Decisions by Default: Incomplete and Contradictory MOLST in Emergency Care

Brian Clemency, Colleen Cordes, Heather A. Lindstrom, Jeanne M. Basior, Deborah P. Waldrop

Research output: Contribution to journalArticle

16 Citations (Scopus)

Abstract

Objectives What patients intend when they make health care choices and whether they understand the meaning of orders for life-sustaining treatment forms is not well understood. The purpose of this study was to analyze the directives from a sample of emergency department (ED) patients' MOLST forms. Procedures MOLST forms that accompanied 100 patients who were transported to an ED were collected and their contents analyzed. Data categories included age, gender, if the patient completed the form for themselves, medical orders for life-sustaining treatment including intubation, ventilation, artificial nutrition, artificial fluids or other treatment, and wishes for future hospitalization or transfer. Frequencies of variables were calculated and the associations between them were determined using chi-square. An a priori list of combinations of medical orders that were contradictory was developed. Contradictions with Orders for CPR (cardiopulmonary resuscitation) included the choice of one or more of the following: Comfort care; Limited intervention; Do Not Intubate; No rehospitalization; No IV (intravenous) fluids; and No antibiotics. Contradictions with DNR orders included the choice of one or more of the following: Intubation; No limitation on interventions. Contradictions with orders for Comfort Care were as follows: Send to the hospital; Trial period of IV fluids; Antibiotics. The frequencies of coexisting but contradictory medical orders were calculated using crosstabs. Free text responses to the “other instructions” section were submitted to content analysis. Results Sixty-nine percent of forms reviewed had at least one section left blank. Inconsistencies were found in patient wishes among a subset (14%) of patients, wherein their desire for “comfort measures only” seemed contradicted by a desire to be sent to the hospital, receive IV fluids, and/or receive antibiotics. Conclusions Patients and proxies may believe that making choices and documenting some, but not all, of their wishes on the MOLST form is sufficient for directing their end-of-life care. The result of making some, but not all, choices may result in patients receiving undesired, extraordinary, or invasive care.

Original languageEnglish (US)
Pages (from-to)35-39
Number of pages5
JournalJournal of the American Medical Directors Association
Volume18
Issue number1
DOIs
StatePublished - Jan 1 2017

Fingerprint

Emergency Medical Services
Anti-Bacterial Agents
Intubation
Hospital Emergency Service
Terminal Care
Cardiopulmonary Resuscitation
Proxy
Ventilation
Hospitalization
Therapeutics
Delivery of Health Care

Keywords

  • Advance care planning
  • end-of-life care
  • MOLST
  • POLST

ASJC Scopus subject areas

  • Nursing(all)
  • Health Policy

Cite this

Decisions by Default : Incomplete and Contradictory MOLST in Emergency Care. / Clemency, Brian; Cordes, Colleen; Lindstrom, Heather A.; Basior, Jeanne M.; Waldrop, Deborah P.

In: Journal of the American Medical Directors Association, Vol. 18, No. 1, 01.01.2017, p. 35-39.

Research output: Contribution to journalArticle

Clemency, Brian ; Cordes, Colleen ; Lindstrom, Heather A. ; Basior, Jeanne M. ; Waldrop, Deborah P. / Decisions by Default : Incomplete and Contradictory MOLST in Emergency Care. In: Journal of the American Medical Directors Association. 2017 ; Vol. 18, No. 1. pp. 35-39.
@article{ca7994f9632e41a2b461047c89ee9146,
title = "Decisions by Default: Incomplete and Contradictory MOLST in Emergency Care",
abstract = "Objectives What patients intend when they make health care choices and whether they understand the meaning of orders for life-sustaining treatment forms is not well understood. The purpose of this study was to analyze the directives from a sample of emergency department (ED) patients' MOLST forms. Procedures MOLST forms that accompanied 100 patients who were transported to an ED were collected and their contents analyzed. Data categories included age, gender, if the patient completed the form for themselves, medical orders for life-sustaining treatment including intubation, ventilation, artificial nutrition, artificial fluids or other treatment, and wishes for future hospitalization or transfer. Frequencies of variables were calculated and the associations between them were determined using chi-square. An a priori list of combinations of medical orders that were contradictory was developed. Contradictions with Orders for CPR (cardiopulmonary resuscitation) included the choice of one or more of the following: Comfort care; Limited intervention; Do Not Intubate; No rehospitalization; No IV (intravenous) fluids; and No antibiotics. Contradictions with DNR orders included the choice of one or more of the following: Intubation; No limitation on interventions. Contradictions with orders for Comfort Care were as follows: Send to the hospital; Trial period of IV fluids; Antibiotics. The frequencies of coexisting but contradictory medical orders were calculated using crosstabs. Free text responses to the “other instructions” section were submitted to content analysis. Results Sixty-nine percent of forms reviewed had at least one section left blank. Inconsistencies were found in patient wishes among a subset (14{\%}) of patients, wherein their desire for “comfort measures only” seemed contradicted by a desire to be sent to the hospital, receive IV fluids, and/or receive antibiotics. Conclusions Patients and proxies may believe that making choices and documenting some, but not all, of their wishes on the MOLST form is sufficient for directing their end-of-life care. The result of making some, but not all, choices may result in patients receiving undesired, extraordinary, or invasive care.",
keywords = "Advance care planning, end-of-life care, MOLST, POLST",
author = "Brian Clemency and Colleen Cordes and Lindstrom, {Heather A.} and Basior, {Jeanne M.} and Waldrop, {Deborah P.}",
year = "2017",
month = "1",
day = "1",
doi = "10.1016/j.jamda.2016.07.032",
language = "English (US)",
volume = "18",
pages = "35--39",
journal = "Journal of the American Medical Directors Association",
issn = "1525-8610",
publisher = "Elsevier Inc.",
number = "1",

