End of Life Care,, Berkshires: A Cautionary Tale

To the editor:

Letter: Be aware of state's end-of-life laws

The Berkshire Eagle  November 17. 2015

I would like to share some important information regarding end of life rights or our loved ones, family and friends.

In Massachusetts we have a provision regarding our end of life health care, it is called MOLST or Massachusetts Orders for Life Sustaining Treatment. Please talk to your physicians about this for more information, but let me tell you what happened to my family.

My father lived with me for six months out of the year. He was a Canadian citizen and all of his health care was in Canada. This year his health was failing, and he wished to be with his family in Massachusetts if possible when he was to pass. He slowed down and finally was confined to his bed. He died peacefully with his family at his side holding his hand. It was the passing we had all hoped, that he would be with us, and not alone in Canada.

After he died we called the funeral home, They asked us to call the local police which we did. The police arrived and asked to see the MOLST. Needless to say, I did not have one in place, and honestly did not think I needed one. The police explained that it was the law that they had to call paramedics. The fire department came, then EMTs. They pulled my father out of his bed onto the floor, put a tube into his airway and started CPR. They also hooked him up to a defibrillator. The responders were very apologetic about having to try to revive him, but since there was not a MOLST in place they had a legal responsibility to act. My father did not revive.

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Needless to say this experience was shocking, and made a difficult situation even more awful. I felt that my father's body was being violated and I feel it is now my obligation to make the community aware of the importance of having a MOLST in place, especially for our older ones or those who may be ill.

Your medical team can give you more information about the MOLST and how to obtain the form. As hard as end of life decisions are to talk about, please be prepared and educate yourself as to the law in Massachusetts.

Julie Rose Morgan
Dalton, Massachusetts

The Trouble Wiith Advanced Directives

This very useful article is worth reading closely.  Paula Span is one of the most lucid and important writers about aging.  She is a regular contributor to "The New Old Age Blog."

NY Times, March 17, 2015 Trouble With Advanced Directives, by Paula Span

"People who aren’t sick or frail, but have strong feelings about what should happen when they are, can’t rely on a POLST or an advance directive alone.

"What they really need, experts say, is an ongoing series of conversations with the relatives or friends who will direct their care when they no longer can. In a crisis, doctors will turn to those people — more than to any document — to learn what the patient wants.

Advanced Directives - NEJM Discussion

End Of Life Advanced Directive Discussion

New England Journal of Medicine, February 12, 2015, vol:372:pages:667-670

PDF of NEJM article.

Who should have the difficult discussion of the goals of care for a terminal patient? With whom does this responsibility lie? What course of action should be taken?

1. As the primary care physician, discuss the goals of care with the patient yourself.

2. Recommend that the oncology team discuss the goals of care with the patient.

3. Refer the patient to a palliative care physician who will discuss the goals of care with the patient.

To aid in your decision-making each of these approaches is defended in a short essay by an expert in the field.

N.B.  This is a an instructive article that will help patients and their care-givers.

The most useful comments came from palliative care physician, Diane Meier:  In an ideal world, every clinician caring for terminal patients would have the training and the team support to care for their patients throughout the course of their illness, especially during its most difficult and challenging phases.  Most primary care clinicians and specialists don't have time to manage complex symptoms, as well as emotional, practical, spiritual, and family needs, amid the escalating productivity requirements characterizing medical practice in the United States.  Most terminal patients’ care will be improved through access to specialist-level palliative care.

About MOLST

MEDICAL ORDERS FOR LIFE SUSTAINING TREATMENT = MOLST
Downloadable Forms

Good MOLST YouTube.

MOLST (Wiki) is an acronym for Medical Orders for Life-Sustaining Treatment. The MOLST Program is an initiative to facilitate end-of-life medical decision-making in New York State that involves use of the MOLST form. The MOLST form is a New York State Department of Health form. MOLST is for patients such as a terminally ill patient who can be expected to die within six months, whether or not treatment is provided. For this example, assume the patient retains medical decision-making capacity and wants to die naturally in a residential setting, not in the intensive-care unit of a hospital on a ventilator with a feeding tube. Using MOLST, with the informed consent of the patient, the patient's doctor could issue medical orders for life-sustaining treatment, including any or all of the following medical orders: provide comfort measures (palliative care) only; do not attempt resuscitation (allow natural death); do not intubate; do not hospitalize; no feeding tube; no IV fluids; do not use antibiotics; no dialysis; no transfusions. The orders should be honored by all health care providers in any setting, including emergency responders who are summoned by a 9-1-1 telephone call after the patient loses medical decision-making capacity.

Some states use the term POLST (Physician's Orders For Life-Sustaining Treatment).  For all practical purposes MOLST = POLST.