OHIO SB 165
Ohio MOLST Talking Points & Questions
MOLST refers to medical orders for life-sustaining treatment. In some states, such documents are referred to as POLST, which stands for physician orders for life-sustaining treatment and similar titles. The POLST form was developed in 1991 by Oregon physicians to address a specific problem: Absent orders to the contrary, many patients who were seriously ill were receiving unwanted CPR (cardio-pulmonary resuscitation). The original intent of the form was to provide legal authority to emergency services personnel to not attempt CPR for patients who did not want it. Since then, the POLST and similar forms have expanded to address virtually any medical intervention.
MOLST goes into effect immediately regardless of the patient’s mental capacity or state of health.
Once signed and completed, “a MOLST form is valid and the instructions in it become operative and govern how the patient who is the subject of the form is to be treated with respect to hospitalization, administration or withdrawal of life-sustaining treatment and comfort care, administration of CPR and any other medical treatment specified on the form.”[1]
Will patients or their decision makers be informed of the form’s immediate effectiveness?
Unlike an advance directive, the signature of the patient or the patient’s decision maker need not be witnessed.
Why is the protection of having a witnessed signature not part of the MOLST form?
The MOLST form need not be discussed with a physician or other health care provider.
The proposed law permits an “issuing practitioner” to sign the form. “Issuing practitioner” includes not only a physician but also a physician assistant, certified nurse practitioner or clinical nurse specialist.[2] But nothing in the proposed legislation requires that the MOLST form be discussed with that issuing practitioner. All such communication can be carried out by a “form preparer” who is an individual who “completes the form pursuant to a practitioner’s delegation and for the practitioner’s signature.”[3]
“Form preparers” who discuss the MOLST form with patients and check the boxes on the form could include chaplains, social workers, volunteers, etc. All that is required is that the form preparer be delegated that role by the issuing practitioner. (In some jurisdictions, the form preparer is referred to as a “facilitator.”[4])
Would the MOLST form accurately reflect a patient’s wishes?
This depends upon how the “form preparer” documents information about discussions with the patient. According to a study of such forms, there is a lack of consensus or understanding about what patients intend, leading to patients either receiving or not receiving treatment contrary to their wishes.[5] The chief executive of one state’s program noted, “The form is only as good as the conversation.”[6]
Some questions about the form’s preparation must be asked:
- Do the preferences reflect those of the form preparer more than those of the patient?
- Was the patient steered toward a particular preference?
- Did the person who checked the boxes on the form correctly interpret the patient’s wishes?
- Did the person providing information about the available options explain them accurately and in a manner that the patient understood?
- Was the patient told that the form would be immediately effective and, even if the patient could recover, treatments that were limited by check boxes would not be provided and the patient could die as a result?
- Was the person checking the boxes hurried or not paying close attention?
Will patients feel pressured to have a MOLST form?
Although the proposed law states that the MOLST form is “always voluntary,”[7] the form in the proposed law[8] does not require that this fact be included on the form itself. Therefore, a patient or patient’s decision maker may be unaware that signing such a form cannot be required.
From a practical standpoint, patients and, in particular, residents of assisted living facilities and nursing homes are hesitant to show any lack of “cooperation” with requests made of them, and they may be reluctant to question the facility’s authority to require a MOLST form. A survey of nursing homes in Allegheny County, Pennsylvania, found that most of the surveyed facilities presented the POLST form to residents as a requirement.[9]
There would be virtually no limit to the categories of individuals who would be considered eligible for a MOLST form.
According to the proposed law, “Patients for whom medical orders for life-sustaining treatment are suggested, but not required, include those persons who are frail or experiencing an advanced or progressive illness.”[10]
Only one type of order needs to be immediately accessible.
That type of order is a do not resuscitate order (DNR), which is already provided in Ohio law.[11]
Once signed, the MOLST form will remain in the patient’s record even if it is revoked.
When transferred, the patient’s MOLST form is to be provided to the new facility. That form may be the original or a copy. Photocopies and faxes are legal and valid.[12] Even if the patient or the patient’s representative revokes the MOLST form, the proposed law states, “A revoked MOLST form shall be retained in the patient’s medical record.”[13]
Why is the form required to remain in the patient’s record? And what will happen to copies of the form that were provided to other facilities? Will patients know that copies of their unrevoked MOLST forms may still be retained in their records at other facilities?
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A recent article in the Journal of the American Medical Association noted that the original intent of the POLST form was to provide legal authority to emergency services personnel to not attempt CPR for patients who did not want it. However, since then, the POLST and similar forms have expanded to address various medical interventions.
The authors warned that, while it is reasonable for terminally ill patients to avoid CPR by having this indicated on a POLST form, “the use of more expansive documents in different populations should not be advocated unless or until the problems with POLST can be convincingly surmounted.”[14]
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[1] Sec. 2133.33 (lines 845-851).
[2] Sec. 2133.30 (N) (lines 549-554).
[3] Sec. 2133.30 (K) (lines 534-538).
[4] The Respecting Choices program at Wisconsin’s Gundersen Health System is a national center for training and certification of facilitators. A one-day program, if successfully completed, qualifies a person to be a certified facilitator. An additional day qualifies one to instruct others to be facilitators. Although a program spokesperson said it is helpful if facilitators have a nursing or social work background, there are no educational or professional prerequisites for such certification.
[5] Mararchi, F., Doshi A., Zerkle, S., Cooney,T., TRIAD VI. How well do emergency physicians understand physicians order for life sustaining treatment (POLST) forms? J. Patient Safety 2015; 11: 1-8, cited in “Study: Emergency providers often lack consensus on what patients intend when end-of-life forms come into play,” AHC Media, May 4, 2015. Available at: http://www.ahcmedia.com/articles/135432-study-emergency-providers-often-lack-consensus-on-what-patients-intend-when-end-of-life-forms-come-into-play (last accessed January 23, 2016).
[6] “Study: Emergency providers often lack consensus on what patients intend when end-of-life forms come into play,” AHC Media, May 4, 2015. Available at: http://www.ahcmedia.com/articles/135432-study-emergency-providers-often-lack-consensus-on-what-patients-intend-when-end-of-life-forms-come-into-play (last accessed January 23, 2016).
[7] Sec. 2133.31 (line 767). This information is included in the “Ohio MOLST Form Informational Supplement: Overview.”
[8] Sec. 2133.31 (lines 575-753).
[9] Jason W. Manne, “Physician Orders for Life Sustaining Treatment (POLST): How Do Nursing Facilities Implement the POLST Program?” (2012), pp. 77 and 82. Available at: http://d-scholarship.pitt.edu/16924/1/mannej_etd2012.pdf (last accessed January 23, 2016).
[10] Sec. 2133.33 (lines 841-844).
[11] ORC 2133.21 – 2133.26.
[12] Sec. 2133.31 (lines 749-750).
[13] Sec. 2133.38 (lines 919-920).
[14] Moore AM, Rubin EB, “The Problems With Physician Orders for Life-Sustaining Treatment,” JAMA, Vol. 315, No. 3, January 19, 2016, pp. 259-260.
© 2016
