MOLST/POLST: A Way to Ensure Your Final Wishes Are Implemented

April 2024

Issue #10 April 2024

In This Issue: Learn about an important tool that can ensure your end-of-life care wishes are implemented rather than simply existing in a document you signed long ago.

MOLST/POLST: A Way to Ensure Your Final Wishes Are Implemented

One of the great innovations of modern medical ethics has been the DNR, the “do not resuscitate” order. Years ago, regardless of an individual’s preference, we spent fruitless hours trying to revive very sick people, often losing them in the end. Some people decided that they didn’t want to wake up after a resuscitation with painfully broken ribs, connected to a ventilator, only to suffer for days or weeks until finally passing. A DNR order is a way to avoid having someone perform CPR when your heart stops. Your physician can write a DNR order, so you avoid this fate.

It took our medical culture a while to consistently implement DNR orders. Years ago, I saw patients who had “DNR” tattoos on their chests—they wanted to ensure that the team understood their wishes. Today, having a DNR order in the hospital will ensure that, if your body starts to fail, nature is allowed to take its course.

However, there is one major shortcoming of the DNR: it is specific to the hospital (or nursing home) where your doctor has written the order. A hospital DNR won’t protect you from being revived, against your wishes, should you have a cardiac arrest in your house. And having your wishes in your living will, somewhere in a file cabinet or computer, won’t help either.  

When EMTs are called to someone’s house, they are obligated to try to save the life of the person, even those who do not wish to be revived. This is their job, and they would be seen as negligent if they did anything else. Their professional obligation is to preserve life, and without a doctor’s order not to do so, they must proceed. Even if you have signed a living will and someone can get their hands on it to show the EMT, without a doctor’s order that covers them, the EMTs are obligated to resuscitate you.

Fortunately, there has been another advancement, but it is far less widely known and utilized. In the 1990s, medical ethicists in Oregon developed what is now known in various states as the Physician / Portable Orders for Life-Sustaining Treatment (POLST) or the Medical Orders for Life-Sustaining Treatment (MOLST). For our purposes, we’ll refer to the MOLST/POLST as MOLST. By any name, the MOLST is an order set signed by a physician that applies outside of hospitals. It can be used to order the EMTs to not resuscitate you. 

The MOLST is a wonderfully useful and flexible document. For one thing, if an EMT arrives at your home, they can see the MOLST. It is printed on bright colored paper and placed by a person on their refrigerator—and EMTs now know to check your refrigerator. In Massachusetts and New York, it’s fluorescent pink, and in Connecticut, it’s lime green. The bright colored paper makes a MOLST easy to find floating in the sea of family photos and refrigerator magnets.

My mother, currently in hospice, had done a MOLST several years ago,  and she recently had it revised with her doctor to ensure that it reflects her most up-to-date wishes. The staff at her independent care apartment have checked it, as has her hospice team. So far, all is well, and her wishes are being followed.

Over time, the MOLST has become better known, and useful, in a variety of situations.

And the MOLST is not just about DNR.  The New York state MOLST form allows you to select if you would want to be on a ventilator, or no ventilatory support at all. You can elect to be sent to the hospital if medically necessary, or only when in pain with severe symptoms that cannot be controlled, or never.

A man I know is 98, with mid to late-stage Alzheimer’s. He was living with his wife, who kept him at home as long as she could. As his Alzheimer’s advanced, he recognized family less often and sometimes wandered off. Some mornings they found him asleep on his floor, unharmed. After he started confusing the bedroom closet with the bathroom, his wife and his children decided it was too much. His loving relatives spent much time selecting a good memory care for him. In his new room, he kept up his old habit, and staff would find him sleeping on the floor next to his bed in the morning, or even just sitting there, perfectly comfy.

In the first three weeks, four times—four times—the memory care facility, finding him on the floor in the morning and concerned about liability should he have hurt himself during the night, called the EMTs and had him taken in an ambulance to an ER. The family was aghast. Not only was this confusing for this poor man with Alzheimer’s, but it was also deeply disrupting for them. Every time it happened, they had to call out of work and spend time in the ER. And ER evaluations and ambulance rides are not free. He never showed signs of injury. The family tried talking with the director of nursing, then her boss, then the boss’s boss. All to no avail. The memory care leadership insisted that since they couldn’t determine with complete certainty if he’d hit his head, they would have to send him to the ER. (And they had a policy against cameras which would have allowed a review of the slide down to the floor).

The solution? Well, it could have been a MOLST. This man didn’t only need a DNR order—the issue wasn’t life-saving measures. What the family wanted was the implementation of a Do Not Transfer to the Hospital (unless needed for comfort) order on the Connecticut MOLST.  The family approached the nurse practitioner at his memory care facility, but they hadn’t heard of the MOLST. Wanting to know more, I called the state and tracked down the person in charge of the MOLST in Connecticut.  It turns out that in that state, they are struggling with MOLST adoption, possibly because their doctors are required to undergo special training and take a test before being legally allowed to sign one. (This strikes me as a case of “great” being the enemy of “good enough”).

For this family, the solution was to move their loved one (about a month ago) to a different memory care facility, one with better nursing assessment capabilities and a different attitude. He is still sometimes found on the floor in the morning. He has yet to be hurt or transported to the ER. He is happily settling in now, and his family feels greatly relieved.

A MOLST, like a DNR, is something that should be considered by anybody who wants to preserve some control over their end-of-life care. You can decide that you don’t want to be hospitalized or resuscitated and a signed MOLST will ensure that happens.  Ask your primary care doctor about one. Even if they aren’t familiar with it, the more people that ask, the more likely a doctor will become interested in including MOLST in their practice.

Email me with your questions, comments, or subscription requests at gm@mymdadvisor.com. I’d love to hear from you. 

Warmly,
Gerda Maissel, MD, BCPA

Dr. Gerda Maissel, Author

Dr. Maissel is a Board-Certified Physical Medicine and Rehabilitation physician and a Board-Certified Patient Advocate.