Introduction

Webcast archive: Medical Orders for Life Sustaining Treatment

Today, we discuss problems with Medical Orders for Life-Sustaining Treatment and other advance directives.

Webcast archive: Medical Orders for Life Sustaining Treatment

In this episode of Euthanasia & Disability, Amy Hasbrouck and Christian Debray discuss Medical Orders for Life Sustaining Treatment.

Please note that this text is only a script and that our webcast contains additional commentary.

MEDICAL ORDERS FOR LIFE SUSTAINING TREATMENT

  • Advance care planning is a good idea in general.  It’s important to have conversations with your loved ones and your doctor about what medical treatments you would or would not want should you become unable to direct your own care.  And it’s important to name a person to carry out your wishes if you are unconscious.
  • One tool used in advance care planning is called a Physician Order for Life Sustaining Treatment (POLST), or a Medical Order for Life Sustaining Treatment, (MOLST)
  • A “Do Not Resuscitate” order is a kind of MOLST.
  • Unlike an advance directive, which is a request made by a patient, a MOLST is signed by a doctor, and has the effect of a medical order.
  • A doctor is supposed to discuss the options with a person who has a terminal illness, help her fill out the form, witness her signature, then sign it, attesting that the discussion took place.  The form is then put into the person’s medical record, and should be followed by staff if the person cannot consent to care.
  • Unfortunately it doesn’t always work out that way.
  • Doctors and hospitals often use MOLST with disabled people with non-terminal illness.  Most people who are terminally ill have a disability, but many people with disabilities are not terminally ill.
  • When deciding whether or not to fill out a MOLST form, a doctor will usually answer the “surprise question”:  would she be surprised if the person died within the next year.  This is not a an official diagnosis, nor a terminal prognosis, and can include many people whose lives are not at risk.
  • Yet some state laws even extend MOLST to people with a five-year prognosis.
  • Filling out a MOLST is often presented to patients as mandatory, though it is not.  People who refuse may be pressured to do so.
  • Many MOLST forms require a simple “yes” or “no” answer to proposed treatments, but without any context.  So to the question “would you accept a feeding tube?” the answer might depend on factors that are not listed on the form.
  • Also, the form might not specify what medical treatments are included in “comfort care” or “intermediate care.”
  • Another problem with MOLST is its bias against life-sustaining technologies.  Interventions such as feeding tubes and tracheotomies are presented as negative, intrusive, limiting, and incompatible with a normal life.  Presented with such biased information, most people refuse these options, though many disabled people are able to pursue fulfilling and productive lives thanks to these technologies.
  • The completed MOLST form may not reflect the person’s wishes, the person must trust the doctor will resist the pressure to cut costs and honour his requests.  Laws allow doctors to overrule a person’s request for life-sustaining treatment if she thinks care would be “futile.”  Some of the worst of these abuses happen in nursing homes.
    • Some forms don’t require the patient’s signature, or the doctor may just sign the form and put it in the person’s record.
    • Many MOLST forms are filled out by nurses or nurses’ aides, and may even lack a doctor’s signature.
    • Sometimes forms are changed after the person signs it.
    • One such form provided that anyone could sign to make medical decisions for the person in case of incapacity.
    • Sometimes nursing home staff ask family members to sign MOLST forms even though the person has capacity to make his own medical decisions.
    • The MOLST form may be explained by a non-medical staff person, such as an admissions coordinator or a business manager leading to a lack of informed consent.
  • Some doctors and nurses follow the instructions only when they agree with the MOLST.  So if the form calls for breathing support but the medical staff think it’s futile, they may simply ignore the order.
  • Also, there is a risk of over-interpretation of the MOLST.  In one study, over 50% of medical staff misinterpreted a MOLST as including a DNR when it didn’t.
  • The form should be in both official languages to be understood by the person and medical staff.
  • There may be confusion and conflict between an advance directive (which comes from the person) and a MOLST, which comes from the doctor, has the authority of a medical order and is more likely to be followed by staff.
  • The MOLST stays in effect until it is removed, and revocation can be difficult.  In one study in of five cases in Manitoba, two people who tried to have a DNR order removed from their loved ones’ charts were refused and harassed, while another person was pressured to accept a DNR order.
  • There may be problems with the physician order signed by a doctor at one institution being honoured by medical staff at another hospital.
  • It’s important that patients and their families be vigilant in checking to see what is written on a MOLST, and demanding that it be changed if it doesn’t agree with their wishes.