SB 165 (Lehner) MOLST

Proponent Testimony before the

Senate Civil Justice Committee

July 24, 2015

Jeff Lycan, RN, MS

Vice-President for Mission Advocacy

Hospice of Dayton

Testifying on behalf of Midwest Care Alliance,

Chair of the Public Policy Committee

Chairman Bacon, Vice-chair Oleslager, and Ranking MemberSkindell, thank you for providing me the opportunity to give testimony on SB 165, the MOLST or Medical Orders for Life Sustaining Treatment statute in Ohio.

My name is Jeff Lycan; I am the Vice-President of Mission Advocacy for the Hospice of Dayton, one of the largest nonprofit community hospices in Ohio as well as in the country. I am here today testifying as the Public Policy Chair for Midwest Care Alliance, a nonprofit trade association, providing advocacy and association services for quality end-of-life care and hospice providers since 1979. Midwest Care Alliance member hospices, across Ohio,in 2013, delivered services to 85 percent of Ohioans that are terminally ill and receiving hospice care.In total, hospices' in Ohioprovided comprehensive patient-centered care to 52% of Ohioans that died in 2013and served more than 68,000 Ohioans.

In simplest terms, MOLST is a voluntary tool for translating patients’ goals of care into medical orders for a certain subset of patients – those with advanced, progressive illness and/or frailty. It represents a significant paradigm change in advance care planning policy by standardizing health care providers' communications,utilizing medical orders to prescribe a plan of care in a highly visible, portable way.

Over eight years ago a broad group of health care providers and stakeholders determined that Ohio's DNR protocol was confusing, cumbersome and didn't meet the goals it originally was intended to meet.1 Thus the Honoring Wishes Task Force (HWTF) formed to develop a more effective tool that would replace Ohio’s DNR protocol.As such, SB165 would sunset the current DNR protocol and replace it with physician's orders that describe life-sustaining treatment. However, two important elements of the DNR protocol would carry over with the MOLST. Those two elements are transportability of the medical order between health settings and the provision of immunity for health care providers and first responders that follow a MOLST order. (POLST, POST, MOST or MOLST, Medical Orders for Life-Sustaining Treatment, are common acronymsused across thedifferent states to describe similar processes. For the sake of simplicity my testimony will refer throughout to the MOLST.)

What is a MOLST? It is a VOLUNTARY patient-centered care plan for those with advanced or progressive illness entering their final stages of life that is expressed as a medical order. It is an opportunity for professional health care providers to document clearly communicationswith frail individuals and patients with terminal conditions about the likely course of treatment they can expect and their available options. This provides the patient with the opportunity to express their wishes and guide their care as theillness progresses.Current research demonstrates that similar tools (those referred to above) used to guide the care of older adults who are near the end-of-life provide clearer direction.2,3,4

A physician can currently write these medical orders today, what is lacking is the continuity of care by allowing these orders tobe transported from one setting to another. In the broad framework of advance care planning, a key concept to understand is thatMOLST is an advance care planning tool that reflects the patient’s here-and-now goals for medical decisions that may confront him or her and converts those goals into specific medical orders. For example, one thing the research identifies is that code status is not predictive of a patient's preferences for other kinds of treatments. This highlights the limitations of relying on code status alone to guide treatment decisions. 3,5,6,7

In a study published in 2012 in the Journal of the American Medical Association, Oregon found that while 72% of registrants had a DNR order, 38% had orders for limited additional interventions, 36% had comfort measures only, and 26% had full treatment orders.8 In other words, these tools allow for greater choice and more individualized care to guide treatment. Additionally, in the Journal of the American Geriatric Society, in 2014, we see patients who wish to die outside an institutional setting more likely to do so if they have a MOLST in place.9The research also demonstrates that those individuals that chose to have full treatment; they are more likely to die in an institutional setting. In the literature today, there is nothing that I am aware of that demonstrates the success, of individual goals of care being met to this level, around these issues.

Why is the legislation needed? Without this legislation,a MOLSTcannot move with the patient across care settings. There are several health locations currently using MOLST within their system, but once the patient leaves their "System", the MOLST cannot travel with them. As is often the case with this population, and encouraged by the shifting environment to home and community-based care, these patients are usually traveling across settings of care during these final stages, to and from the hospital, to long-term care, to the rehab center, to home, etc.Currently, medical orders only apply to the setting in which they were written. This bill will authorize the MOLSTto be utilizedacross all care settings with a patient.

