The attending physician or nurse practitioner leads the medical team and and is ultimately responsible for identifying appropriate patients based on health status and prognosis as well as initiating the MOLST discussion. Other medical team members may also participate in the discussion within scope of practice. All members of the team who are trained in MOLST can assist in identification, as well as educate, engage and empower patients and families. Social workers can assist with identifying and helping to resolve family conflict. Chaplains and spiritual advisers can address religious, spiritual and existential issues.
Refer to the What’s My Role? page to identify the ways that different professionals may participate in the conversation.
The attending physician or nurse practitioner is always accountable for the full MOLST process, including confirming the discussion, answering any questions, following all ethical and legal requirements, and signing the MOLST form. As the medical team prepares for MOLST conversations they should be considering several elements:
Patients and families may also initiate the MOLST discussion if they feel the patient may be appropriate for MOLST. The patient and families can review the criteria for appropriateness.
Patients and families should request adequate time for this conversation. Patients, families, and the medical team can all think more clearly and respond more effectively when they are not in crisis.
Patients may request to have this in-depth end-of-life discussion with their preferred physician or nurse practitioner. They may prefer to do this discussion with their primary care physician or nurse practitioner or with the specialist physician or nurse practitioner who has been caring for them intensively; alternatively they may prefer to do this discussion with a palliative care physician or nurse practitioner. It is always okay to request a palliative care consultation.
More than one discussion is often needed. This is reasonable as it takes time to understand health status and prognosis and additional time may be required to reflect on current goals for care and preferences about treatment, as well as what can and cannot be accomplished.
Remember that MOLST is not an advance directive. MOLST should only be completed with orders on how the patient must be treated today. MOLST discussions and MOLST forms can and should be updated over time to reflect any changes in the person’s health status, prognosis, goals, or preferences. Ask for another conversation if the patient’s goals or preferences change.
Whenever possible, prior to MOLST discussions, patients and families should watch the MOLST Video and consider these questions:
When it comes time to make decisions, patients and families should use these key questions with their physician to make decisions that are well informed using shared medical decision-making:
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The MOLST Update is a Newsletter dedicated to providing up-to-date information on advance care planning, MOLST and eMOLST.