Julie Bushey provided a comprehensive history at last week’s chapter meeting on the development of the new Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) form. Julie is chairperson of the palliative care committee at her hospital, and described how she is co-directing their plans to adopt MOLST by mid-April.
Julie noted MOLST is based on the ‘POLST paradigm.’ POLST is the acronym for Physician/Provider Orders for Life-Sustaining Treatment, which attempts to help patients more fully articulate their end of life wishes beyond the simple ‘do not resuscitate’ order clinicians are currently familiar with.
MOLST enhances the two basic choices patients currently have regarding goals of care - the DNR (do not resuscitate with cardiopulmonary resuscitation and/or intubation/artificial ventilation), by providing the opportunity to indicate their wishes regarding additional options: intubation and artificial ventilation for a limited time; noninvasive ventilation assistance, such as with C-PAP; hemodialysis; artificial nutrition and hydration; and transfer to a hospital. There is also space for other measures not directly addressed on the form, such as antibiotic therapy.
MOLST is intended for patients facing potentially life-limiting events, such as a diagnosis of advanced cancer, progressive disease, trauma, or other acute event. In completing the form, the patient and clinician affirm they have discussed goals of care.
I found Julie’s presentation, and the discussion it generated, useful. But at the same time, the experience emphasized how even this latest attempt to encourage honest discussion between patient, family, and clinicians still falls far short of the ideal. It seems to me the greatest risk with MOLST and the tools which preceded it, is that the discussion often lacks meaningful context.
In other words, we can help patients and families fill out a form, but that’s not nearly enough. We risk ending up with a simple shopping list, when we really need to understand much more.
I think our patients and families are much better served if we also consider, internalize, and use a simple set of 4 questions developed by Susan Block to guide our initial and ongoing conversations about goals for care at end of life:
1. What do you know about your prognosis?
2. What are your fears?
3. How do you want to spend your time?
4. How much suffering would you be willing to endure, if it offered the possibility of more time?
The actual wording of each of these questions will vary, depending on who it is we’re talking to, and where they are in the overall process of achieving a peaceful acceptance of death. But we can keep the questions as written in mind, as we develop our skills in guiding conversations about goals of care at end of life.
Put another way - if you understand your patients and families based on their answers to Susan’s 4 simple questions, you’ll have much more than a signed form to guide the care they really want and need.
Here’s Atul Gawande speaking to Susan’s questions at the 2010 New Yorker Festival: