Maryland's Medical Orders for Life-Sustaining Treatment Form Use: Reports of a Statewide Survey

Abstract

Background:

Advance directives (ADs) and Physicians Orders for Life-Sustaining Treatment (POLST) orders perform different but complementary functions in documenting a patient's treatment preferences and translating them into actionable orders that change in keeping with the patient's evolving clinical picture. Maryland's Medical Orders for Life-Sustaining Treatment (MOLST) form developed through a stakeholder-driven process that deviates from other POLST forms. While a patient or surrogate can decline discussing MOLST orders with a clinician, clinicians must write MOLST orders for certain patients (e.g., those admitted to a nursing home (NH), assisted living facility (ALF), hospice, home health (HH) agency, or dialysis center, discharged from a hospital to any of these facilities, or transferred between hospitals).

Objective:

To gather data on Maryland MOLST form use to evaluate performance and inform future research and practice.

Design:

Chart reviews (CRs).

Setting/Subjects:

MOLST forms and patient data collected from Maryland hospitals (adult nonpsych, nontrauma, nonobstetric patients), NHs, ALFs, hospices, HH agencies, and dialysis centers.

Measurements:

Facility demographic tool and CR tools.

Results:

A total of 1959 CRs were received from 137 facilities, including 2064 MOLST forms. Most patients required to have MOLST orders had them (84%); fewer had ADs (47%). Few patients or surrogates declined discussing MOLST orders (1%). Few MOLST orders were written based on medical ineffectiveness criteria defined in Maryland law (<1%). MOLST form completion error rates ranged from 1% to 3%. Non-white patients were about twice as likely to have a MOLST “Attempt CPR” order (62%) as white patients (32%).

Conclusions:

MOLST error rates are relatively low and consistent with other research. Areas for improvement include selecting one order option where required, avoiding contradictions between Page 1 and 2 orders, offering MOLST Page 2 options if relevant, and documenting in the medical record a summary of the discussion informing MOLST orders.

Background

The Physicians Orders for Life-Sustaining Treatment (POLST) medical order form was developed to improve end-of-life (EOL) care by ensuring that patients' EOL treatment orders are consistent with their preferences and goals of care, and honored across heathcare settings.¹ Advance directives (ADs) allow individuals to communicate preferences for future EOL care. Do-not-resuscitate (DNR) orders specify which life-sustaining treatments to withhold now in patients who are unresponsive, pulseless, and not breathing. POLST orders were a response to recognized shortcomings of ADs and DNR orders to effectively direct care across settings for patients with “advanced progressive illness and/or frailty.”^2–3 To date, 27 states have implemented a POLST-type order form, and 23 more are developing one.²

The National POLST Paradigm Task Force (NPPTF) adopted POLST standards and a vetting process for endorsing states' forms.⁴ Three states (Massachusetts, Maryland, and Vermont) have been designated as “nonconforming” to NPPTF standards.⁵ Implicit in this designation is that excessive variation in how NPPTF standards are implemented in state POLST forms may impair POLST effectiveness. The goal of this article is to describe the process Maryland used to develop its Medical Orders for Life-Sustaining Treatment form (hereafter “the MOLST”), identify similarities and differences between the MOLST and mature POLST forms (e.g., Oregon's POLST), and present data evaluating MOLST use across Maryland healthcare delivery settings.

MOLST evolution

The MOLST developers reviewed the NPPTF standards and available POLST literature, explored successes and challenges of states using NPPTF-endorsed POLST forms, and gathered extensive statewide feedback. From 1996 to 2009, staff from Maryland's Department of Health and Mental Hygiene collected input from 52 stakeholder organizations and hundreds of individuals to inform successive revisions to the MOLST.⁶ From 2009 to 2011, the POLST subcommittee of Maryland's State Advisory Council on Quality Care at the EOL oversaw additional revisions to the MOLST, which was implemented in 2011.⁷

