Choices about Life-Sustaining Medical Treatments

Jena Bauman Adams, MPH MOLST Project Director Hearing that you or a loved one may be nearing the end of life because of a serious illness or injury is very difficult. It often takes time to adjust to the situation and to consider what it may mean. In addition, medical information – especially about one’s health status, what can happen next and the potential benefits and risks of treatment – can be confusing or overwhelming.

All adults have a legal and ethical right to make choices about medical treatments they want or do not want to receive when they are nearing the end of life. However, patients’ wishes are often unspoken, unknown, or unavailable to health providers at the time treatment decisions are made. That is why it is so important for individuals to have conversations with their loved ones and doctors about all of these matters – not only when they are very sick, but also before an unexpected illness or injury may occur.

In Massachusetts, all adults ages 18 and older are encouraged to fill out a health care proxy form to appoint a person they trust as their “health care agent.” In Massachusetts, if an individual is not capable of making medical decisions as determined by their clinician (e.g. because they are unconscious or due to dementia or other mental limitations), it is their “health care agent” officially named in a health care proxy who is authorized to make medical decisions on their behalf. It cannot be assumed that a family member or next of kin will be authorized to make medical decisions in every situation or setting.

Therefore, appointing a health care agent is the first essential step in advance care planning for every adult after they have turned 18 years old, even if they are perfectly healthy. The next step is to have conversations with your health care agent about your values and goals for medical care, so he or she can make the medical decisions you would have wanted should the need occur.

For individuals with serious advancing illnesses, especially those who may be nearing the end of life, physician-patient conversations about life-sustaining treatment preferences are of particular importance. Such conversations are often difficult for everyone involved; however, they serve to help patients, their loved ones and health care providers better understand the patient’s medical condition, treatment options and goals for care. In fact, these discussions have proven to improve quality of life scores for patients near the end of life and bereavement outcomes for their caregivers. (1)

To assist seriously ill or injured individuals communicate their wishes about end-of-life medical treatments, a new process is being tested in several Worcester-area health care institutions. Called Medical Orders for Life-Sustaining Treatment, the process entails conversation between a patient and the patient’s loved ones and doctor to explore and establish the patient’s treatment goals and preferences. One possible outcome of these discussions is completing and signing a “MOLST” form. A MOLST form is filled out and signed by a patient and doctor together to communicate the patient’s treatment wishes. MOLST instructions are honored by all health professionals across health care settings (e.g. at home, by emergency responders, in nursing homes, at hospitals).

The MOLST process involves:

1. Discussing your medical condition, treatment options, and your values, hopes, expectations and goals for care with your doctors and loved ones
2. Learning about the types of medical treatments you might be given if your heart or breathing stop – including the benefits or risks of such treatments and how effective they might be
3. Identifying any preferences you may have about receiving or not receiving certain types of life-sustaining treatments
4. Deciding whether or not to document your preferences by completing a MOLST form with your doctor
5. Completing the MOLST form with your doctor and signing it to confirm that the form reflects the treatment preferences you expressed to the doctor (the doctor also signs the form)
6. Keeping the MOLST form with you in a location where it can be easily seen or found by your loved ones and health professionals
7. Telling your loved ones, health care agent and caregivers about your MOLST instructions and the location of your MOLST form

Completing a MOLST form is voluntary and individuals may decide to wait until another time to consider MOLST, or not to complete a MOLST form at all. Individuals can also change their minds about treatments any time, even after signing the MOLST form.

For more information about Medical Orders for Life-Sustaining Treatment, you may ask your doctor, visit: www.molst-ma.org, or call the MOLST program at 508-856-5890.
--------------------------
(1) Wright, A.A., et al., Associations between end of life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA, 2008. 300(14): p. 1665-73.