Transcript MOLST and Family Health Care Decisions Act (FHCDA) Honoring Patient Preferences for Care at the End of life: Recognizing the Value of.

MOLST and Family Health Care Decisions Act (FHCDA)
Honoring Patient Preferences for Care at the End of life:
Recognizing the Value of the MOLST Program
July 2010
Patricia Bomba, M.D., F.A.C.P.
Vice President and Medical Director, Geriatrics
Chair, MOLST Statewide Implementation Team
Leader, Community-wide End-of-life/Palliative Care Initiative
Chair, National Healthcare Decisions Day New York State Coalition
[email protected]
CompassionAndSupport.org
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A nonprofit independent licensee of the BlueCross BlueShield Association
Objectives
 Contrast traditional advance directives and the MOLST
form, a set of actionable medical orders
 Explain the MOLST Program as a person-centered,
end-of-life care transitions program that ensures patient
preferences are honored at end of life and all health
care professionals must follow these medical orders as
the patient moves from one location to another
 Review the NEW revised DOH-5003 MOLST form
 “Plain Language”
 Conforms to procedures and decision-making standards
set forth in FHCDA, effective June 1, 2010
 Describe development of eMOLST as a new resource
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Continuum of Care Model for Patients with Serious Illness
Medical Management of Chronic Disease
Integrated with Palliative Care
Goals of Care shift
12 mo
Diagnosis
Palliative Care (PC):
Advance care planning, pain and symptom
control, supportive care
Death
Hospice
 Progression of Serious Illness 
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6mo
Bereavement
Palliative Care: System Change Needed
to Ensure Patient Preferences are Met
 Advance Care Planning
Step 1: Community Conversations on
Compassionate Care (CCCC) Program
Step 2: Medical Orders for Life-Sustaining
Treatment (MOLST) Program
 Pain and Symptom Management
 Support for the Patient and Family
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Advance Care Planning
Compassion, Support and Education along the Continuum
Advancing chronic illness
Multiple comorbidities, with
increasing frailty
Chronic disease or
functional decline
Healthy and
independent
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Maintain &
maximize
health and
independence
Death with
dignity
Advance Directives
Traditional ADs
Actionable Medical Orders
For All Adults
For Those Who Are Seriously Ill
or Near the End of Their Lives
Community Conversations on
Compassionate Care (CCCC)
 New York
 Health Care Proxy
 Living Will
 Organ Donation
 State-specific forms
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CompassionAndSupport.org
CaringInfo.org
Medical Orders for Life-Sustaining Treatment
(MOLST) Program
 Do Not Resuscitate (DNR) Order
 Medical Orders for Life Sustaining
Treatment (MOLST)
 Physician Orders for Life Sustaining
Treatment (POLST) Paradigm
CompassionAndSupport.org
POLST.org
Community Conversations on Compassionate Care
Five Easy Steps
1.
Learn about advance directives
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Remove barriers
Motivate yourself
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4.
View CCCC videos
Complete your Health Care Proxy and Living Will
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5.
NYS Health Care Proxy
NYS Living Will
Advance Directives from Other States
Have a conversation with your family
Choose the right Health Care Agent
Discuss what is important to you
Understand life-sustaining treatment
Share copies of your directives
Review and Update
A Project of the Community-Wide End-of-life/Palliative Care Initiative
Medical Orders for Life-Sustaining Treatment
(MOLST Program), A POLST Paradigm Program
 Improve the quality of care people
receive at the end of life
 effective communication of patient wishes
 documentation of medical orders on a
brightly colored pink form
 promise by health care professionals to
honor these wishes
 Complements the use of traditional
advance directives
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A Project of the Community-Wide End-of-life/Palliative Care Initiative
Paradigm of communication, documentation, and system responsiveness
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POLST Paradigm Program July 2010 POLST.org
 A decade of research in Oregon has
proven that the POLST Program more
accurately conveys end-of-life
preferences and yields higher
adherence by medical professionals.