Differences between MOLST and POLST

The MOLST differs from mature POLST forms in how NPPTF standards are implemented. MOLST page 1 (P1) contains resuscitation status orders, and MOLST page 2 (P2) contains optional orders intended for non-emergency medical services staff (Table 1). Application of NPPTF standards throughout the many revisions to the MOLST involved extensive, iterative stakeholder input. For example, in Oregon's POLST, the provision to receive noninvasive ventilation (e.g., through continuous positive airway pressure or bilevel positive airway pressure) is contained under POLST Section B, “Medical Interventions,” whereas in the MOLST, this is a resuscitation status option. This reflected a widespread stakeholder preference to ensure that resuscitation status orders contained options reflecting patients' wishes regarding ventilation and intubation.

Table 1.

Comparison between POLST Task Force Standards, Maryland's MOLST, and Oregon's POLST Forms

POLST task force standard	Maryland's MOLST form	Page	Oregon's POLST form	Page
A = CPR What to do when a patient is unresponsive, pulseless, and not breathing	Section 1 orders:	1	Section A orders:	1
	Attempt CPR		Attempt resuscitation/CPR
	No CPR, option A-1: Comprehensive efforts to prevent arrest may include intubation and artificial ventilation		Do-not-attempt resuscitation/DNR
	No CPR, option A-2: Comprehensive efforts to prevent arrest may include limited ventilatory support by CPAP or BiPAP, but do not intubate		“If patient is not in cardiopulmonary arrest, follow orders in B and C.”
	No CPR, option B: Palliative and supportive care
B = Medical interventions	(See Section 1 above)	1	Section B orders:	1
			Comfort measures only …
			Limited treatment …
			Full treatment …
C = Artificially administered nutrition	Section 7 (optional non-EMS) orders:	2	Section C orders:	1
	May give artificially administered fluids and nutrition, even indefinitely, if medically indicated		Long-term artificial nutrition by tube.
			Defined trial period of artificial nutrition by tube.
	May give artificially administered fluids and nutrition, if medically indicated, as a trial. Time limit:___		No artificial nutrition by tube.
	May give fluids for artificial hydration as a therapeutic trial, but do not give artificially administered nutrition. Time limit: __		Additional orders (e.g., defining the length of a trial period):
	Do not provide artificially administered fluids or nutrition.
Other order options	Section 2–6 and 8–9 (optional non-EMS) orders:	2	(See Section C above)	—
	Artificial ventilation …
	Blood transfusion …
	Hospital transfer …
	Medical workup …
	Antibiotics …
	Dialysis …
	Other orders (blank space)
Documentation of basis for orders	Certification that orders entered as a result of discussion with and informed consent of patient or legally authorized decision-maker, or based on instructions in AD, or physician determination of medical ineffectiveness, or that patient/surrogate declined to discuss/unable to make decision about treatments	1	Section D:	1
			Documentation of discussion (patient, healthcare representative, or surrogate)
			Name and relationship to patient
Signatures	No patient/surrogate signature option	1 and 2	Section E: Patient/surrogate signature (recommended) and registry opt-out	1
	Clinician name, signature, license no., phone no. and date		Section F: Clinician attestation name, date, phone no., signature

Instructions	Page 1 (top) and separate page		Page 2 (primarily)
Voluntary?	Patient/surrogate may decline MOLST discussion; clinician must complete MOLST for patients admitted to NH, ALF, hospice, HH, or dialysis center, and discharged to these from a hospital or transferred between hospitals		“Completing a POLST is always voluntary and cannot be mandated for a patient.”
Other	No specified color		Pink

AD, advance directive; ALF, assisted living facility; BiPAP, bilevel positive airway pressure; CPAP, continuous positive airway pressure; CPR, cardiopulmonary resuscitation; DNR, do-not-resuscitate; EMS, emergency medical services; HH, home health; MOLST, Medical Orders for Life-Sustaining Treatment; NH, nursing home; POLST, Physicians Orders for Life-Sustaining Treatment.

