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MOLST Form

The MOLST form is a set of medical orders that defines life-sustaining treatment the patient wants to receive or avoid now.  A physician or nurse practitioner must complete or change the MOLST based on the patient’s current medical condition, prognosis, values, goals, preferences, and MOLST Instructions. If the patient is unable to make medical decisions, the orders should reflect patient wishes, as best understood by the health care agent or surrogate and based on the patient’s values, beliefs and goals.

MOLST became a New York State Department of Health (NYSDOH) form, at the same time Family Health Care Decisions Act (FHCDA) became effective on June 1, 2010. NYSDOH made a decision to have the DOH-5003 (6/10) MOLST written in plain language to ensure the physicians, nurse practitioners, patients, health care agents, surrogates and all who are involved in the process of completing the MOLST understand what MOLST represents.  In addition, using plain language allows for appropriate translation into other languages for educational purposes only and to prepare the medical decision maker for the MOLST discussion.

Proposed Revisions

Proposed revisions to the DOH-5003 (6/10) MOLST form are currently under review by the New York State Department of Health (NYSDOH).  The MOLST form has undergone annual NYSDOH review since the MOLST form was first approved for use in all healthcare facilities in 2005.  Since that time, the MOLST form and supporting documentation of the MOLST completion process has changed to comply with changes to New York State Public Health Law (NYSPHL) and based on clinical feedback from physicians accountable for the MOLST process, legal counsel in health systems, as well as EMS and other clinicians who must follow MOLST in an emergency.

The revised MOLST form that is awaiting approval has been reviewed through several iterations by members of the MOLST Statewide Implementation Team & the EMS MOLST work group, key palliative care physicians, nurse practitioners and other clinicians who use MOLST &/or eMOLST extensively as well as key leaders from the Office for People with Developmental Disabilities (OPWDD) and Mental Hygiene Legal Services (MHLS).

The revisions are recommended to comply with new public health law and needed changes based on clinical use since June 1, 2010.

Due to a Change in the Law

Legislation S1869 (Hannon)/A7277 (Gottfried) that went into effect May 28, 2018 expands the authority of nurse practitioners under FHCDA for making end-of-life decisions that result in medical orders in all clinical settings.  The new law aligns the authority of the nurse practitioner with the authority of the “attending physician” under FHCDA.

Legislation S7713-B (Hannon)/ A10345A (Gottfried) passed the Senate and Assembly in the 2018 legislative session.

A bill introduced in the 2018 legislative session S7713-B (Hannon)/ A10345A (Gottfried) aligns Health Care Proxy law with FHCDA. The bill passed the New York Assembly and Senate and is awaiting the Governor’s signature.  The law will go into effect 90 days after the bill is signed.

Neither the new law nor the 2018 bill amends the Surrogate Court Procedures Act (SCPA) 1750-b, which relates to individuals with developmental disabilities.

Needed to Improve Quality and Reduce Harm

The proposed language revisions that are not directly a result of the new and proposed change in public health law are based on clinical feedback focused on ensuring MOLST is completed correctly to ensure patient preferences for resuscitation and life-sustaining treatment is honored. Through use of the MOLST form, consensus has been achieved on suggestions to clarify language to improve quality and reduce patient harm, including adding MOLST instructions to the form and clarifying MOLST is not for everyone and that MOLST is a set of medical orders to be followed now and not an advance directive created for future use when future health status and prognosis is unknown.

The proposed revisions are based on feedback received from multiple sources since June 1, 2010, objective data and comments from working with health systems and physicians on the paper to eMOLST conversion since 2011 was reviewed.  Feedback was also gathered through outreach to key palliative care physicians, NPs and others across the state via personal phone conversations, emails, NY MOLST Update, and at presentations since legislation S1869 (Hannon)/A7277 (Gottfried) passed in the Senate and Assembly in the 2017 legislative session.

History

The MOLST program began as a community initiative in Rochester to improve end‑of-life care in 2001. After working from 2001 to 2003 on the creation of the MOLST form and the MOLST Supplemental Documentation Forms for Adults and Minors, the MOLST program was launched in the Greater Rochester Region in 2004, followed quickly by adoption in Syracuse and the areas surrounding both communities.

Collaboration with the NYSDOH began in 2004. NYSDOH reviewed, suggested needed revisions and then approved use of MOLST in all health care facilities in 2005, prompting use in all counties. Simultaneously, the MOLST Supplemental Documentation Forms for Adults and Minors were also reviewed, revised and approved for use.  Each four-page MOLST Supplemental Documentation Forms outlined the necessary requirements for issuing a Do Not Resuscitate (DNR) order in Adults and/or Minor patients in New York, per the 1987 DNR law. At that time, New York did not have surrogacy laws; a health care proxy and/or “clear and convincing evidence” was needed to make decisions regarding life-sustaining treatment.

An annual review of the MOLST form and program is conducted in August following each legislative session. The review includes the need to revise the MOLST based on statutory changes and feedback from physicians, clinicians, health systems and EMS who use MOLST.

In order to permit EMS to use a MOLST to follow DNR and Do Not Intubate (DNI) orders in the community, legislation was required and obtained in 2005 to modify NYSPHL.  Legislation permitted testing community use of MOLST in Monroe and Onondaga counties to ensure EMS could read, interpret and follow both DNR and DNI orders. After a successful legislated community pilot (2005-2008), the MOLST form became the only NYSDOH approved form that EMS can follow for both DNR and DNI orders. NYSDOH directs all health care providers to follow MOLST orders in all settings, including the community. At the same time, NYSDOH approved statewide use of MOLST in all settings.

MOLST became a New York State Department of Health (NYSDOH) form in 2010 when F. MOLST became a New York State Department of Health (NYSDOH) form, at the same time FHCDA became effective on June 1, 2010. NYSDOH made a decision to have the DOH-5003 (6/10) MOLST form written in plain language to ensure the physicians, nurse practitioners, patients, health care agents, surrogates and all who are involved in the process of completing the MOLST understand what MOLST represents.  In addition, using plain language allows for appropriate translation into other languages for educational purposes only and to prepare the medical decision maker for the MOLST discussion.

When FHCDA became effective, the MOLST Supplemental Forms for Adult and Minor Patients were no longer legally accurate, nor sufficient to document the ethical-legal requirements to make resuscitation and life-sustaining treatment decisions in accordance with changes put into effect as a result of the  MOLST, Health Care Proxy law, FHCDA and Surrogate Court Procedures Act (SPCA) 1750-b.  The NYSDOH created five MOLST Checklists for Adults and one MOLST Checklist for Minors to ensure compliance with public health law.

SPCA 1750-b outlines special procedures and requirements for making end-of-life decisions regarding resuscitation and life-sustaining treatment for persons with developmental/intellectual disabilities.  The Office for People with Developmental Disabilities (OPWDD) created the MOLST Legal Requirements Checklist for Individuals with Developmental Disabilities. If the patient has a developmental disability, is appropriate for the MOLST and does not have ability to decide, only a physician (not a nurse practitioner) must follow special procedures as outlined by SCPA 1750-b and attach the completed OPWDD legal requirements checklist before signing the MOLST.  If the patient has a developmental disability, is appropriate for the MOLST, and has the ability to decide, the patient makes their own decisions. If the patient has a developmental disability, is appropriate for the MOLST, does not have ability to decide, but has a properly completed health care proxy, the health care agent is able to make MOLST decisions.

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The MOLST Update is a Newsletter dedicated to providing up-to-date information on advance care planning, MOLST and eMOLST.