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Lee, Brummel-Smith, et al. JAGS. 2000; 48(10): 1219-1225
Meyers, et al. J Gerontol Nurs. 2004; 30(9): 37-46
Schmidt, Hickman, Tolle, Brooks. JAGS. 2004; 52(9): 1430-1434
Program Requirements
Core Elements of MOLST
 Contains actionable medical orders
 Recommended for use in persons who have
advanced chronic progressive illness and anyone
interested in further defining their end of life care
wishes
 May be used either to limit medical interventions or to
clarify a request for all medically indicated treatments
 Provides explicit direction about resuscitation status if
the patient is pulseless and apneic
 Includes directions about other types of intervention
that the patient may or may not want
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CompassionAndSupport.org
POLST.org
Program Requirements
Core Elements of MOLST
 Is a bright pink color easily identifiable in
emergency
 Accompanies the patient and orders apply as he
or she is transferred home or to a new care
setting (e.g. long-term care facility or hospital).
 Should be reviewed and renewed:
 Periodically & as required by NYS and federal law &
regulations
 If the individual’s preferences change
 If the individual’s health status changes
 If the patient is transferred to another care setting
 Includes education and training
 Features a plan for ongoing monitoring of the
program
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CompassionAndSupport.org
POLST.org
MOLST:
Who Should Have One?
 Generally for patients with serious
health conditions
 Wants to avoid or receive any or all
life-sustaining treatment
 Resides in a long-term care facility
or requires long-term care services
 Might die within the next year
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MOLST: EOL Care Transitions Program
Hospital
LTC
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Office
MOLST: EOL Care Transitions Program
 Created by the Community-wide End-of
Life/Palliative Care Initiative
 To provide a single document that would function as
an actionable medical order
 To transition with a patient through all health care
settings
 Intended that the form will be transported with
the patient between different health care
settings in order that their wishes for lifesustaining treatment and CPR will be clearly
indicated and followed
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Framework for the Conversation
8-Step MOLST Protocol*
1. Prepare for discussion
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Understand the patient and family
Understand the patient’s condition and prognosis
Retrieve completed Advance Care Directives
Determine “Agent” (Spokesperson) or responsible party
2. Determine what the patient and family know
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re: condition, prognosis
3. Explore goals, hopes and expectations
4. Suggest realistic goals
5. Respond empathetically
6. Use MOLST to guide choices and have patient/family share
wishes
• Shared medical decision-making
• Conflict resolution
7. Complete and sign MOLST
8. Review and revise periodically
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*Developed for NYS MOLST, Bomba, 2005
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www.compassionandsupport.org/pdfs/professionals/training/MOLST_Documentation_Form_FINAL_120208.pdf
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DOH-5003 MOLST Form
 More user-friendly
 Aligns with recently enacted Family Health Care
Decisions Act (FHCDA)
 Under FHCDA
 rules concerning the use of MOLST to document
medical orders issued based on the consent of
surrogates have changed
 rules for decisions by health care agents based on
health care proxies have not changed
 NYSDOH developing checklists
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 MOLST instructions and checklists setting forth the
legal requirements for issuing LST orders
 Supplemental Forms no longer required
 document in medical record
MOLST Instructions and Checklists
 Adult Patients
 Minor Patients
 Patients with Developmental Disabilities
who lack medical decision-making
capacity
 Patients with Mental Illness in a mental
hygiene facility
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MOLST Use Cases in Adults
 Step 1: Assess health status and prognosis
 Step 2: Check all advance directives known to
have been completed
 Step 3: If there is no health care proxy, assess
capacity to complete a health care proxy
 Step 4: Assess patient’s medical decisionmaking capacity
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MOLST Use Cases in Adults
 Step 5: Identify the anticipated decision maker
 Step 6: Discuss goals of care with the person
who will make the decision
 Step 7: Document where the MOLST form is
being completed
 Step 8: Complete legal requirements based
on who makes the decision and the setting
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MOLST Use Cases in Adults
Legal Requirements Vary
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Checklist #1 - Adult patients with medical decision-making capacity
(any setting)
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Checklist #2 - Adult patients without medical decision-making
capacity who have a health care proxy (any setting)
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Checklist #3 - Adult hospital or nursing home patients without
medical decision-making capacity who do not have a health care
proxy, and decision-maker is a Public Health Law Surrogate
(surrogate selected from the surrogate list)
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Checklist #4 - Adult hospital or nursing home patients without
medical decision-making capacity who do not have a health care
proxy or a Public Health Law Surrogate
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Checklist #5 - Adult patients without medical decision-making
capacity who do not have a health care proxy, and the MOLST form is
being completed in the community
MOLST Use Cases in Adults
Legal Requirements Vary
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Determination of medical decision-making capacity
Notification of patient
Identification and notification of surrogate
Identification of patient’s prior decisions to forego lifesustaining treatment
Informed consent by decision maker
Decision standards
Clinical standards
Witness requirements
Physician signatures
Documentation requirements
Determination of Actively Involved Close Friend and signed
statement in medical record
Notification of directors of mental hygiene facility (and Mental
Hygiene Legal Services - MHLS) and correctional facilities
Family Health Care Decisions Act (FHCDA)
 Part of Laws of 2010, Chapter 8, effective June 1, 2010
 FHCDA is Public Health Law (PHL) Article 29-CC.
 PHL Article 29-CC is applicable in general hospitals
and residential health care facilities (nursing homes).
 Laws of 2010, Chapter 8 also repealed PHL § 2977
(Nonhospital orders not to resuscitate) and created a
new PHL Article 29-CCC (Nonhospital Orders Not to
Resuscitate)
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Jonathan Karmel, Esq., NYSDOH, EMS Briefing, May 2010
Before FHCDA, PHL Article 29-B was law for
all Orders Not to Resuscitate
 Article 29-B had been the law for do not
resuscitate (DNR) orders since 1987.
 A DNR order is a physician’s order not to perform
cardiopulmonary resuscitation (CPR) in the event
of cardio or pulmonary arrest.
 Article 29-B provided definite procedures for
consent to and issuing DNR orders.
 Article 29-B used to include § 2977, which was
the law for nonhospital orders not to resuscitate.
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Jonathan Karmel, Esq., NYSDOH, EMS Briefing, May 2010
FHCDA Changes
 A new article of the Public Health Law
(Article 29-CC: Family Health Care
Decisions Act) applies to all health care
decisions for patients of general hospitals
and residents of nursing homes, including
DNR orders.
 Under FHCDA, a DNR order is just one
type of decision to withhold or withdraw
life-sustaining treatment.
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Jonathan Karmel, Esq., NYSDOH, EMS Briefing, May 2010
FHCDA Applicability
 Applies only to “health care,” not providing nutrition or
hydration orally
 Applies to patients of general hospitals and residents
of nursing homes but not OMH and OMRDD facilities
 Not applicable if:
 a health care agent under a health care proxy has authority
to make decisions
 a SCPA Article 17-A guardian has authority to make
decisions (for a person with a developmental disability)
 Surrogate decision-making is provided for by MHL Article 80
and 14 NYCRR Part 710 (Surrogate Decision-Making
Committees), 14 NYCRR §§ 633.11 (OMRDD facility
patients), 27.9 or 527.8 (OMH facility patients)
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Jonathan Karmel, Esq., NYSDOH, EMS Briefing, May 2010
Decisions by Adults with Capacity under
FHCDA
 No “therapeutic exception” anymore
 Even if the patient lacks capacity, there is no
surrogate decision-making where the patient has
already made a decision about the health care
prior to losing capacity:
 in writing or orally
 with respect to a decision to withdraw or withhold lifesustaining treatment, such oral consent must be during
hospitalization in the presence of two witnesses eighteen
years of age or older, at least one of whom is a health or
social services practitioner affiliated with the hospital
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Jonathan Karmel, Esq., NYSDOH, EMS Briefing, May 2010
Surrogate Decision-Making Under FHCDA
 Patients are presumed to have capacity unless a
physician, with the concurrence of another health
or social service practitioner at the facility acting
within his or her scope of practice, determines that
the patient lacks capacity.
 In a general hospital, the concurring determination
is only required for decisions to withhold or
withdraw life-sustaining treatment.
 If patients lack capacity, there is a surrogate list.
