We are continuing our review of some of the speakers and content at our Convention on April 2, in no particular order of their appearance at the event.
The Medical Orders for Life-Sustaining Treatment (MOLST) is the latest tool in the toolbox of end-of-life care, but as Sandra Kucharski MS, RN, warned the attendees at our annual Convention, it is a dangerous one. In her talk, she thoroughly outlined the ways in which it is dangerous and an alternative for everyone to consider.
She began by noting the disconnect between the fact that most people understand the need to state clearly in advance their wishes for how they are to be cared for when they are unable to speak for themselves and taking the actual steps necessary to do something about it. So, Advance Care Planning is, in fact, necessary and important for everyone.
But there are different kinds of advance care planning and MOLST is just one of them. They include living wills, durable powers of attorney, health care proxies, the MOLST, and others. Sandra warned, however, that they aren't all created equal, that some are better than others for the person using them.
Sandra then discussed some of the questions we should ask ourselves when preparing for the future, including what is most important to us, what would make life not worth living, what kind of treatments would you accept if you were ill, and more. And yet it must be understood that not every set of questions can be comprehensive enough to cover every situation and certainly don't encompass the fact that what you decide today may change tomorrow or in five years.
This is the first problem with the MOLST form1, as Sandra described it, that it asks you to make a detailed plan for a future that you can’t predict.
As for the MOLST itself, it is not a contract, but a medical order, and yet it is not a typical medical order in important ways, including the fact that it is valid anywhere in Massachusetts, not just in the facility where the patient is located and the doctor who signs it doesn’t have to have privileges in the facility where the patient eventually ends up. Very importantly, it is not affected by the patient’s capacity to make decisions, is effective immediately, and is signed in advance perhaps of the future medical condition that causes it to be used.
Sandra noted that even the backers of MOLST/POLST say that it is intended for people who are seriously ill or in advanced state of health decline, but in practice it is being pushed on people of all categories, including those who are currently healthy and not frail. In fact, MOLST can end up being used to deny ordinary care to those who may be ill, but not terminally, and elderly and frail, but not near death.
On the other hand, an advance directive or health care proxy, appoints someone who can make decisions when you can’t make them for yourself, a decision-making that resides in a person you trust and not a piece of paper that directs a doctor. And it only goes into effect if you are unable to speak for yourself, unlike the MOLST. Sandra then described who can be a proxy as well as some good sources of information on the advance directive, including National Right to Life and the Massachusetts Catholic Conference. Of course, MCFL’s own web site provides information on this topic as well: Healthcare Proxies: Securing Your Future Medical Care.
An important difference between MOLST and an advance directive/health proxy is that the former is a medical document, but the latter is a legal document, which includes the requirement for two witnesses of the signature, whereas the MOLST does not.
Thinking about life-threatening illness and the end of life isn’t pleasant, but it is necessary for everyone, even those who are still young and healthy. As Sandra said in her well-received talk, when you do decide to take up the task, be sure to use a tool that respects your values, doesn’t unduly burden your loved ones, and upholds the dignity of every human life.
For more on MOLST, see the following pages on our site:
- In other states, MOLST can be called POLST, MOST, or POST. There are variations from place to place, but the essential elements are the same. ↩︎