Another difference is that the MOLST must be completed for certain patients—generally, adults transferred between facilities where clarification of code status is deemed important (e.g., from a hospital to hospice, dialysis, home care, long-term care [LTC], or between hospitals). If a patient or surrogate declines discussing MOLST orders, the default is to select “Attempt CPR” (cardiopulmonary resuscitation) unless contraindicated by the AD or considered “medically ineffective” as per Maryland's Health Care Decisions Act (HCDA).⁸ Thus, discussion of code status remains voluntary for the patient/surrogate, but documentation of code status by a clinician is not voluntary (for certain patients).

The rationale here is that resuscitation status is an essential component that should be communicated in medical orders and accompanying documentation, particularly when transferring certain patients between facilities.⁹ Currently in the United States, absent a DNR order, the default is to attempt CPR. Clinicians implement this decision for patients either actively (i.e., after discussing options with the patient or surrogate and confirming preferences) or passively (i.e., by allowing the default of full code status without discussion to confirm resuscitation preference). Maryland's approach requires that a process be followed for certain patients to determine and document resuscitation status. This includes discussing options with the patient or legally recognized decision-maker (if available/willing), reviewing the patient's AD (if relevant), certifying CPR as medically ineffective consistent with Maryland's HCDA (if relevant), and communicating orders through the MOLST and supporting documentation.¹⁰ One assumption here is that while “unilateral” DNR orders may violate patients' rights if a fair process is not followed,^11–13 default full code orders may also violate patients' rights if patients or surrogates are not properly informed and involved.

These differences raise questions about whether the MOLST performs comparably to the POLST. Accordingly, this study evaluates how the MOLST form is being used and calculates detectable completion errors to inform future research and clinical practice.

Design

A Maryland MOLST Study Advisory Panel was assembled to help develop chart review (CR) forms, facility demographic forms, sampling strategies, and study training materials. CR forms were adapted from resources in the POLST Quality Research Toolkit,¹⁴ piloted, and modified based on pilot data and advisory panel feedback. CR forms elicited demographic data (age, race, health insurance); AD data (whether completion of an AD was noted in the patient's medical record, the year completed, and whether a healthcare agent [HCA] was appointed); medical data (varied based on facility type, for example, hospital and nursing home [NH] CRs elicited whether the patient was in a terminal or end-stage condition, persistent vegetative state, or lacked decisional capacity); and MOLST data. Patient age over 89 was entered as “90” (censored) to avoid facilities having to obtain a Health Insurance Portability and Accountability Act (HIPAA) waiver. The University of Maryland Institutional Review Board determined that the study did not meet the definition of human subjects research.

MOLST completion errors included leaving required sections of the form blank or selecting multiple options when only one option was required (e.g., for resuscitation status), and selecting contradictory orders (such as no intubation or ventilation allowed under resuscitation status orders on MOLST P1 and intubation or ventilation allowed on MOLST P2, or discussion with the patient's HCA [or AD instructions] selected as the basis for MOLST orders for patients with no appointed HCA [or AD]). Not documenting a summary of the conversation informing the MOLST orders in the medical record (asked in the CR tool) was considered an omission error. CRs for patients who lacked decision-making capacity, had an AD, and had medical record documentation indicating that their AD was in effect (e.g., a documented terminal or end-stage condition) provided an opportunity to evaluate coherence between ADs and MOLST orders.

Between December 2014 and February 2015, all Maryland adult, nonpsychiatric hospitals (n = 50), home health (HH) agencies (n = 56), hospices (n = 26), dialysis centers (n = 27), a random selection of half of the NHs stratified by bed size (<100 or ≥100; equal sampling from each) (n = 115), and a random selection of half of the assisted living facilities (ALFs) stratified by city versus county (equal sampling from each) (n = 175) were invited to participate. The study was advertised statewide and a contact person was identified at each facility to receive study materials. Contact persons were provided with an instruction packet with suggestions for identifying facility staff or volunteers to assist with CRs. Chart reviewers were instructed to complete the facility demographic form and requisite number of CRs (Table 2), and to staple to each CR copies of all MOLST forms (current and voided) and relevant pages of the AD (if present) with patient identifiers redacted. The most recent MOLST was considered “active” for cases of multiple forms with earlier dated MOLST forms incorrectly voided. A facility-specific “demo” CR was included with sample answers. Volunteer assistance in completing CRs was offered, and CR forms included study staff contact information, which several chart reviewers accessed to clarify instructions.

