Completion of the MOLST begins with a conversation or a series of conversations between the patient, the health care agent or the surrogate, and a physician or nurse practitioner using the 8-Step MOLST Protocol. Conversations may include other medical team members, within scope of practice. The conversation(s) should be documented in the medical record.
Ideally, the health care agent and family should listen to the discussion when a patient is able to make MOLST decisions. If the patient had not previously completed a health care proxy and the patient has the ability to choose a health care agent, the patient should complete a health care proxy.
If the patient is unable to make complex medical decisions on the MOLST, the health care agent becomes the medical decision-maker. If the patient does not have or is unable to complete a health care proxy, the Surrogate identified under Family Health Care Decisions Act becomes the medical decision maker.
The patient has the right to:
When the physician or nurse practitioner signs a MOLST form, the physician or nurse practitioner is accountable for a thoughtful MOLST discussion and must:
Changes to Family Health Care Decisions Act became effective May 28, 2018. Changes to Health Care Proxy Law became effective on February 3, 2019.
However, neither law amends the Surrogate Court Procedures Act (SCPA) 1750-b, which relates to individuals with developmental disabilities. Only a physician, not a nurse practitioner, is accountable for the process and can sign a MOLST for individuals with developmental disabilities who lack the ability to make MOLST decisions. See the Authority of Nurse Practitioners under Current NYS Law.
Other members of the care team that are qualified and trained health care professionals must act within their scope of practice, meaning doing what they’ve been trained to do professionally.
The physician’s assistant cannot sign the MOLST form but can participate in thoughtful MOLST discussions in collaboration with the physician:
The nurse can participate in a team based approach to MOLST discussions:
The social worker can participate in a team based approach to MOLST discussions:
The chaplain or spiritual adviser can participate in a team based approach to MOLST discussions:
Ideally, the health care agent should listen to a thoughtful MOLST discussion and/or be informed of the patient’s values, beliefs and goals for care, as well as the preferences for care and treatment documented as medical orders on the MOLST.
The family must follow the patient’s preferences for care and treatment. When a patient makes a decision to withhold life-sustaining treatment based on current health status and prognosis, MOLST orders to withhold treatment can only be changed by the patient if the patient has the ability to make MOLST decisions. If the patient loses the capacity to make MOLST decisions, the Health Care Agent or Surrogate is authorized to make MOLST decisions but must act as described below.
If the patient is unable to make complex medical decisions on the MOLST, the health care agent stands in the shoes of the patient and is authorized to make MOLST decisions. The health care agent or surrogate must:
A health care agent and surrogate have rights and obligations.
If the patient loses the ability to make MOLST decisions and the patient has already made decisions to withhold certain life-sustaining treatment (e.g. Do Not Resuscitate (DNR) and Do Not Intubate (DNI), the healthcare agent or surrogate cannot undo the patient’s decision.
If the patient loses the ability to make MOLST decisions and the patient has requested full treatment for certain life-sustaining treatment, the health care agent or surrogate can make a decision to withhold and/or withdraw other life-sustaining treatment on the MOLST for which the patient requested full treatment, as full treatment represents the standard of care.
For example, a decision to forego future hospitalization, a feeding tube or other life-sustaining treatment can be made if it is consistent with known wishes or in the best interest of the patient, based on a major change in health status or prognosis.
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