MARCH 2020
COVID-19: The Value of MOLST & eMOLST

Patricia Bomba, MD, MACP, FRCP
MOLST & eMOLST Program Director

New York Governor Andrew Cuomo warns the coronavirus (COVID-19) pandemic may overwhelm the US healthcare system. Further, Gov. Cuomo predicts the spread of the virus in the US is an “impending catastrophe.” I agree with Gov. Cuomo.

The health care system in Italy is failing because the health care system was overwhelmed by a flood of people requiring critical medical care, all arriving too close together in time. The intent of containment, mitigation strategies and “social distancing” is to “straighten the curve” and prevent the potential the “wave” and collapse of our health care system.

If our health care system fails, everyone will suffer. If the hospital is filled with COVID-19 patients, people with heart attacks, acute abdomens, fractured hips, and so on will not be able to be treated. Everyone is at risk if there is a systemic failure of our health care system, not just those with COVID-19.

Limited ICU Beds and Ventilators
Further, Gov. Cuomo points out New York has 3000 ICU beds with 3000 ventilators at 80% utilization AND no easy access to additional ventilators. Similarly, Italy does not have enough ICU beds, ventilators, and medications to manage all the patients that need it. Physicians in Italy are judging who gets an ICU bed and critical care and who does not because there is not enough supply to take care of everyone.

While we do not want to see this happen here, it will happen soon if very bold steps are not taken at this time. Sending frail MOLST appropriate patients to the ED who wish to avoid hospitalization and respiratory support on a ventilator will wreak havoc on the hospital systems, place health workers at risk and these high-risk patients have the least chance of surviving.

Amid the pandemic, thoughtful MOLST discussions delivered with honesty and compassion add value. There are approximately 35,000 – 40,000 patients in the eMOLST system, with approximately a 50-50 split between Downstate: Lower Hudson Valley, NYC (particularly Manhattan & Brooklyn) and Long Island and Upstate (the rest of the state). There are thousands more paper MOLST forms. It is critical that MOLST/eMOLST reflect today’s preferences for care during the COVID-19 crisis.

Proposed Action Steps
Residents of Post-Acute Long-Term Care (PALTC) and Assisted Living are at especially high risk of severe morbidity and mortality due to COVID-19.
1. For those in PALTC with existing DOH MOLST/eMOLST forms, it is time for review and renewal of the medical orders. The physician, NP or PA should have a thoughtful MOLST discussion with the appropriate decision maker (patient, health care agent or surrogate), using the 8-Step MOLST Protocol. A care plan that includes palliation and supportive care is necessary for those who choose to remain in place.
2. For those in PALTC who do not have a DOH MOLST/eMOLST, screen and identify residents who are appropriate for MOLST. Once identified, capacity assessment is needed to determine the right decision-maker (patient, health care agent or surrogate); secure copies of health care proxies and maintain in the medical record; have a thoughtful MOLST discussion; and develop a care plan.
3. Family and loved ones should be included in the discussion via phone call or secure telemedicine. Families need to be part of the discussion and be aware of patient preferences, particularly regarding preferences re: Resuscitation, Respiratory Support & Hospitalization.
4. Ideally, this approach would include all MOLST appropriate patients. However, the eMOLST team has learned through experience that it is nearly impossible to easily access these paper MOLST forms. Further, primary care physicians, NPs and PAs are overworked and dealing with COVID-19.
5. Have Governor Cuomo consider accelerating the implementation of PAs being authorized and accountable for MOLST, scheduled to go into effect June 17.
6. Collaborate on expediting eMOLST access to physicians, NPs and PAs and other members of the medical team and ensuring all hospitals, especially the emergency departments, have access to and processes are in place to check the registry for medical orders regarding resuscitation preferences and respiratory support.
7. Given the limited availability of ventilators, special consideration should be given to residents on long term ventilatory support to ensure the person’s current goals for care align with their current medical condition, prognosis and preferences considering COVID-19.

Additional eMOLST Benefits During COVID-19

Katie Orem, MPH
MOLST & eMOLST Program Director

During the era of COVID-19 many health systems and the associations of hospitals and nursing homes have reached out to our team for help and assistance in managing best practices regarding end-of-life discussions and MOLST completion. We continue to recommend eMOLST implementation for all levels of care. Importantly, we will also be offering our current partner organizations additional benefits (particularly see #3 below) during this crisis to help them manage this population of their most seriously ill patients.

