Lessons Learned from New York

Patricia A. Bomba, MD, MACP, FRCP

The statistics are sobering. According to the Johns Hopkins Coronavirus Resource Center, COVID-19 caused the deaths of nearly 700,000 individuals globally, including in excess of 150,000 Americans, and more than 32,000 New Yorkers. COVID-19 produced massive unemployment resulting in loss of health insurance coverage, as well as wreaked havoc on the economy, including the health care industry.

New York survived the onslaught of the COVID-19 crisis and “flattened the curve” through valiant efforts of health care professionals, essential workers and the population at large. As a result, infection rates, hospitalizations, ICU admissions and deaths have fallen to record lows in New York. Unfortunately, infection rates are soaring to record high numbers in many states in the South and West.

In response to increased rates of COVID-19 transmission in states, New York joined New Jersey and Connecticut in jointly issuing a travel advisory for anyone returning from travel to states that have a significant degree of community-wide spread of COVID-19. Guidance and an up-to-date list of the restricted states is found at NYSDOH COVID-19 Travel Advisory. The list is based upon a seven-day rolling average, of positive tests in excess of 10%, or number of positive cases exceeding 10 per 100,000 residents.

Lessons learned in New York reflect the need for a public health approach that emphasizes social distancing, use of masks, closing and cautious reopening based on data, vigilant testing, contact tracing, adequate staffing and personal protective equipment (PPE).

The pandemic affirms the value of advance care planning for everyone 18 years and older. Make time to follow Five Easy Steps, choose the right person to make medical decisions if you lose the ability to do so, share what matters most with your loved ones, and put it in writing by completing a health care proxy. Planning for possible lack of capacity to make medical decisions is more important than legal planning, like creating a power of attorney to manage practical matters, and a last will and testament to distribute property after death.

The value of screening patients who are appropriate for MOLST and offering discussions to patients with advanced illness and/or advanced frailty by using eMOLST and telemedicine was documented in prior MOLST Updates. This is especially important now as part of preparing for a second wave.

As we prepare for the fall, many key questions remain.

• Are we prepared for another wave of COVID-19?
• Will we optimally use our lessons learned?
• What will be the impact of the influenza season?
• When will we have a vaccine?
• What is the optimal treatment for early versus advanced illness?
• Will we have adequate testing, contact tracing and PPE?
• Will health care professionals recover from the moral distress experienced during the surge?
• Have we have learned the value of advance care planning?
• Will we encourage everyone to have a thoughtful advance care planning discussion now?
• Will we screen patients in nursing homes, assisted living and homebound patients for appropriateness for MOLST and encourage eMOLST now?

During times of uncertainty, adequate coping skills are imperative for the wellbeing of all health care professionals, patients, families and caregivers. These skills help us live and work comfortably. We are challenged to recognize change as opportunity to grow and thrive in unpredictable environments.

Featured Resource: COVID-19 Guidance on

A COVID-19 section on provides added guidance on MOLST and eMOLST to assist our physicians, nurse practitioners and physician assistants who have authority and accountability for MOLST discussions and patients, families, health care agents and surrogates. Effective communication skills for completing MOLST considering COVID-19 and removal of barriers for MOLST discussions are highlighted. The OPWDD: Individuals with I/DD page aims to expedite completion of the 1750-b process. The Ethics & The Law page addresses guidelines for allocating ventilators. View also eMOLST: Urgent Access; Federal & State Guidance and Contact Us.

New pages addressing each medical order on the MOLST Form are available. The Resuscitation, Respiratory Support and Hospitalization pages provide the evidence base for key issues in the review and renew process recommended for all patients who have a MOLST or are offered MOLST. The Feeding Tube Guidelines, updated March 2020, features an array of tools including disease specific Benefits & Burdens and Legal & Ethical Issues. The Dialysis page includes the Renal Physicians Association’s Shared Decision-Making in the Appropriate Initiation and Withdrawal from Dialysis: Clinical Practice Guideline.

FAQ: Can PAs Sign the MOLST?

Yes! Effective June 17, 2020, licensed physician assistants are permitted to authorize orders to withhold/withdraw life-sustaining treatment for the first time in New York, as a result of legislation signed by Governor Cuomo in 2019.

PAs, like NPs, can follow the MOLST process and sign MOLST/eMOLST for patients with 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 SCPA 1750-b process is followed and only a physician can sign MOLST orders for individuals with I/DD who lack capacity and do not have a HCP.

View the Authority of Physician Assistants web page for more information.

eMOLST Champion: UHS Primary Care Provider – Julie Barnes, FNP

Julie Barnes, FNP, is a family medicine and primary care nurse practitioner with United Health Services (UHS) in Binghamton, NY. Julie was an early adopter of eMOLST among UHS PCPs as she began using the system routinely in Spring 2018. Since then, she’s initiated countless discussions for her most seriously ill and frail patients, with many others reviewed/renewed post-hospitalization or SNF stay.