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Jonathan Karmel, Esq., NYSDOH, EMS Briefing, May 2010
Surrogate List
 MHL Article 81 guardian
 Spouse, if not legally separated from
the patient, or the domestic partner
 Adult child
 Parent
 Adult sibling
 Close friend
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Jonathan Karmel, Esq., NYSDOH, EMS Briefing, May 2010
Surrogate Decision-Making Under FHCDA
 Decisions based on “patient’s wishes,” or if
they’re unknown, “best interests”
 Special provisions for decisions to withhold or
withdraw life-sustaining treatment
 Includes DNR orders
 Consent must be in writing or expressed orally to an
attending physician
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Jonathan Karmel, Esq., NYSDOH, EMS Briefing, May 2010
Surrogate Decision-Making Under FHCDA:
Clinical Criteria for Decisions to Withhold or
Withdraw Life-Sustaining Treatment
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Treatment would be an extraordinary burden to the patient and an
attending physician determines, with the independent concurrence of
another physician, that, to a reasonable degree of medical certainty
and in accord with accepted medical standards:
 the patient has an illness or injury which can be expected to cause death
within six months, whether or not treatment is provided; or
 the patient is permanently unconscious; or
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The provision of treatment would involve such pain, suffering or other
burden that it would reasonably be deemed inhumane or
extraordinarily burdensome under the circumstances and the patient
has an irreversible or incurable condition, as determined by an
attending physician with the independent concurrence of another
physician to a reasonable degree of medical certainty and in accord
with accepted medical standards
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For DNR orders, this is a change in the law, because the criteria are
slightly different under Article 29-B
Jonathan Karmel, Esq., NYSDOH, EMS Briefing, May 2010
Surrogate Decision-Making Clinical Criteria for
DNR Orders: FHCDA vs. Article 29-B
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FHCDA (new law)
Article 29-B (old law)
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patient has an illness or injury
which can be expected to
cause death within six
months, whether or not
treatment is provided
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patient has a terminal condition:
an illness or injury from which
there is no recovery, and which
reasonably can be expected to
cause death within one year
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patient is permanently
unconscious
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patient is permanently
unconscious
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The provision of treatment
would involve such pain,
suffering or other burden that
it would reasonably be
deemed inhumane or
extraordinarily burdensome
under the circumstances and
the patient has an irreversible
or incurable condition
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resuscitation would be medically
futile
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resuscitation would impose an
extraordinary burden on the
patient in light of the patient's
medical condition and the
expected outcome of
resuscitation for the patient
Jonathan Karmel, Esq., NYSDOH, EMS Briefing, May 2010
Health Care Decision-Making for Patients for
Whom No Surrogate is Available under FHCDA
 Different procedures for:
 Routine medical treatment
 Major medical treatment: 2nd physician must concur
 Decisions to withhold or withdraw life-sustaining
treatment, which again include DNR orders
 Change in clinical standard for DNR Orders:
under Article 29-B, a DNR Order could have been
put in place if CPR would have been “medically
futile,” meaning that CPR would have been
unsuccessful in restoring cardiac and respiratory
function or that the patient would have
experienced repeated arrest in a short time period
before death occurred.
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Jonathan Karmel, Esq., NYSDOH, EMS Briefing, May 2010
Health Care Decision-Making for Patients for
Whom No Surrogate is Available under FHCDA:
Life-Sustaining Treatment
 A Court may make a decision to withhold or
withdraw life-sustaining treatment; or
 The attending physician, with independent
concurrence of a second physician, determines
to a reasonable degree of medical certainty that:
 life-sustaining treatment offers the patient no medical
benefit because the patient will die imminently, even if
the treatment is provided; and
 the provision of life-sustaining treatment would violate
accepted medical standards
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Jonathan Karmel, Esq., NYSDOH, EMS Briefing, May 2010
Nonhospital DNR Orders
 New Article 29-CCC clarifies that home care
services agencies and hospices must honor them,
as well as EMS
 Surrogates can consent to them under FHCDA rules
 Consent must be orally to the attending physician or
in writing
 NYSDOH authorizes use of a new “alternative form”
(MOLST form) that complies with FHCDA
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Jonathan Karmel, Esq., NYSDOH, EMS Briefing, May 2010
MOLST Orders
 Under the statute (now PHL § 2994-dd(6)),
The Department of Health “may authorize the
use of . . . alternative forms for issuing a
nonhospital order not to resuscitate. . . . Such
alternative form or forms may also be used to
issue a non-hospital do not intubate order.”
