Introduction

Webcast archive: MOLST – Part II – Filling out the forms

This week, we resume our discussion of Medical Orders for Life Sustaining Treatment.

Webcast archive: MOLST – Part II – Filling out the forms

In this episode of Euthanasia & Disability, Amy Hasbrouck and Christian Debray discuss:

  • MOLST – Part II – Filling out the forms

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

MOLST – PART II – FILLING OUT THE FORMS

  • After our discussion of Medical Orders for Life Sustaining Treatment last week, we felt that something was still missing.  We talked in general terms, but didn’t look at any actual MOLST forms.
  • So this week, we obtained several forms from the U.S. and Canada that represent a mix of MOLST and advance directive orders.  That way we can go over exactly what questions are on the forms, and how the questions are asked.
  • Québec’s and Ontario’s forms were not available on the internet, though we did find a copy of a form used in nursing homes in Québec.
  • Though the forms are for “life-sustaining treatment”, many present the option of rejecting life-saving treatments first.
  • Some of the forms offer the least to most life-saving care options in that order.  For example, the Fraser Health form from British Columbia offers comfort care first, then moves up to critical care.
  • Some of the forms talk about what the person doesn’t want, while a few, such as form from the Regina-Qu’Appelle region in Saskatchewan, is phrased in terms of what the person wants.
  • Some forms offer life-saving treatment on a “trial basis.”  This means that all measures would be taken to revive a person, then could be withdrawn later if the person wants them stopped, if she does not appear to be responding to treatment, or her condition is getting worse.
  • The CPR (cardiopulmonary resuscitation) option is usually the first item on the list.  The New York and Massachusetts forms offer “do not resuscitate” as the first option, but most others put “attempt resuscitation” first.
  • Sometimes the option of “no intubation” is offered, so that instead of having a breathing tube in your throat, only a breathing mask that provides positive airway pressure would be used.  This choice is available on the Fraser Health form, and several from the U.S.
  • Most regions seem to have three levels of care
    • Do everything, including CPR, cardiac defibrillation and intubation.
    • Elevated level of care, including some services, but not others.
    • Comfort care.
  • The services that make up the higher levels of care include:
    • Transfer to hospital, which applies both for people in long-term care and at home.  If the person does not want to be resuscitated and just wants to die at home, she can refuse to be taken to the hospital.
    • “Artificial” nutrition is feeding a liquid diet through a tube that is either inserted into the oesophagus via the nose, or through a gastric tube surgically inserted directly into the stomach.  Refusing artificial nutrition means the person will die of starvation within a few weeks, depending on her health.
    • “Artificial hydration” is when fluids are given intravenously instead of by mouth.  Refusing fluids means the person will die of dehydration within about 5-7 days.
    • Transfusions and blood products are given if a person has lost blood or if there is something wrong with the blood.  Refusing blood or blood products could cause death within a few hours or days, depending on the problem.
    • Kidney dialysis is needed when the kidneys are not working properly.  It cleans toxins and impurities from the blood that could poison a person if its not done every few days.  Refusing dialysis would cause death in a matter of days to weeks, depending on the level of kidney function.
    • Antibiotics are necessary to cure infections.  Refusing antibiotics will only cause a problem if you have a bacterial infection such as a urinary tract infection, an infected bed sore, C-difficile, pneumonia or other hospital-borne bug, any of which could cause death if untreated.
  • What is available in the higher level of care is different in each region, so it’s important to read the form carefully to know what services are available at each level of care.
  • Comfort care is medical care and treatment provided with the primary goal of relieving pain and other symptoms, and reducing suffering.  It includes:
    • Reasonable measures to offer food and fluids by mouth, including spoon feeding and liquids via a straw.
    • Administering medications (by mouth or in some regions, by IV).
    • Turning and positioning the person
    • Caring for wounds.
    • Providing oxygen and suctioning (if the windpipe becomes clogged with secretions)
  • As we said last week, a doctor is supposed to discuss these 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.
  • And, as we said, it doesn’t always work out that way.
  • Also, when doctors are describing these treatments, they often put a negative spin on them.  So, for example, instead of describing tube feeding as a medical technology that enables people to live normal lives, they may describe it in very medical terms that make it seem undignified.
  • It’s important to remember that doctors only see people when something goes wrong; at their worst, in the hospital.  They don’t see people, even people with feeding tubes or using ventilators living their everyday lives out in the community.
  • One problem we found with the MOLST forms was that they were not specific or confusing as to what treatments were required for each level of care.
    • For example, on the Québec form, level 2 care requires “Correction of any reversible deterioration using the resources available at the facility.  Transfer to a hospital as needed.”
    • The Georgia form’s “limited additional interventions” includes “comfort measures and medical treatment, IV fluids and cardiac monitor as indicated.  Does not include intubation or mechanical ventilation.  Avoid intensive care.  Transfer to hospital if indicated.”  This definition requires you to refer to the Comfort Care guidelines, then includes both Dos and Don’ts
  • As we said last week, it’s crucial that patients and their families be vigilant in checking to see if there is a DNR or MOLST form in their medical charts, verify what is written on the form, and demand that it be changed if it doesn’t agree with their wishes.