MOLST forms – everyone knows about them, everyone talks about them, but they are still subjects of controversy.
Recently we had a discussion at the Medicine Quality Committee meeting about MOLST forms, specifically about how to up regulate the care. As it turns out, it is pretty straightforward to de-escalate the care when a proxy feels that new limitations are appropriate. For example, if someone’s MOLST indicates that they had wished to be resuscitated, but the clinical situation has changed and it would be appropriate to make the person a DNR, a healthcare proxy can make the patient a DNR either with requesting that an order being placed in the chart or by completing an updated MOLST form, and then the appropriate order being placed in the chart. The justification needs to be there to support such a change in care limitations, but the process isn’t complex
Up regulating the care is a very different issue and generally should not be done. But even that discussion has two different subcategories as to how it needs to be looked at.
The easiest branch on that tree is if the proxy – rather than the patient – was the person who completed the MOLST form. When the patient was not directly involved and the proxy has been the creator of the care limitations, then it is simply a matter of the proxy updating the MOLST and listing any care limitation changes. When the proxy feels that the care restrictions should be changed, and the justification for such is present, then they may increase or decrease the restrictions on care that is being provided, and they are authorized to update the most form in accordance with the new care limitations. This works the same for increasing or decreasing the care restrictions. This is the easy option.
However, when the patient created and signed the MOLST themselves, then that is considered a binding document and those limitations, which were the legal and considered preferences of the patient, must be honored both morally and legally. Such limitations should basically be considered inviolable and no care should be provided – intubation, surgery, dialysis, tube feeding, CPR, etc – that the patient has eliminated as per their MOLST. Physicians and hospitals remain obliged to follow those care limitations, even if there is active and vocal objection to the patient’s wishes by the proxy, family members, or others who become engaged in dealing with care providers.
It would be highly unusual to see a situation where MOLST signed by the patient can be up-regulated in a way that does not respect the stated and legally binding wishes of the patient. Matt Batt from our Risk Management department recommends that in all situations where there may be controversy within the family or friends that the best approach is to keep the lines of dialogue and discussion open, communicate frequently and regularly, listen as well as providing appropriate explanations and support, and try and head off any conflicts before they escalate. Although there are rare situations where it may be appropriate to provide care that was otherwise banned by the patient, it would take much more than simply compelling evidence and testimony about the patient’s wishes to allow such a change to take place.
Despite the intended simplicity of MOLST forms, we know there will always be some controversies. The recommendation to communicate frequently and openly with family members is always our best strategy, even if there are times when that is difficult to do and frustrating as a process.