 What about other MOLST orders besides
DNR and DNI?
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Jonathan Karmel, Esq., NYSDOH, EMS Briefing, May 2010
MOLST Orders in addition to DNR and DNI
 The courts have said that all individuals have a
constitutional right to refuse medical treatment.
 Before a patient’s right of self-determination can be
enforced, however, his or her wishes must be
ascertained.
 If the patient cannot presently express those
wishes, they will be enforced if established by “clear
and convincing evidence.”
 In the EMS context, this is difficult to operationalize.
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Jonathan Karmel, Esq., NYSDOH, EMS Briefing, May 2010
MOLST Orders
 All health care professionals must follow these medical
orders as the patient moves from one location to another,
unless a physician examines the patient, reviews the
orders and changes them.
 EMS personnel may disregard orders if:
 They believe in good faith that consent to the order has been
revoked, or that the order has been cancelled
 Family members or others on the scene, excluding such
personnel, object to the order and physical confrontation
appears likely
 Hospital emergency services physicians may direct that
the order be disregarded if other significant and
exceptional medical circumstances warrant disregarding
the orders.
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Jonathan Karmel, Esq., NYSDOH, EMS Briefing, May 2010
DOH-5003 MOLST Form
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 Patient demographics
 eMOLST Number (This is not an eMOLST Form)
 HIPAA permits disclosure of MOLST to other health care
professionals & electronic registry as necessary for treatment
 This MOLST form has been approved by the NYSDOH for
use in all settings.
DOH-5003 MOLST Form
 Description of MOLST program
 Target patient population
 If patient has DD and lacks medical decision-making capacity,
physician must follow Surrogate Court Procedures §1750-b
process and legal requirements checklist must be attached
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DOH-5003 MOLST Form – Section A
 Resuscitation Instructions when the patient has no pulse
and/or is not breathing
 CPR Order: Attempt Cardio-Pulmonary Resuscitation
 defined; includes intubation
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 DNR Order: Do Not Attempt Resuscitation (Allow Natural
Death)
 DNR and DNI differ
 DNR does NOT mean “Do Not Treat”
 N.B. reverse order of CPR and DNR
DOH-5003 MOLST Form – Section B
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 Two witnesses are always recommended.
 The physician who signs the orders may be a witness.
 If it is documented that the attending physician witnessed the
consent, the attending physician just needs to sign the order
and does not need to sign a second time as a witness.
 Witness signatures are not required.
 Identify who made the decision.
DOH-5003 MOLST Form – Section C
 Physician signature, name, date/time, license # and
phone/pager#
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DOH-5003 MOLST Form – Section D
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Health Care Proxy
Living Will
Organ Donation
Documentation of Oral Advance Directive
DOH-5003 MOLST Form – Section E
 New form separates treatment guidelines and future
hospitalization/transfer
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DOH-5003 MOLST Form – Section E
 DNI vs. A trial period vs. Intubation & long-term mechanical
ventilation
 DNI should not be checked if full CPR is checked in Section A.
 For trial period, discuss mechanical and/or noninvasive
ventilation options, if it is appropriate
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DOH-5003 MOLST Form – Section E
 New form separates treatment guidelines and future
hospitalization/transfer
 Specific directions to EMS re: preferences for future
hospitalization/transfer
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DOH-5003 MOLST Form – Section E
 Make a choice for feeding tube and IV fluids
 See Guidelines for long-term feeding tube placement
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DOH-5003 MOLST Form – Section E
 New language for choices for use of antibiotics
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DOH-5003 MOLST Form – Section E
 Include “Other Instructions” about starting or stopping
treatments discussed with the doctor or about treatments not
otherwise listed
 Dialysis
 Transfusions
 Etc.
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DOH-5003 MOLST Form – Section E
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Two witnesses are always recommended.
The physician who signs the orders may be a witness.
If it is documented that the attending physician witnessed the
consent, the attending physician just needs to sign the order and
does not need to sign a second time as a witness.
Witness signatures are not required.
Identify who made the decision.