Julie’s approach to eMOLST has been straightforward: screen seriously ill or frail patients for MOLST-appropriateness by considering the 5 clinical screening questions; review information about the patient’s condition, including any new details from specialists; ensure the patient understands their health status and prognosis, often first raising eMOLST as part of a routine visit or TCM appointment, although sometimes a separate time to discuss goals and treatment preferences is scheduled; document the goals and orders in eMOLST. The practice uses the advance care planning CPT codes (99497 and 99498) to bill appropriately for the time that these conversations take, including when they’re completed over multiple visits or when using telemedicine. Julie’s workflows have been shared across UHS and soon she’ll be presenting to a large upstate NY PCP-ED quality collaborative on best practices in ACP and eMOLST use.

Julie says, “from the perspective of a PCP I feel a responsibility and a privilege to care for people; it’s my duty to ensure that all my seriously ill and frail patients are offered the opportunity to discuss eMOLST with someone that they have trusted and built a relationship with over time. My patients should not have to wait to be hospitalized in order to talk about their end-of-life preferences. There is never going to be a perfect time to have this discussion, but eMOLST is a very valuable tool to make the conversation a normal part of the care they receive. Having a plan in place is reassuring and helpful to the patient and their family; both the hospital and PCP teams benefit from having these discussions when the patients are not in crisis.”

UHS hospitalist director, Dr. Jeff Gray, agrees, saying “In the hospital we are seeing patients at their most vulnerable and often need to have end-of-life discussions. For those whom the illness is acute, the straightforward way we use eMOLST to document has been very useful. It walks you through the discussion you need to have. For those patients who come into the hospital having had this discussion with their PCP the eMOLST system makes finding that discussion and applying those decisions very simple.  No longer do we have to look through paper charts or call and fax PCPs to find this. It’s all at our fingertips.”

ECHO MOLST + eMOLST – A “Telementoring” Approach to End-Of-Life Care Education

Meg Greco, MPA
ECHO MOLST + eMOLST Coordinator

Do you have questions about the MOLST process and form? Are you preparing for a second COVID-19 wave and want to ensure your patient’s end-of-life preferences are honored? Are you a PA or NP wondering how recent legislative changes affect you? If you answered “Yes” to any of these questions, please consider attending ECHO MOLST + eMOLST. The ECHO MOLST + eMOLST clinic series kicks off on September 17, 2020. Weekly videoconferencing clinics are held via Zoom on Thursdays from 12:00 – 1:00pm ET. Each weekly clinic has been approved for 1.0 AMA PRA Category 1 CreditTM and 1.0 ANCC contact hour at no cost to participants. Interested in joining? Email me at

ECHO is an all-teach-all-learn telementoring model that uses case-based learning. Specialists and experts at a “hub” meet regularly with clinicians at “spokes” via videoconferencing to support in the delivery of specialty care services. The ECHO Model and virtual telementoring approach are particularly well-suited to a time when we need to be physically separated but the need for sharing knowledge is higher than ever, particularly when it comes to end-of-life care. To learn more about the ECHO model and its history, watch this short video by Project ECHO’s founder, Dr. Sanjeev Arora and visit

The aims of ECHO MOLST + eMOLST are to provide sustainable MOLST education and to improve the quality of thoughtful MOLST discussions and documentation to ensure patient preferences are honored. The goals of the clinic series were updated to reflect the pandemic, as accurate documentation of these preferences is critical amidst the rapidly changing situation with COVID-19.

Weekly hour-long clinics begin with brief introductions and a short 15-minute didactic presentation. This is followed by a 35 to 40-minute real patient case presentation given by a “spoke” using a Q&A and discussion format. Upon completion of the 9-week ECHO MOLST + eMOLST clinic series, attendees will:

• Use MOLST for appropriate patient populations
• Describe the difference between standard medical care, advance directives & MOLST
• Utilize a standardized 8-Step MOLST protocol to ensure accurate MOLST completion
• Improve their comfort level with end-of-life conversations
• Describe the benefits of eMOLST vs. paper MOLST
• Manage correct usage of the eMOLST system
• Earn free CME/CNE – and much more!

Data collected using a pre-test, post-test method from each clinic series proves that ECHO MOLST + eMOLST works. In the Fall 2019 series, participants overall MOLST knowledge increased by 16%. Before the Fall 2018 clinic series, only 34% of respondents could identify that MOLST is not an advance directive. After the clinic series, that number increased to 72%. Through participation in the clinic series, attendees recognize the importance of their own advance care planning, with health care proxy completion rates among participants rising an average of 36%. To date, ECHO MOLST has provided end-of-life education to 676 participants from 98 health care organizations across New York State. This rapid spread of knowledge is crucial to ensuring patient preferences are honored amidst a pandemic such as COVID-19.

Don’t miss out on this important educational opportunity. For more information on ECHO MOLST + eMOLST, including objectives and who should attend, visit or contact me at to enroll in the next ECHO MOLST + eMOLST clinic series today.