Compassion and Support
Authority of Nurse Practitioners Expanded

On November 29th, 2017, Governor Cuomo signed S.1869 (Hannon)/A.7277 (Gottfried), legislation enabling nurse practitioners to execute medical orders not to resuscitate and other orders pertaining to withholding and/or withdrawing life-sustaining treatment, as Chapter 430 of the laws of 2017.

Chapter 430 amends the Public Health Law to expand the authority of the “attending nurse practitioner” and align with the authority of the “attending physician” under Family Health Care Decisions Act (FHCDA) for making end-of-life decisions that result in medical orders in all clinical settings. Under the Palliative Care Information Act, nurse practitioners are obliged to – and do – counsel patients and families about end-of-life options. The new law will go into effect in May 28, 2018, six months after the Governor signed the legislation, with very limited exceptions. The new law, however, does not amend the Surrogate Court Procedures Act (SCPA) 1750-b, which relates to individuals with developmental disabilities, or statutes governing health care proxies. While these laws were not amended under this legislation, the scope of practice for NPs allows for NPs to assess capacity and notify the patient of the capacity determination in these circumstances.

Thus, the new law will impact the Medical Orders of Life Sustaining Treatments (MOLST) form and process, the DOH MOLST Checklists, the MOLST Chart Documentation forms and eMOLST. Revisions to the documents and eMOLST are needed to acknowledge the new statutory authority afforded to nurse practitioners with this legislation. We will be working with the Department of Health to align the MOLST documents with the new law.

In 2010, the FHCDA was enacted, and a bill that would have authorized NPs to execute DNR orders passed both houses of the legislature. Governor Paterson vetoed that legislation pertaining to nurse practitioner because its provisions were inconsistent with the new FHCDA. This recently enacted legislation was revised to be congruent with the FHCDA. The Nurse Practitioner Association New York State (The NPA) looks forward to continue working on reducing arbitrary barriers that will include addressing the existing statue for health care proxies and Surrogate Court Procedures Act in the upcoming legislative sessions.

Stephen Ferrara, DNP, FNP, FAANP
Executive Director, The Nurse Practitioner Association New York State
Associate Dean and Assistant Professor, Columbia University School of Nursing

Patricia Bomba, MD, MACP
Chair MOLST Statewide Implementation Team
eMOLST Program Director

Featured Resource:
8-Step MOLST Protocol

Completion of the MOLST is a process that begins with identification of the patients appropriate for a MOLST discussion and preparing for the discussion. The 8-Step MOLST Protocol outlines the communication process. MOLST is based on the patient’s current health status, prognosis, and goals for care. The discussion emphasizes shared medical decision-making that helps the patient understand what can and cannot be accomplished. Step 7 is the result, a set of medical orders that must be honored by all health care professionals in all settings.

Can a PA sign the MOLST?

The amendment to New York State Public Health Law that goes into effect May 28, 2018 extends the authority only to nurse practitioners. Separate legislation would be needed to authorize PAs to execute orders not to resuscitate and orders relating to life sustaining treatments. Legislation would need to provide a PA the same authority as the attending physician, including giving them the ability to determine capacity and address clinical standards, not only permit a PA to sign a MOLST form.

eMOLST Champion: UHS Senior Living at Ideal

UHS Senior Living at Ideal (Ideal), a 150-bed nursing home in Endicott, NY, began implementing eMOLST in December 2016. Ideal was recognized as a great site to begin using eMOLST because all long-term care residents in the facility are appropriate for comprehensive eMOLST discussions. Ideal’s Administrator, Michele Gordon, RN, LNHA, led the effort by engaging key stakeholders from across the organization including their administrative team, their medical director & medical team, their social workers and their nurses. Michele’s prior bedside experience allowed her to see the value in eMOLST in ensuring clear direction for care aligned with patient preferences. The Ideal leadership team required all staff to undergo MOLST training and also offered hands-on use of the eMOLST system to increase staff comfort with it before going live. Before going live Ideal also incorporated a link within SigmaCare (their EMR) so that staff would have a quick shortcut to the eMOLST system. Ideal went live on one long-term care unit to start. Afterwards they performed a staff drill to see if the staff was aware of eMOLST and could quickly retrieve the document on appropriate patients. This drill led to process improvement and implementation of eMOLST then quickly spread from unit to unit. Staff realized how easy the system was to use and saw the benefits to the residents and their families. Families also were notified about the transition to eMOLST and during a Family Council meeting there were family members lining up to schedule eMOLST discussions with staff to ensure that their loved ones’ preferences could be documented in the eMOLST system. Ideal’s methodical implementation coupled with open family communication about the benefits of eMOLST has contributed to their implementation success. Ideal is the first nursing home in the Southern Tier to go live with eMOLST; their work is being incorporated into the implementation model for other nursing homes in the region.

The Patron Saint of New York’s MOLST

By Patricia Bomba, MD, MACP

It’s hard to believe ten years have passed since my mother Sophie Bomba died on December 16, 2007 as a result of diffuse abdominal cancer. Affectionately known as Babci, our family finds great comfort in knowing she died peacefully in our home just as she wanted. And, that her end-of-life preferences for care and treatment were honored as a result of thoughtful discussions that led to completion of the MOLST and years of annual family discussions about what mattered most. Her initial MOLST expressed a desire for a natural death, foregoing intubation and mechanical ventilation and tube feedings, but a desire for hospitalization and all other treatment. Her decision to forego treatment for her cancer led to review and modification of the MOLST when her health status and prognosis worsened and goals for her care changed.

Her MOLST was honored in Pennsylvania when she became acutely ill traveling to her granddaughter’s wedding. At this time, the POLST was not yet recognized in eastern Pennsylvania. This was directly related to the Emergency Department physicians recognizing MOLST is a set of medical orders authorized by a licensed New York physician, as well as the additional information provided by her primary care physician. The information included a problem list, a medication list, allergies, advance directives, the MOLST, a non-hospital DNR, a list of contacts and their information (primary care physician and health care agent.)

Her final personal goal for care was ensuring all seriously ill people, especially frail and vulnerable seniors would have an opportunity to work with their physician and have a thoughtful MOLST discussion. In addition, every patient will have a palliative care plan available 24/7 that supports their preferences documented on the MOLST, especially when hospitalization was no longer preferred. And finally, caregivers would receive education and support.

Five days before she died, I presented the EMS quality data and outcomes from the legislated community pilot. The data affirmed EMS could read and follow the MOLST and met the requirements to change New York State Public Health Law and to change the scope of practice of EMS in New York. As a result of the successful pilot testing, the DOH MOLST is the only medical order form approved by the Commissioner of the Department of Health that EMS can follow both Do Not Resuscitate (DNR) and Do Not Intubate (DNI).

She wanted me to share the value of MOLST. Her goal has driven me to continue to lead NY’s MOLST and eMOLST programs. As a founding member of the National POLST Paradigm, I share lessons learned from New York’s MOLST with developing POLST Paradigm programs across the country.

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