DOH-5003 MOLST Form – Section E
 Physician signature, name and date/time
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DOH-5003 MOLST Form – Section F
 No change
 Form voided, new form completed
 Form voided, no new form
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DOH-5003 MOLST Form - Section F
Review and renewal of MOLST Orders
 DNR/Allow Natural Death orders: Public Health Law
requires the physician to review non-hospital DNR orders
and record the review at least every 90 Days. In hospitals
and nursing homes, MOLST orders must be reviewed
regularly in accordance with facility policies.
 for residents of OMRDD and OMH facilities, the physician
must review MOLST order at least every 60 Days.
 Life-Sustaining Treatment orders: The patient’s medical
condition, prognosis, values, wishes and goals for his/her
care may change over time. The physician must review
these orders at the same time as DNR/Allow Natural
Death orders are reviewed and review is recorded.
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Advance Care Planning
Outcomes: Advance Directives and MOLST
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Traditional Advance Directives Outcomes
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MOLST Short Term Outcomes
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Consistent uniform application of the Medical Orders for Life-Sustaining
Treatment (MOLST) program.
Successful MOLST Community Pilot and adoption of a MOLST as a
statewide program.
Expanded cadre of volunteers prepared to engage in one-to-one and
community conversations regarding end-of-life issues, options and the
value of advance directives, including the MOLST form.
MOLST Long Term Outcomes
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Every adult (18 and older) will complete a Health Care Proxy
Every adult will have meaningful discussions about end-of-life
Every adult will have access to an easily recognizable document
Every adult will have access to educational sessions
Informed & prudent use of life-sustaining & intensive care services.
Greater efficiencies in health care delivery.
Improved patient and family satisfaction.
Reduction in costs associated with medical liability and defensive
medicine by providing physicians an efficient framework for discussing
end-of-life options.
Advance Care Planning
Community Goals: National Quality Forum
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Document the designated agent (surrogate decision maker) in a
Health Care Proxy for every patient in primary, acute and long-term
care and in palliative and hospice care.
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Document the patient/surrogate preferences for goals of care,
treatment options, and setting of care at first assessment and at
frequent intervals as condition changes.
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Convert the patient treatment goals into medical orders and ensure
that the information is transferable and applicable across care settings,
including long-term care, emergency medical services, and hospital,
i.e., the Medical Orders for Life-Sustaining Treatment—MOLST, a
POLST Paradigm Program.
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Make advance directives and surrogacy designations available across
care settings; through collaboration with the RHIO
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Develop and promote healthcare and community collaborations to
promote advance care planning and completion of advance directives
for all individuals. e.g. Respecting Choices and Community
Conversations on Compassionate Care
National Quality Forum, Framework and Preferred Practices
for Quality Palliative Care & Hospice Care, 2006, Adapted for New York State
Advance Directives
National Metrics: Completion Rates
 1991 - Patient Self-Determination Act
 20% had a form of Advance Directive (AD)
 75% approved of a Living Will
 2002 - Means to a Better End i
 15 -20% Americans have AD
 2005 –Pew Research Center for the People and
the Press ii
 29% - Americans have AD – living wills
 2008-AARP survey iii
 <40% -Americans 35 yo and older have AD
i Means
to a Better End: A Report on Dying in America Today, November 2002
ii The Pew Research Center for the People and the Press.
More Americans Discussing and Planning End-of-life Treatment. January 5, 2006
iii http://assets.aarp.org/rgcenter/il/getting_ready.pdf
Behavioral Readiness to Complete a
Health Care Proxy
 See no need
 Recognize need, but have
barriers
 Ready to complete
 Advance Care Directive
reflects wishes
 Advance Care Directive
needs update
Drs. Bomba and Doniger, 2002
Bomba, Doniger, Vermilyea, 2002.
Community Conversations on Compassionate Care
60%
55%
52%
50%
48%
45%
Percent
40%
30%
20%
10%
0%
Before Workshop
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Approximately 6 Weeks After Workshop
Improvement in people with advance directives from 44% to 53% is statistically significant
Workshop Attendee Responses
( p < .01).
