Skip to main content Accessibility help
×
Home

Medical orders for life-sustaining treatment: Is it time yet?

  • Anna Clarissa Araw (a1), Anna Marissa Araw (a1), Renee Pekmezaris (a2) (a3) (a4), Christian N. Nouryan (a2), Cristina Sison (a5), Barbara Tommasulo (a1) and Gisele P. Wolf-Klein (a1) (a4) (a6)...

Abstract

Objective:

As the aging population faces complex end-of-life issues, we studied the intervals between long-term care admission and advance directive completion, and between completion and death. We also sought to determine the interdisciplinary team's compliance with documented wishes.

Method:

A cross-sectional study of 182 long-term care residents in two facilities with and without completed medical orders for life-sustaining treatment (MOLST) in the New York Metropolitan area was conducted. Demographic variables included: gender, age, ethnicity, and diagnosis. Measures included: admission date, MOLST execution date, and date of death. Resident advance directive documentation was compared with clinical intervention at time of death, including intubation and mechanical ventilation.

Results:

Of the residents studied, 68.7% were female, 91% were Caucasian and 91.8% were ≥ 65 years of age (mean age: 83). The median time from admission to MOLST signing was 48 days. Median time from admission to MOLST signing for Caucasians was 21 days; for non-Caucasians was 229 days. Fifty-two percent of MOLST were signed by children, and 24% by residents. Of those with signed forms, 25% signed on day of admission, 37% signed within 7 days, and 47% signed within 21 days. Only 3% of residents died the day their MOLST was signed, whereas 12% died within a week, and 22% died within 30 days. Finally, among the 68 subjects who signed a MOLST and died, 87% had their wishes met.

Significance of results:

In this era of growing time constraints and increased regulations, medical directors of long-term care facilities and those team members caring for residents urgently need a clear and simple approach to the goals of care for their residents. The MOLST is an ideal tool in caring for older adults at the end of life, providing concrete guidance, not only with regard to do not resuscitate (DNR) and do not intubate (DNI) orders, but also for practical approaches to daily care for the interdisciplinary team.

Copyright

Corresponding author

Address correspondence and reprint requests to: Renee Pekmezaris, North Shore Long Island Jewish Health System, Health Services Research, 175 Community Drive, Suite 242G, New Hyde Park, New York11021. E-mail: rpekmeza@nshs.edu

References

Hide All
Administration on Aging, United States Department of Health and Human Services. A Profile of Older Americans: 2005. http://assets.aarp.org/rgcenter/general/profile_2005.pdf.
Alabi, T.O. & Haines, CA. (2009). Predicting survival from in-hospital CPR. Clinical Geriatrics, 17, 3436.
Bomba, P. (2006). Medical orders for life-sustaining treatment (MOLST): A paradigm shift in advance care planning. New York State Bar Association Health Law Journal, 11, 3951.
Center for Ethics in Health Care, Oregon Health & Science University. (2008). Physician Orders for Life-Sustaining Treatment Paradigm (POLST). http://www.ohsu.edu/polst/.
Center for Ethics in Health Care, Oregon Health & Science University. (2008). POLST Paradigm Program Contact List by State. http://www.ohsu.edu/polst/programs/state-contacts.htm.
Earle, C.C., Park, E.R., Lai, B., et al. (2003). Identifying potential indicators of the quality of end-of-life cancer care from administrative data. Journal of Clinical Oncology, 21, 11331138.
Ehlenbach, W.J., Barnato, A.E., Curtis, J.R., et al. (2009). Epidemiologic study of in-hospital cardiopulmonary resuscitation in the elderly. New England Journal of Medicine, 361, 2231.
Hoover, D.R., Siegel, M., Lucas, J., et al. (2010). Depression in the first year of stay for elderly long-term nursing home residents in the USA. International Psychogeriatrics, 22, 11611171.
Intrator, O., Zinn, J. & Mor, V. (2004). Nursing home characteristics and potentially preventable hospitalizations of long-stay residents. Journal of the American Geriatrics Society, 52, 17301736.
Jones, A.L., Moss, A.J. & Harris-Kojetin, L.D. (2011). Use of advance directives in long-term care populations. NCHS data brief, no 54. Hyattsville, MD: National Center for Health Statistics. http://www.cdc.gov/nchs/data/databriefs/db54.pdf.
Kinsella, K. & He, W. (2009). U.S. Census Bureau, International Population Reports, P95/09-1, An Aging World: 2008. Washington, DC: U.S. Government Printing Office. http://www.census.gov/prod/2009pubs/p95-09-1.pdf.
Levin, T.T., Li, Y., Weiner, J.S., et al. (2008). How do-not-resuscitate orders are utilized in cancer residents: Timing relative to death and communication-training implications. Palliative & Supportive Care, 6, 341348.
Miller, K.E., Zylstra, R.G. & Standridge, J.B. (2000). The geriatric patient: A systematic approach to maintaining health. American Family Physician, 61, 10891104.
Murray, L.M. & Laditka, S.B. (2010). Care transitions by older adults from nursing homes to hospitals: Implications for long-term care practice, geriatrics education, and research. Journal of the American Medical Directors Association, 11, 231238.
New York State Department of Health form # DOH-5003 (6/10) Medical Orders for Life-Sustaining Treatment (MOLST). (2010). http://www.compassionandsupport.org/pdfs/professionals/molst/DOH-5003_06.10_.FINAL__.pdf.
New York State Department of Health letter to all New York Nursing Homes. (2007). Dear Administrator — Resident Advance Directives and Basic Life Support. http://www.health.state.ny.us/professionals/hospital_administrator/dal/dal_2007-01-04.htm.
New York State. (2008). Public Health Law §#2877. www.compassionandsupport.org/pdfs/legislation/MOLST%20Legislation%202008.pdf.
Pekmezaris, R., Breuer, L., Zaballero, A., et al. (2004). Predictors of site of death of end-of-life patients: the importance of specificity in advance directives. Journal of Palliative Medicine, 7, 917.
Sam, S., Pekmezaris, R., Nouryan, C.N., et al. (2011). Survey of emergency medical services professionals' experience with advance directives and medical orders for life-sustaining treatment. Journal of the American Geriatrics Society, 59, 23832384.
Vo, H., Pekmezaris, R., Guzik, H., et al. (2011). Knowledge and attitudes of health care workers regarding MOLST (Medical Orders for Life-Sustaining Treatment) implementation in long-term care facilities. Geriatric Nursing, 32, 5862.
Zhang, B., Wright, A.A., Huskamp, H.A., et al. (2009). Health care costs in the last week of life: Associations with end of life conversations. Archives of Internal Medicine, 169, 480488.

Keywords

Metrics

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed