be offered a MOLST discussion. Now is the time to be sure the individual’s health care proxy is current and accessible in the medical record.
Patients Appropriate for MOLST Discussions
Coronavirus in U.S. Could Hit Nursing Homes Hardest – The Atlantic
Given the current circumstances, it is critically important to have thoughtful, honest, compassionate discussions with the patient with capacity or the decision-maker if the patient lacks capacity and that the ethical legal requirements are followed. The discussion needs to ensure well informed decision-making in the setting of COVID-19.
For those who reside in nursing homes and have existing DOH MOLST/eMOLST forms, it is time for review and renewal of the medical orders. For those who do not have a DOH MOLST/eMOLST, screen and identify patients who are appropriate for MOLST and offer MOLST.
The physician, NP or PA should have a thoughtful MOLST discussion with the appropriate decision maker (patient, health care agent or surrogate), using the 8-Step MOLST Protocol. A care plan that includes palliation and supportive care is necessary for those patients who choose to remain in place.
Family and loved ones should be included in the discussion via phone call or telemedicine. Families need to be aware of patient preferences, particularly regarding Resuscitation, Respiratory Support & Hospitalization.
How to Complete a MOLST
Thoughtful MOLST Discussion
8-Step MOLST Protocol
Ethical Legal Requirements
Authority of Nurse Practitioners Under Current NYS Law
Authority of Physician Assistants as of June 17, 2020
Crucial conversations require wisdom. There is an ancient Chinese proverb.
Physicians, nurse practitioners, and physician assistants need to hone their communication skills now to effectively convey the impact of COVID-19 for high risk patients in all setting where the prognosis is poor, and the chance of survival is low.
Vital Talk COVID-Ready Communication Skills
For a resident in a nursing home who does not want hospitalization or to be placed on a ventilator, the care plan must include palliation and supportive care for the family and loved ones. The care plan must include good symptom management for respiratory distress. This requires supplemental oxygen and providing morphine (or another opioid). Many nursing homes and assisted living facilities may have had little experience with supporting people dying with respiratory failure as the cause. Hospice and palliative care practitioners have experience with titrating medicine to receive air hunger while leaving the possibilities open that the person might survive. If you’re not skilled in palliative care, check out resources and ask for help.
The care plan must also include caregiver support for families, loved one, and health care workers.
Families and loved ones may be experiencing increased anxiety facing the uncertainty of their envrionments and the changes in access to health care. Health care workers are under stress as well. Doubt and fear are very normal. Recognize this is normal and empathize with others. Day to day rituals and habits are altered based on national and state guidance, and part of our role is to help them navigate this experiences and identify alternative ways to cope and thrive.
eMOLST is the only way to ensure quality and patient safety and be sure MOLST is done correctly. Too often, discussions are poorly done or done outside scope of practice. Incompatible medical orders (CPR + DNI) exist. Skilled nursing facilities send patients against their wishes, as they do not use MOLST or check medical orders and/or have not developed an adequate care plan to support treatment in place. This is the message we hear from health systems who are doing it correctly and using eMOLST. Read More
During the era of COVID-19 many health systems and the associations of hospitals and nursing homes have reached out to our team for help and assistance in managing best practices regarding end-of-life discussions and MOLST completion. We continue to recommend eMOLST implementation for all levels of care. Importantly, we are offering our current partner organizations additional benefits during this crisis to help them manage this population of their most seriously ill patients. Read More
The MOLST/eMOLST Team is available and willing to be a resource for physicians, nurse practitioners, physician assistants, hospitals, post-acute long-term care facilities and physician practices.
Patricia Bomba, MD, MACP, FRCP
MOLST/eMOLST Program Director
Katie Orem, MPH
Meg Greco, MPA
ECHO MOLST + ECHO eMOLST Coordinator
A physician, nurse practitioner or physician assistant that needs help with a difficult MOLST case should contact Dr. Bomba.
A physician leader in a health system with public health concerns of the impact of nursing home, assisted living, and community dwelling older adults with multiple comorbidities and/or frailty and immunocompromised individuals should contact Dr. Bomba.
A hospital that wishes to access eMOLST should contact Katie.
A skilled nursing facility that wishes to enroll physicians, NPs and PAs in eMOLST to review & renew MOLST given COVID-19 should contact Katie and Meg.
Can’t find your answer? Contact Katie.
Review ECHO MOLST + ECHO eMOLST. To register, contact Meg.
Advance Care Planning
Can’t find your answer? Contact Dr. Bomba.
*Waldman E, Glass M. (2019) A Field Manual for Palliative Care in Humanitarian Crises. Oxford University Press Print Publication Date: Nov 2019 Print ISBN-13: 9780190066529 Published online: Nov 2019 DOI:10.1093/med/9780190066529.001.0001. https://oxfordmedicine.com/view/10.1093/med/9780190066529.001.0001/med-9780190066529-chapter-2
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The MOLST Update is a Newsletter dedicated to providing up-to-date information on advance care planning, MOLST and eMOLST.