Do Not Have Advance Directives
Do Have Advance Directives
End-of-life Care Community
Survey Methodology
 United Marketing Research - conducted interviews
 Random sample of residents living in a 39county area of upstate New York
 2,000 adults,18 and older, interviewed by phone
 Between March 6, 2008 and April 6, 2008
 Selection - random digit dialing (RDD) sample
 Quota sampling approach
• ensure meaningful number of individuals (about 400)
surveyed within each of five regions
• established for respondents 55 and older - minimize
age bias
Disparity between consumer attitudes & actions
regarding advance directives
End-of-Life Care Survey of Upstate New Yorkers:
Advance Care Planning Values and Actions
Excellus BlueCross BlueShield, April 2008
Disparity between consumer attitudes and
actions regarding health care proxies
End-of-Life Care Survey of Upstate New
Yorkers: Advance Care Planning Values and Actions,
Summary Report, 2008
Has your doctor ever talked to you about Health
Care Proxies and Living Wills?
End-of-Life Care Survey of Upstate New
Yorkers: Advance Care Planning Values and Actions,
Summary Report, 2008
Language and Functional Health Literacy
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Functional Health Literacy: Consequences
 Poorer health status
 Lack of knowledge about medical care and
medical conditions
 Decreased comprehension of medical
information
 Lack of understanding and use of preventive
services
 Poorer self-reported health
 Poorer compliance rates
 Increased hospitalizations
 Increased health care costs
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MOLST Education and Training
Two-Step Approach to Advance Care Planning
 Advance Care Planning Facilitators
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Community Conversations on Compassionate Care Program
MOLST Program
goal-based, patient-centered discussions
patient-centered program and process
educational resources on CompassionAndSupport.org
 Program Implementation
 facility: hospital, long term care, home care, hospice
 physician practice – opportunity for process improvement
 Community education
 CCCC, MOLST, reliable information on web site
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Overcoming Functional Health Literacy
Model for Community Education
 Three-Part Community Educational Series on
Advance Care Planning and Palliative Care
• Session 1: Community Conversations on
Compassionate Care video with Five Easy Steps
• Session 2: Writing Your Final Chapter video
• Session 3: share available community resources;
e.g. information on hospice
 Session 1 and 2
 Videos (available on DVD) followed by facilitated
discussion and Question and Answer period
 Session 3
 Refer to CompassionAndSupport.org Web site
 Videos also available on-line for individual use
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NationalHealthcareDecisionsDay.org
New York State
 National Healthcare Decisions Day
 NHDD New York State Coalition
 NHDD NYS Coalition Collaborators
NHDD New York State Coalition Goals
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increase conversations that lead to completion of health care
proxies
increase awareness of the MOLST Program in the community
ensure that the Family Healthcare Decisions Act is passed in 2010
CompassionAndSupport.org
Community Conversations on Compassionate Care
Advance Care Planning Community Resources
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Advance Care Planning Booklet (English, Spanish)
Advance Care Planning Brochure, Poster and Table Topper
Advance Care Planning Facilitator Training
Advance Care Planning Clinical Pathways
Behavioral Readiness “tools”
Community Conversations on Compassionate Care (CCCC)
workshop
Community Conversations on Compassionate Care (CCCC) DVD
Advance Care Planning Public Service Announcements DVD
CCCC video on-line with Five Easy Steps
On-line resources at CompassionandSupport.org
Internal tracking and evaluation
CompassionAndSupport.org
Medical Orders for Life-Sustaining Treatment
Advance Care Planning Community Resources
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MOLST 8-Step Protocol
MOLST Guidebook including FAQs
MOLST Patient & Family Brochure (English, Spanish)
Sample Facility Policies & Procedures
Sample Facility Implementation Workplans
Sample Facility Education Workplans
MOLST Training Manual
MOLST Train-the-Trainer Sessions
MOLST Conferences
MOLST DVD and web-based tools
MOLST Training Center: CompassionAndSupport.org
– New York State repository for MOLST resources
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Web site
CompassionAndSupport.org
Reliable Information: Patients, Families & Professionals
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Advance Care Planning
MOLST for Patients/Families
MOLST Training Center for Professionals
Life-Sustaining Treatment
Guidelines for Long Term Feeding Tube Placement
Pain Management for Patients/Families
Pain Management for Professionals
Hospice & Palliative Care
Death & Dying
Faith Based Perspectives Patients and Families
Pediatrics
En Espanol
Care Transitions Intervention
Health Care Reform: focus on HR3200 Section 1233
Compassion And Support Video Library