MOLST is Signed. Now What?

People nearing the end of life often experience multiple transitions between care settings—including high rates of preventable/potentially unwanted hospitalizations—that can fragment the delivery of care and create burdens for patients and families. Appropriate patients should be offered a thoughtful MOLST discussion(s). After MOLST is signed by the physician or nurse practitioner, a palliative care plan is needed to ensure the patient’s preferences for care and treatment are honored.

A patient with advanced cancer has completed a MOLST and no longer wishes to be hospitalized or transported to the ER for assessment and treatment of uncontrolled pain. What is the plan for 24/7 assessment and treatment of uncontrolled pain or a myriad of other symptoms? Who should be called in an emergency if the plan fails?

A patient with advanced chronic lung disease has required multiple hospitalizations for respiratory support, including several bouts of prolonged mechanical ventilation with and without intubation. He wants to forego such treatment in the future. Oxygen and morphine have been prescribed to treat dyspnea. What is the plan for 24/7 assessment and treatment of air hunger? Does the patient and family recognize morphine is effective treatment and will not cause the patient to become an “addict”?

A dynamic care plan that supports MOLST must be developed and in place to manage pain and symptoms that readily adapts to the patient’s changing needs and revised MOLST medical orders. The attending clinician must list the steps to be taken by the patient and/or caregivers to manage escalating pain and symptoms 24/7.

For example, a seriously ill patient may have multiple sites and causes of pain that vary in the degree of severity at any one point in time, over the course of a day and in between assessments. A single pain score on a scale of 1-10 is grossly inadequate. A Pain Drawing may help along with assessing the interference of pain with the enjoyment of life and general activity (PEG Scale). While identifying a specific etiology for pain is often challenging, a complete assessment, including physical, mental, emotional, and spiritual components is helpful in determining the appropriate course of management. Seriously ill patients should be engaged in management of their pain to the extent possible. The patient should establish what is acceptable control of pain and tolerable impact on mental acuity and function. An array of symptoms aside from pain and dyspnea must be equally addressed.

The demand on family caregivers is increasing, and the types of tasks performed by family caregivers are expanding from personal care and household tasks to include medical and nursing tasks, such as medication management. Caregivers must be engaged, educated, and empowered to perform all tasks that meet the needs of the patient. Caregivers must be supported and encouraged to optimize self-care in order to minimize the potential for burnout.

Featured Resource: Article on Key Role of Social Work in MOLST Process

A well-trained social worker plays a key role in educating patients and families about advance care planning, the differences between advance directives and MOLST and the shared medical decision-making process. Social workers can participate in MOLST discussions within scope of practice. Social workers are uniquely trained in family dynamics and conflict resolution but are not trained to write medical orders. Issues related to unresolved family conflict often arise at the end of life and play a key role in the conflict resolution process. Read more.

FAQ: How do I obtain more MOLST forms?

The NYSDOH is fulfilling orders for DOH-5003 MOLST forms on Pulsar Pink paper. To have MOLST forms mailed to you:

1) Complete the DOH Order Form 2) Mail the form to the address listed at the top of the form or email it to OGS.SM.GDC@OGS.NY.GOV We also encourage you and your organizations to implement eMOLST in your setting and encourage use in the communities you serve.

eMOLST Champion: Christine Wilkins, PhD, LCSW

Christine Wilkins, Ph.D., LCSW, is the advance care planning program manager for NYU Langone Health (NYULH) and has been integral to the success of eMOLST across their organization.

NYULH’s launch of eMOLST in 2016 proceeded systematically with Christine’s direct leadership and the endorsement of Dr. Kimberly Glassman, SVP of patient services and CNO, Dr. Fritz Francois, CMO, and Dr. Jonathan Austrian, Epic Inpatient Medical Director. The team prioritized eMOLST because, according to Christine, “eMOLST helps promote coordinated and person-centered care. With eMOLST, providers can more easily access the patient’s orders and build on them.” Christine organized the rollout of eMOLST from their Manhattan hospital to Brooklyn and across the health system – both inpatient and outpatient – in short order. As new organizations have joined NYULH they have adopted eMOLST as part of their “onboarding” to the health system. Most recently Winthrop Hospital joined NYULH and implemented eMOLST within 2 months of joining the health system. Christine’s leadership has ensured that “at NYULH eMOLST is the standard of care for patients with serious illness and frailty. It allows for richer conversations that address wishes regarding resuscitation and other life sustaining treatments.”

Christine’s work on changing the culture around advance care planning and ensuring robust end-of-life discussions occur across NYULH has paid dividends both inside and outside their organization. Numerous other organizations in NYC have followed suit including nursing homes, home care and hospice agencies, several other health systems, and Healthix. NYULH and others have also seen the benefits of these additional organizations using the eMOLST system as patients have been seen in multiple places and by multiple providers. Christine shared that “NYULH’s hope is that all of NYC implement eMOLST so that we can ensure that our patients’ wishes are honored wherever they are.” NYULH is also continuing its community leadership to encourage partners to adopt eMOLST.

In addition to her role at NYULH, Christine serves as the National POLST social work rep and sits on NYS’ MOLST Statewide Implementation Team and the Team’s Executive Committee.
Community Principles of Pain Management (CPPM) Updated 2019

Chronic pain and prescription opioid misuse are both major public health problems that exist across the continuum of care. Pain is a major driver for visits to physicians, a major reason for taking medications, a major cause of disability, and a key factor in quality of life and productivity. The CPPM aim to identify and promote the essential elements of acute, chronic and palliative pain assessment and management for both children and adults, as well as recognize the risks of opioid use disorder. The revised complete pain toolkit aligns with national guidelines and aim to help clinicians meet federal and state regulations.

Improving the way opioids are prescribed through clinical practice guidelines can ensure seriously ill patients have access to safe and effective chronic pain treatments, while reducing the number of people who misuse or overdose from these drugs. Drug overdose deaths and opioid-involved deaths continue to increase in the United States. Deaths from drug overdose are up among men and women, all races, and adults of nearly all ages.

It is essential to establish and focus treatment on patient specific SMART (Specific, Measurable, Agreed Upon, Realistic, Time-based) goals that result in improved function and quality of life and reduction in suffering. All patients should be engaged in active management of their pain (active approach.) Because chronic pain affects the whole person (body, mind, and spirit), patient-centered nonpharmacologic therapies that acknowledge the patients’ roles in their own healing processes have the potential to provide more efficient and comprehensive chronic pain management. Active self-care therapies allow for a more diverse, patient-centered treatment of complex symptoms, promote self-management, and are relatively safe and cost-effective.

When opioids are indicated, treatment should be based on the patient’s goals and combined with an active nondrug approach and & nonopioid pharmacologic therapy, as indicated. A written treatment plan should be developed and documented in the medical record and reviewed periodically, at least annually, using a risk/benefit analysis.

Treatment plans must include the goals for pain management and functional improvement based on the patient’s diagnosis. A full discussion of how this opioid treatment will be tapered to lower doses or tapered and discontinued, if benefits do not outweigh the risks, is required. The prescriber must also advise the patient of alternatives to and the risks of alternatives to opioids (informed consent is a discussion of the risks/benefits/alternatives including the alternatives, no treatment, and risks of alternatives). When opioids are indicated, a Pain Management Agreement and Informed Consent should be used.

Continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. If benefits do not outweigh harms of continued opioid therapy, optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids. Avoid abrupt cessation of opioids.

Additional information is found on Pain Guidelines, Opioid Use Disorder, Patient Resources and Help with Addiction.