Adopt My Family’s Thanksgiving Tradition

By Patricia Bomba MD, MACP, FRCP

My family has a Thanksgiving tradition dating back to 1992 that has nothing to do with food or football, but rather personal values and beliefs. It’s our annual family advance care planning discussion when we focus on what makes life worth living at this point in our lives. I encourage every family to embrace our Thanksgiving tradition. Our Thanksgiving and thoughtful MOLST discussions helped our family honor our mom’s wishes at the end of her life.

Advance care planning is a gift to yourself and your family. Choose the person you trust to make medical decisions if you lose the ability to make medical decisions and share your values, beliefs and what matters most with your family and loved ones.

Years ago my family started this tradition on Thanksgiving because it’s an American holiday that just about everyone celebrates, attracting family members from far and wide. While at first you might think it’s morbid to discuss such issues at a festive gathering, we’ve found sharing our wishes for end-of-life care actually brings us closer. We gain peace of mind knowing our own wishes will be understood and honored in the event we can’t speak for ourselves.

In our family, “No pumpkin pie, until you tell me how you want to live until you die.” After the dinner dishes are cleared, the adults in our family stay at the table and talk about what matters most in our lives. We review our advance directives to make sure they reflect our current feelings. We have blank forms handy in case new documents need to be completed and witnessed.

As a physician and health plan medical director with an expertise in geriatrics, palliative care and end-of-life issues, I’m especially passionate about advance care planning. I recommend that everyone 18 and older participate in these discussions and complete a Health Care Proxy. Everyone should share copies with their physician, lawyer and most importantly, loved ones.

Discussing and documenting each family member’s values and goals for their care at that point in time will save heartache and family turmoil in the future. Download a free step-by-step Advance Care Planning Booklet that helps guide the process and contains blank forms for the New York Health Care Proxy and explains MOLST at

Conversations change lives! Start yours today! What better time to start a conversation than when your family gathers for the holidays. For a sharable, more detailed version of this article, please see my 2016 piece in A Healthier Upstate.

Featured Resource: Holiday Season Advance Care Planning News Segment

For the latest installment of A Healthier Rochester sponsored by Excellus BlueCross BlueShield, 13 WHAM News Anchor Alexis Arnold sat down with Deb Stamps, who shared her personal advance care planning story, and our own Katie Orem who explained the importance and 5 Easy Steps of Advance Care Planning. Watch here.

FAQ: What is the difference between a health care proxy and the MOLST?

The health care proxy is a legal document that lets you name someone to make decisions about your medical care, including decisions about life-sustaining treatment. It is recommended for everyone 18 years and older. It only applies when a person is no longer is able to make medical decisions.

The MOLST contains specific and actionable medical orders that can be followed by EMS in an emergency and transition with a patient across health care settings. MOLST is for seriously ill persons who might die in the next year.

eMOLST Champion:
The Maplewood

The Maplewood, a 74-bed nursing home in Webster, NY, began implementing eMOLST in Spring 2019. The Maplewood clinical staff, including their medical director and nurse practitioners, participated in ECHO MOLST during the Spring 2019 clinic series and this laid the groundwork for the eMOLST transition. Their medical director, Dr. Diane Kane, who is also a geriatrician and palliative medicine physician with Rochester Regional Health, had used eMOLST previously. She and The Maplewood’s Owner/Administrator, Greg Chambery, LNHA, saw the value in transitioning the organization to eMOLST in a quick and methodical manner to guarantee the quality and process used in their end-of-life discussions, as well as to further the electronic transformation across the organization.

During the Spring the facility staff, led by Laurie Zazzara, Assistant Administrator, worked through their policy and procedure review; social work audited all charts for the presence of a Health Care Proxy to ensure they had the correct advance directive information, and Dr. Kane and NPs Erika Griffin and Dawn Schmitt confirmed accuracy of all MOLST orders prior to converting to eMOLST. Tonie Oneil, HIM, enrolled all users, captured scans of all the paper forms, and assisted the IT staff with implementing Single Sign On for clinicians’ convenience.

Simultaneously, given The Maplewood’s ideal size and commitment to quality the eMOLST team at Excellus BlueCross BlueShield offered to assist with the paper conversion using a new optical character recognition tool called ABBYY, which used the high-quality scans of the paper forms. This process streamlined the paper conversion process from something that could have taken the clinical team a few weeks into one that took less than three days in total, with the nurses, NPs & physician spending only a few hours confirming all documentation and re-signing the orders. Read more about the process of using ABBYY with eMOLST in the accompanying article in this newsletter.

The Maplewood’s quick and methodical approach, commitment to quality conversations and excellent documentation made them an ideal site to implement eMOLST, as well as pilot the ABBYY process. Their work has served as a model for eMOLST implementation as well as using ABBYY with other organizations.

eMOLST + ABBYY = A Match for Quality & Efficiency in Paper Conversion

Katie Orem, MPH
eMOLST Administrator for New York State

For years we have wanted to assist nursing homes, physician/NP offices and hospices with shortening the sometimes-painful period of transitioning from paper charts to eMOLST. Most nursing home residents are clinically appropriate for end-of-life discussions, so it is not uncommon to find high-quality facilities that want to convert to eMOLST but are sometimes overwhelmed by the conversion process. Fortunately, at Excellus BlueCross BlueShield we also have a lot of experience transitioning from paper to electronic, so we sought out the expertise of our Document Services team. We asked them how we could simplify the transition from paper to eMOLST and they responded with ABBYY, a state-of-the-art enterprise tool in optical character recognition (OCR) that is already being used for other projects.

ABBYY was coded to “read” high quality scans of paper MOLST forms and identify which boxes were checked and where there were consents or signatures, as well as dates, etc. After ABBYY documents everything it sees, there are two levels of human verification included in the ABBYY software to ensure that ABBYY has read everything correctly, that names are spelled correctly, etc. Assuming everything is accurate, the data is transmitted to the eMOLST system which uses its logic engine to identify errors, incompatible orders and capture any additional gaps. As long as the paper MOLST form is able to be used in an emergency (a minimum standard of quality) then eMOLST will accept the scan and all the data that accompanies it so that the next time the clinician enters the system a signed eMOLST is present (the scanned form) and a draft has been pre-created for clinicians to enter additional documentation (all applicable ethical and legal requirements) and for physicians and nurse practitioners to confirm and re-sign the orders.

In the meantime, the eMOLST team is documenting all errors and gaps that need corrections in a report that can be shared with the facility so the physicians/NPs and other clinical staff understand where they need to focus their time. The biggest examples of errors that would result in rejection of the paper MOLST (and the need to re-do the conversation) include incompatible medical orders (i.e. CPR + DNI) and missing dates of consent or physician/NP signature. The eMOLST system will also point out any gaps in documentation, even when the orders themselves are valid, such as when concurring capacity is missing, or when the facility hasn’t done appropriate clinical standards documentation or ethics review as needed.

The conversion to eMOLST is a quality improvement project for facilities, offices and hospices that offers benefits to the patients and ensures high quality MOLST completion, increasing the likelihood that patients’ MOLST orders will be honored. The use of ABBYY with eMOLST takes organizations from paper to eMOLST in a matter of days, instead of weeks, a major convenience and helps in reducing errors that can take place when they live in the hybrid paper + electronic world. eMOLST then ensures their patients’ orders are accessible 24/7 in all settings with internet access and that the orders were completed in compliance with all applicable public health laws.

As we enter 2020 we will be looking for additional facilities to closely partner with in transitioning to eMOLST, leveraging the ABBYY technology.