Table 2.

Facility Site Types, Sampling Strategy, and Data Received

Site	Sampling instructions to each facility	Facility response rates, N (%)	CR with 1 or more MOLST forms/total CRs, N (%)^a	Total no. of MOLSTS ^b
Hospitals (nonpsych, adult)	Last 20 adult discharges to qualifying site,^c and last 10 adult deaths (nontrauma/psych/OB) (if <300 beds: half above)	24/50 (48)	351/452 (78)	451
NH	Last 15 admits and last 15 deaths; (if 30–149: 8 admits and 8 deaths; if <30: current residents)	51/115 (44)	666/702 (95)	881
Assisted Living	Last 15 admits and last 15 deaths (if 30–149: 8 admits and 8 deaths; if <30: current residents)	45/175 (26)	303/417 (73)	356
Hospices	Last 30 deaths (if <30: current patients)	12/26 (46)	212/235 (90)	254
HH agencies	Last 30 admits	2/56 (4)	32/60 (53)	32
Dialysis centers	Random 30 current patients (if <30: current patients)	3/27 (11)	90/93 (97)	90

Maryland law requires MOLST orders for admissions to these facilities, for transfers between hospitals (for certain patients), and for discharges from hospitals to these facilities.

Numerator indicates no. of CRs coupled with at least one MOLST; denominator = total no. of CRs received.

Includes all active and voided MOLST forms.

Qualifying site = ALF, NH/skilled nursing facility, HH, hospice, and dialysis center.

CR, chart review; OB, obstetrics.

Results

Response rates were just under half for hospitals, hospices, and NHs (48%, 46%, and 44%, respectively), and lower for ALFs, dialysis centers, and HH agencies (26%, 11%, and 3.5%, respectively). More for-profit LTC facilities (NH and ALF) participated in the study than not-for-profit facilities (56% vs. 44%). Average bed size was higher for participating than nonparticipating hospitals (279 vs. 183).

A total 1959 CRs and 2064 MOLST forms were received from 137 facilities (Table 2), with 1654 CRs (84%) having at least one MOLST form. Nurses most frequently completed CRs (39%), followed by social workers (27%), quality improvement personnel/administrators (27%), and medical record staff (8%). Patient demographic data are presented in Table 3.

Table 3.

Chart Review Patient Demographics

	N (%)
Sex
(Female)	908/1463 (62)
Race
Asian	40/1930 (2)
Black/African American	335/1930 (17)
Hispanic/Latino	17/1930 (1)
White	1520/1930 (79)
Other/mixed	18/1930 (1)
Age^a
Mean years (n = 1926)	78.5
Median years (n = 1926)	83
Insurance
Medicare	1236/1930 (64)
Medicaid	151/1922 (8)
Other/mixed insurance	406/1922 (21)
None/self-pay	129/1922 (7)
Site
Hospital	452/1959 (23)
NH	702/1959 (36)
ALF	417/1959 (21)
Hospice	235/1959 (12)
HH	60/1959 (3)
Dialysis	93/1959 (5)

Denominator <1959 are due to redacted/missing CR data. Percentages not adding to 100% are due to rounding.

Censored: age >89 = 90.

MOLST education and training

Facilities estimated that on average, 78% of their staff were trained in MOLST form use, most commonly through internal seminars (70%), followed by external seminars (47%), online training (38%), and self-paced materials (14%). A MOLST champion was present in 91% of hospitals, 65% of hospices, and 62% of LTC facilities.

Methods of MOLST form education for patients/families varied by individual clinician for most facilities (56%). More hospices (46%) than LTC facilities (25%) or hospitals (17%) used similar approaches delivered by trained staff to educate patients/families about MOLST orders. About a quarter (27%) of facilities offered informational packets to patients/families, with the MOLST worksheet and instructions¹⁵ commonly mentioned as resources.

AD data

Chart reviewers noted documentation of an AD for 915 of 1930 patients (47%) across facilities, but indicated presence of the AD in the medical record for only 673 of these (35%). Of these, 552 had relevant sections of the AD attached (i.e., an 82% compliance with CR instructions). An AD was more common for LTC patients (52%) than hospital patients (31%). Of note, while 31% of hospital patients had an AD noted in the medical record, only 18% noted the AD being on file. Among patients with an AD, the mean age of AD completion was 75 years (median 78 years; n = 610), with a mean of 7 years (median 5 years) since AD completion.

MOLST descriptive data

Patients targeted for inclusion in this study were required by Maryland law to have MOLST orders; 84% had them. The basis for MOLST orders was most commonly a discussion with the patient (51%), followed by discussion with an appointed HCA (Table 4). Only 13 of 2064 MOLST orders (<1%) were written based on a determination of medical ineffectiveness. Only 28 of 2064 MOLST forms (1%) indicated that a patient or surrogate declined discussing or was unable to decide about MOLST orders.

Table 4.

Active MOLST Order Selections (Page 1)

	Hospital (N = 351), n (%)	Non-hospital (N = 1303), n (%)	White (N = 1286), n (%)	Non-White (N = 348), n (%)
Certification for basis of MOLST orders (discussion with or authority of)
Patient	223 (63.5)	668 (51)	691 (54)	186 (53)
HCA	45 (13)	293 (22)	278 (22)	55 (16)
Guardian	6 (2)	39 (3)	33 (3)	11 (3)
Surrogate^a	32 (9)	89 (7)	77 (6)	44 (13)
AD	3 (1)	22 (2)	21 (2)	4 (1)
Maryland's HCDA	2 (<1)	6 (<1)	6 (<1)	2 (<1)
Declined	1 (<1)	14 (1)	7 (<1)	5 (1)
Multiple	11 (3)	102 (8)	94 (7)	19 (5)
Errors^b	28 (8)	70 (5)	79 (6)	22 (6)
Resuscitation status
Attempt CPR	182 (52)	441 (34)	408 (32)	214 (61)
No CPR, option A-1, intubate	17 (5)	16 (1)	24 (2)	6 (2)
No CPR, option A-2, DNI	59 (17)	212 (16)	232 (18)	35 (10)
No CPR, option B	87 (25)	619 (47.5)	612 (46)	83 (24)
Errors^c	6 (2)	13 (1)	10 (<1)	10 (3)

Percentages not adding to 100% are due to rounding.

Surrogate as per Maryland's HCDA.

Errors in this section included no selection, parent checked for adult, HCA or AD checked but no HCA or AD on record, or patient/surrogate noted as both discussing and declining to discuss MOLST.

Errors in this section included no selection or multiple entries for resuscitation status (one selection required).

DNI, do not intubate; HCA, healthcare agent (i.e., durable power of attorney for healthcare); HCDA, Healthcare Decisions Act.

Sixteen percent (33/201) of hospital patients with an MOLST on admission had it voided and new orders written during their hospital stay, with a mean of seven days (median = 4) between admission and change in MOLST orders. Of 69 discharged hospital patients with a DNR order while in the hospital, 67 (97%) had MOLST DNR orders written at discharge.

Subgroup comparisons

Among charts with at least one MOLST and noted patient race, 1286 patients (79%) were white and 348 (21%) were non-white. Non-white patients were about twice as likely to have an “Attempt CPR” MOLST order (62%) compared to white patients (32%). “Attempt CPR” was more commonly ordered for hospital patients (52%) than nonhospital patients (34%).

While most LTC patients had MOLST orders on P2 (73%), 66% of hospital patients had no MOLST P2 orders. Among patients who had “Attempt CPR” selected on MOLST P1 and any orders on P2 (n = 770), 310 (40%) had P2 orders limiting life-prolonging treatment, including intubation/ventilation (n = 99), blood products (n = 12), hospital transfer (n = 13), medical tests (n = 11), antibiotics (n = 4), artificial nutrition or hydration (ANH) (n = 72), and dialysis (n = 62). Among patients who had “No CPR” selected on P1 (resuscitation status option A or B) and any orders on P2 (n = 832), 629 (76%) had P2 orders to provide life-prolonging treatment, including intubation/ventilation (n = 38), blood products (n = 172), hospital transfer (n = 155), medical tests (n = 165), antibiotics (n = 272), unrestricted ANH (n = 51), trial ANH (n = 38), trial fluids (n = 143), any dialysis (n = 17), and time-limited dialysis (n = 25).

MOLST errors

Errors in MOLST form completion included the following:

• P1 errors:

○ Basis for certification of orders blank, ambiguous, “parent” checked for adult, or patient/surrogate noted as both discussing and declining to discuss MOLST: 46/2064 (2%).

○ No documented HCA but HCA discussion selected as basis for orders: 54/2064 (3%).

○ No documented AD but instructions in AD selected as basis for orders: 18/2064 (<1%).

○ Resuscitation status blank or multiple options selected: 63/2064 (3%).

• Contradictions between P1 and P2:

Intubation and ventilation precluded under resuscitation status on P1 but allowed on P2: 14/905 (1.5%).

• Other errors:

○ MOLST orders on P2 precluded hospital transfer but patient transferred to the hospital without the MOLST order being voided/rewritten in the hospital: 11/127 (9%).

○ MOLST orders incorrectly voided (line through + “VOID” + clinician's initials): 539/680 (79%).

○ Low compliance in documenting in the medical record a summary of the discussion informing the MOLST orders: 4/32 (12.5%) HH; 92/248 (37%) hospital; 159/384 (41%) ALF patients.

■ Compliance was higher for dialysis (85/90; 94%), hospice (154/228; 67.5%), and NH (378/579; 65%) patients.

MOLST and AD coherence

Coherence between MOLST orders and ADs was difficult to confirm based on the low numbers of patients with an AD attached to the CR and notation of a condition invoking the AD (e.g., terminal or end-stage condition—elicited for hospital and NH patients) along with documented decisional incapacity. Of 41 patients in a terminal condition whose AD dictated DNR in such a condition, 37 (90%) had MOLST DNR orders (2 had “Attempt CPR” MOLST orders, and 2 had no MOLST on record). Of 35 patients in an end-stage condition whose AD dictated DNR, 34 (97%) had MOLST DNR orders (one had an “Attempt CPR” MOLST order). Of 61 patients in terminal or end-stage conditions whose AD precluded ANH in such a condition, 43 (70%) had MOLST P2 orders precluding ANH (one was discharged from the hospital with “trial fluids” allowed; 15 NH patients had MOLST P2 orders allowing ANH, and eight NH patients lacked MOLST P2 orders).

Discussion

This study sampled patients required by Maryland law to have MOLST orders, and 84% had them. This indicates one measure of statewide MOLST clinician training success (on average, 78% of staff across facilities reportedly received MOLST training).¹⁶ MOLST form completion error rates were relatively low (1%–3%) and consistent with other POLST research.^17–19 Hickman et al.¹⁸ found that POLST orders were consistent with patients' prior decisions and treatment actually provided. We found some evidence of MOLST orders matching patients' prior preferences in that 114 of 137 patients (83%) in terminal or end-stage conditions with ADs precluding CPR attempts or ANH had MOLST orders precluding CPR and ANH. The most disconformity surrounded ANH (24% of these MOLST orders failed to specify no ANH on P2, as per the AD).