Why are transferability and portability important? This allows EMS and first responders, as well as other health care providers, the opportunity to honor the wishes of the patient when they are transporting them from one setting to another. It demonstrates the conversation and identifies those involved in completing the orders. Once the patient is safely transported, the MOLST will help improve better care coordination with a smoother “hand-off” from one care environment to another when the wishes of the patient are clearly expressed in a medical order.While some of the research is limited at this time due to the sample size, the evidence thus far suggests, that the orders on a MOLST tool are usually honored and that treatment across settings are consistent with orders.6,10,11,12,13,14

Can a MOLST be changed? Yes. Since the MOLST is a medical order, it can change as the patient’s condition changes. At the beginning of treatment, patients may choose care that explores utilizing alltreatment options. As treatments begin to fail, patientsmay choose options that focus more on symptom management and less on invasive treatment as their goals for care may move more towards comfort.

However, as indicated earlier, the research demonstrates that individuals can have orders that describe a variety of treatment options from comfort to full interventions, even as their condition points towards an end of life. In the same 2014 Journal of the American Geriatric Society articleidentified earlier,there is referencemade regarding individuals who have a MOLST for more than one year. In a sub-sample population, the research noted that as changes in the trajectory towards deathoccurs, as conditions decline, the form is updated to guide further care.9

MOLST Moving Forward:SB 165 establishes the specifics of the medical order form in the statute (Draft Form), which will require any future changes to the form to have to be approved by the General Assembly.To address medical advancements, there is a box on the form that will allow the physician to write any additional orders or comments as necessary.

The bill does provide for a five-year review by the stakeholders to evaluate the effectiveness of the tool, and make any recommended changes to the General Assembly.

In closing let me reiterate, SB165is a voluntary, patient-centered end oflife care plan that educates the patient and their family about their care options in the concluding stages of a progressing disease and illness. It allows health care providers that work with the patient in those final stages of life to know that they are honoring the patient’s wishes. It allows for important conversations to occur prior to a medical crisis, and ensures that the patient is involved in their care planning. I hope you will join me in support of this important legislation.

Thank you for the opportunity to testify on this bill today, and I am available to answer any questions you may have at this time.

REFERENCES

1. DNR-Comfort Care in Ohio: Confusing & Inadequate. A White Paper Report. Columbus, OH. DNR Task Force, 2006.

2. Schmidt TA, Zive D, Fromme EK. Physician Orders for Life-Sustaining Treatment (POLST): Lessons learned from analysis of the Oregon POLST Registry. Resuscitation 2014;85:480-485.

3.Fromme EK, Zive D, Schmidt TA. POLST Registry do-not-resuscitate orders and other patient treatment preferences. JAMA 2012;307:34-35.

4. Hammes BJ, Rooney BI, Gundrum JD. The POLST program: A retrospective review of the demographics of use and outcomes in one community where advance directives are prevalent. J Palliative Medicine 2012;15:77-85.

5. Hickman SE, Tolle SW, Brummel-Smith K et al. Use of the PhysicianOrders for Life-Sustaining Treatment program in Oregon nursing facilities:Beyond resuscitation status. J Am GeriatrSoc 2004;52:1424–1429.

6. Hickman SE, Nelson CA, Moss AH et al. Use of the Physician Orders for Life-Sustaining Treatment (POLST) paradigm program in the hospice setting. J Palliat Med 2009;12:133–141.

7. HappMB, Capezuti E, Strumpf NE et al. Advance care planning and end-of- life care for hospitalized nursing home residents. J Am GeriatrSoc2002;50:829–835.

8. Fromme EK, Zive D, Schmidt TA, Olszewski E, Tolle SW: POLST Registry Do-Not-Resuscitate Orders and Other Patient Treatment Preferences JAMA. 2012;307(1):34-35.

9. Fromme EK, Zive D, Schmidt TA, Cook J, Tolle SW: Association between Physician Orders for Life SustainingTreatment Scope of Treatment and in-hospital death in Oregon J AmerGertairSoc2014

10. Schmidt TA, Hickman SE, Tolle SW et al. The Physician Orders for Life-Sustaining Treatment program: Oregon emergency medical technicians’ practical experiences and attitudes. J Am GeriatrSoc 2004;52:1430–1434.

11. Vo H, Pekmezaris R, Guzik H et al. Knowledge and attitudes of health care workers regarding MOLST (Medical Orders for Life-Sustaining Treatment) implementation in long-term care facilities. GeriatrNurs2011;32:58–62.

12. Sugiyama T, Zingmond D, Lorenz KA et al. Implementing Physician Orders for Life-Sustaining Treatment in California hospitals: Factors associated with adoption. J Am GeriatrSoc 2013;61:1337–1344.

13. Waldrop DP, Clemency B, Maguin E et al. Preparation for frontline end-of- life care: Exploring the perspectives of paramedics and emergency medical technicians. J Palliat Med 2014;17:338–341.

14. Wenger NS, Citko J, O’Malley K et al. Implementation of Physician Orders for Life Sustaining Treatment in nursing homes in California: Evaluation of a novel statewide dissemination mechanism. J Gen Intern Med 2013;28:51–57.

Website:

Draft Ohio Form submitted by Midwest Care Alliance, June 2015

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