1. eMOLST at its core serves as a list of the very sickest patients who are most likely to suffer the worst outcomes if infected with COVID-19. Organizations can use these lists to help target their care management efforts and create care plans for those who wish to avoid hospitalization.
2. eMOLST houses data about specific critical medical orders such as CPR/DNR, respiratory support orders, and hospitalization orders that are accessible 24/7, including across care settings. Accessing the orders at the point of care ensures patients are receiving treatment in line with their preferences and avoiding unwanted interventions.
3. For the first time ever we are working to make the eMOLST parsed order sets available to partner health systems for their eMOLST patients en masse (vs. viewing every order individually). The eMOLST Administrator will be reaching out with these data based on patient volumes and location within New York State.
4. Skilled nursing facilities, primary care, specialty practices and hospices will all need to focus energy on additional care planning for their seriously ill patients and particularly for those who would like to avoid hospitalization. eMOLST will provide a consolidated list of those orders.
5. eMOLST offers a streamlined process for high-quality goals for care discussions and authorizing end-of-life medical orders, including ensuring ethical compliance which is essential during this crisis.
6. After thoughtful discussions, patients may want their resuscitation, respiratory support and/or hospitalization preferences updated in light of the COVID-19 crisis. Review and renew is easiest with the eMOLST system.

We recognize that many health systems and organizations are feeling an additional sense of urgency regarding offering appropriate end-of-life discussions to seriously ill patients who may want to avoid specific life-sustaining treatments. eMOLST provides a framework for these conversations and provides guard rails to ensure the process is offered to patients who are clinically appropriate and that the decisions are made in a patient-centered, ethical and legal way. We encourage all organizations to gain access to eMOLST to retrieve orders for the tens of thousands of patients with existing orders in the system and initiate eMOLST discussions with all clinically appropriate patients that they see in their care settings.

Featured Resource: and focuses on advance care planning & advance directives for the general population, along with palliative care & hospice, pain & symptom management, and death & dying. focuses on advance care planning and the MOLST process for seriously ill people supported by a person-centered, family-oriented, 24/7 responsive palliative care plan.

The two websites are complementary, focus on a population health approach and seamlessly connect. Together, and aim to engage, educate and empower patients, families, health care and other professionals about the key pillars of palliative care.

Why is COVID-19 a threat?

COVID-19 is a severe respiratory illness caused by the virus named SARS-CoV2. It is a novel virus, which means that no one in the world has antibodies to it because no one has ever been infected by it before. When the COVID-19 virus invades our body, we do not have antibodies. We do not have resistance from a previous exposure to rapidly create a defense against the virus. Because no one has antibodies, everyone is at risk for catching the virus, becoming ill, and spreading the virus so that it can infect those around you.

COVID-19 has been described by some as “just a cold,” or just like the common influenza. COVID-19 is not a common flu. COVID-19 is an order of magnitude worse than the flu. The fatality rate is approximately ten times worse than the flu. This is particularly the case for patients with advanced medical conditions and frailty.

Influenza spreads from September through April in the U.S. Patients will require hospital treatment over the course of a few weeks rather than the 3-4 months of a typical flu season.

Know Your Choices. Share Your Wishes. Create Certainty During Uncertain Times.

Patricia Bomba, MD, MACP, FRCP
Chair, National Healthcare Decisions Day NYS Coalition

As the situation with COVID19 continues to develop, I want to first and foremost thank you all for all you have done over the past two decades to support advance care planning (ACP) with your family, loved ones, and your community. At first, I encouraged everyone to emulate my family’s 28 year Thanksgiving tradition of having ACP discussions. I know the positive impact ACP conversations have had for me and for my family. Subsequently, we expanded our efforts to National Healthcare Decisions Day and we continue to spread the word throughout the year.

We recognize that with the rapidly changing COVID-19 situation around the world, this is an unprecedented time for everyone. Time filled with uncertainty can lead to significant stress.

Stress increases as we are bombarded by messaging at work, at home, on the news, on social media and in conversations with family, friends and colleagues. To reduce the stress that occurs with uncertainty, let’s focus on our biologic or family by choice. Start by asking a few simple questions:
• What would happen if you contract COVID-19 and were unable to make your own medical decisions?
• Who would make medical decisions if you were infected with COVID-19 and lacked the ability to make medical decisions?
• How would you ensure that you receive the kind of care you want?
• Would our loved ones know enough about what matters most?

As medical practitioners, we can lead by example and make time to have a discussion with loved ones and complete or update the necessary legal advance directive. In NY, the key legal document is the Health Care Proxy.

Choosing the right Health Care Agent and an alternate agent is critically important as they have the tough job of standing in your shoes and making decisions based on your known wishes or best interests. The right Health Care Agent isn’t always the obvious choice. Discover what qualities the right Health Care Agent should possess and watch/share this short video. When choosing a health care agent, there are special considerations when the person has intellectual/developmental disabilities, can’t find a health care agent or is a young adult turning 18.

“Social distancing” has brought some nuclear families together and separated others. Through the power of technology, these important advance care planning conversations can occur through videoconferencing. Advance care planning conversations helps you to maintain control and achieve peace of mind for you and your family by reducing uncertainty, as well as to avoid confusion and conflict over your care. The ACP booklet can help guide you through the process.

Adaptability and preparation are key to successfully navigating through this uncertain time.