In addition, of discharged hospital patients who had an in-hospital DNR order, 97% had DNR MOLST orders at discharge. For the two who had “Attempt CPR” MOLST orders, it is unknown whether this reflected a change in condition or patient/surrogate preference warranting the change from DNR to “Attempt CPR,” whether the DNR order was inappropriate during the hospital stay, or whether the “Attempt CPR” MOLST order was inappropriate. Likewise, for the 11 patients with “no hospital transfer” orders on MOLST P2 who were transferred to the hospital, it is unknown whether this represented an error in overriding their preference for no hospital transfer, or in not voiding the MOLST form and writing new orders based on a change in the patient's preference on hospital admission.

The question arises whether our data demonstrating coherence between MOLST orders and patients' preferences are comparable to POLST performance in other states, given Maryland's approach to mandate MOLST orders for certain patients. Given that so few patients or surrogates declined discussing MOLST orders (1%) provides some evidence that patients and surrogates are willing to have the discussion. Indeed, prior research has shown that barriers to advance care planning (ACP) conversations are more clinician based than patient based.^20,21 The finding that MOLST resuscitation status for whites and non-whites aligns with other research findings (i.e., non-whites are more likely than whites to request “Attempt CPR” orders)^17,22 is reassuring, although clinician bias could also account for this (i.e., clinicians may have written “Attempt CPR” orders more frequently for non-whites based on race-based assumptions rather than on discussions eliciting the patient's preferences). More research is needed to assess the quality of the discussions clinicians are having with patients/surrogates to inform MOLST orders.

Considering that among patients with any P2 orders, 40% of those with “Attempt CPR” orders on P1 had some orders on P2 to limit life-prolonging treatments, and that 76% of those with DNR orders on P1 had some orders on P2 to provide life-prolonging treatments, this supports eliciting rather than assuming patients' P2 order preferences. This is notable, given that two-thirds of MOLST orders for patients transferred from the hospital to LTC had no P2 MOLST orders. A brief summary in the medical record of the conversation informing MOLST orders (missing for about two-thirds of hospital, HH, and ALF patients) would likely help clinicians interpret whether MOLST orders are accurate or warrant revision based on a change in condition or patient preferences.

Conclusions and Implications

Maryland used a stakeholder-driven iterative process that produced variations from NPPTF-endorsed POLST forms. Yet, data reveal that most staff have been trained in use of MOLST orders, most patients targeted to benefit from clearer documentation regarding resuscitation orders have MOLST orders, and errors are relatively low and consistent with other research. While some research casts doubt on the promise of ADs and POLST orders to improve EOL care,^23,24 these tools are only of benefit if informed by effective ACP conversations.^25–27 Thus, MOLST success rests on ensuring that clinicians have effective, recurring ACP discussions with patients, that individuals' EOL preferences are documented in interpretable and accessible ADs and medical record notation, and that MOLST orders reflect known preferences and goals of care. These efforts continue to evolve.²⁸

Our ability to draw conclusions is limited by this study's CR design. We assumed that medical record information was accurate and that chart reviewers correctly completed reviews. This study is a first step in evaluating Maryland's MOLST form use. Future research involving observation of ACP discussions and feedback from clinicians, patients, and surrogates about how such discussions inform MOLST orders and EOL care could reveal ways to improve the complementarity of ACP discussions, ADs, and MOLST form use. Reasons for race-based differences in POLST/MOLST orders require further evaluation. A state AD and MOLST registry (in progress^28,29) would greatly aid in tracking forms and evaluating outcomes.

Footnotes

Acknowledgments

We are most grateful to our MOLST Study Advisory Panel, our MOLST study volunteers, and all those who completed chart reviews for this study. This study was funded by a grant from the Maryland Department of Health and Mental Hygiene.

Author Disclosure Statement

No competing financial interests exist.

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