}

TY - JOUR

T1 - Decisions by Default

T2 - Incomplete and Contradictory MOLST in Emergency Care

AU - Clemency, Brian

AU - Cordes, Colleen

AU - Lindstrom, Heather A.

AU - Basior, Jeanne M.

AU - Waldrop, Deborah P.

PY - 2017/1/1

Y1 - 2017/1/1

N2 - Objectives What patients intend when they make health care choices and whether they understand the meaning of orders for life-sustaining treatment forms is not well understood. The purpose of this study was to analyze the directives from a sample of emergency department (ED) patients' MOLST forms. Procedures MOLST forms that accompanied 100 patients who were transported to an ED were collected and their contents analyzed. Data categories included age, gender, if the patient completed the form for themselves, medical orders for life-sustaining treatment including intubation, ventilation, artificial nutrition, artificial fluids or other treatment, and wishes for future hospitalization or transfer. Frequencies of variables were calculated and the associations between them were determined using chi-square. An a priori list of combinations of medical orders that were contradictory was developed. Contradictions with Orders for CPR (cardiopulmonary resuscitation) included the choice of one or more of the following: Comfort care; Limited intervention; Do Not Intubate; No rehospitalization; No IV (intravenous) fluids; and No antibiotics. Contradictions with DNR orders included the choice of one or more of the following: Intubation; No limitation on interventions. Contradictions with orders for Comfort Care were as follows: Send to the hospital; Trial period of IV fluids; Antibiotics. The frequencies of coexisting but contradictory medical orders were calculated using crosstabs. Free text responses to the “other instructions” section were submitted to content analysis. Results Sixty-nine percent of forms reviewed had at least one section left blank. Inconsistencies were found in patient wishes among a subset (14%) of patients, wherein their desire for “comfort measures only” seemed contradicted by a desire to be sent to the hospital, receive IV fluids, and/or receive antibiotics. Conclusions Patients and proxies may believe that making choices and documenting some, but not all, of their wishes on the MOLST form is sufficient for directing their end-of-life care. The result of making some, but not all, choices may result in patients receiving undesired, extraordinary, or invasive care.

AB - Objectives What patients intend when they make health care choices and whether they understand the meaning of orders for life-sustaining treatment forms is not well understood. The purpose of this study was to analyze the directives from a sample of emergency department (ED) patients' MOLST forms. Procedures MOLST forms that accompanied 100 patients who were transported to an ED were collected and their contents analyzed. Data categories included age, gender, if the patient completed the form for themselves, medical orders for life-sustaining treatment including intubation, ventilation, artificial nutrition, artificial fluids or other treatment, and wishes for future hospitalization or transfer. Frequencies of variables were calculated and the associations between them were determined using chi-square. An a priori list of combinations of medical orders that were contradictory was developed. Contradictions with Orders for CPR (cardiopulmonary resuscitation) included the choice of one or more of the following: Comfort care; Limited intervention; Do Not Intubate; No rehospitalization; No IV (intravenous) fluids; and No antibiotics. Contradictions with DNR orders included the choice of one or more of the following: Intubation; No limitation on interventions. Contradictions with orders for Comfort Care were as follows: Send to the hospital; Trial period of IV fluids; Antibiotics. The frequencies of coexisting but contradictory medical orders were calculated using crosstabs. Free text responses to the “other instructions” section were submitted to content analysis. Results Sixty-nine percent of forms reviewed had at least one section left blank. Inconsistencies were found in patient wishes among a subset (14%) of patients, wherein their desire for “comfort measures only” seemed contradicted by a desire to be sent to the hospital, receive IV fluids, and/or receive antibiotics. Conclusions Patients and proxies may believe that making choices and documenting some, but not all, of their wishes on the MOLST form is sufficient for directing their end-of-life care. The result of making some, but not all, choices may result in patients receiving undesired, extraordinary, or invasive care.

KW - Advance care planning

KW - end-of-life care

KW - MOLST

KW - POLST

UR - http://www.scopus.com/inward/record.url?scp=84998785422&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=84998785422&partnerID=8YFLogxK

U2 - 10.1016/j.jamda.2016.07.032

DO - 10.1016/j.jamda.2016.07.032

M3 - Article

C2 - 27692663

AN - SCOPUS:84998785422

VL - 18

SP - 35

EP - 39

JO - Journal of the American Medical Directors Association

JF - Journal of the American Medical Directors Association

SN - 1525-8610

IS - 1

ER -