QUALITY PATIENT care is a primary focus for all individuals receiving healthcare services. Following the Supreme Court decision on the Cruzan case, which set legal precedent regarding the withdrawal of life-sustaining treatment, the Patient Self-Determination Act of 1990 was passed in 1991.1,2 The law requires healthcare professionals to counsel patients on their treatment options, giving them autonomy in decision-making.3 In accordance with the law, Oregon developed the first Physician Orders for Life-Sustaining Treatment (POLST) form to aid in honoring patient preferences regarding life-sustaining treatment.3,4
In 1993, The Maryland Health Care Decisions Act was signed into law, paving the way for the Medical Orders for Life-Sustaining Treatment (MOLST) form. The MOLST is meant to accompany patients throughout the healthcare continuum, standardizing definitions, facilitating the review of treatment options, and honoring patient wishes. This article discusses a study on healthcare professionals' perceptions regarding barriers and facilitators in the completion and comprehension of the MOLST form and the implications of orders for life-sustaining treatment across the US.
The MOLST is a two-page form that is divided into nine sections, covering options for CPR and other life-sustaining treatments.5,6 It can be signed by physicians, NPs, or physician assistants (PAs).6 For the purposes of this article, these professionals will be referred to as healthcare providers.
The first page is related to the patient's CPR status with two options: attempt CPR or no CPR, which includes subchoices for patient intubation or palliative and supportive care.6 The second page includes other options for life-sustaining treatments in situations other than cardiopulmonary arrest, such as:6
- artificial ventilation
- blood transfusion
- hospital transfer
- medical workup
- artificially administered fluids and nutrition
The Maryland MOLST program aids in decision-making regarding end-of-life care.7 Healthcare providers completing the form are required to complete the first section related to CPR and fill out one choice in each of the subsequent sections.6 Any options in sections two through nine that do not apply should be left blank, but no clear directions for how to interpret these options are provided. This may lead to variances in patient care in Maryland.
There has been a national focus on the importance of advance care planning. The National POLST Paradigm focuses on end-of-life planning and encourages discussion between patients and providers for treatment consistent with patient goals and wishes.7 The POLST form is used to document these discussions. Although many states have developed a POLST program, the specific forms vary from state to state. The differences between the MOLST and POLST forms include the document's name, layout, included information, and any required information to make it a complete and valid legal document.7
Like completed POLST forms, advance directives (ADs) such as a living will or healthcare power of attorney are recognized as legal documents. With a living will, patients can determine what treatments may and may not be used to keep them alive in the event of a healthcare emergency.8 Healthcare powers of attorney allow patients to designate a representative to make decisions on their behalf if they are incapacitated due to illness.8 ADs and POLST forms each address advance care planning, but they differ in many ways.
An AD provides individual patient preferences in the event of a medical emergency and allows for the appointment of a healthcare agent should the patient become incapacitated or otherwise unable to voice his or her wishes. In contrast, a POLST is a medical order form designed to address specific life-sustaining treatment measures and is utilized for individuals with serious, life-threatening illnesses.7 Depending on the state or setting, a POLST may be referred to as MOLST, Physician Orders for Scope of Treatment (POST), Provider Orders for Life-Sustaining Treatment, Medical Orders for Scope of Treatment (MOST), or other orders for life-sustaining treatment.7,9
As of 2013, Maryland state legislation requires some organizations to have a completed MOLST for certain individuals, including all newly admitted patients to assisted living programs, home healthcare agencies, hospices, kidney dialysis centers, and skilled nursing facilities.10 Similarly, hospitals must obtain MOLST forms for certain patients.10 The National POLST Paradigm, however, highlights the voluntary nature of the form and states that this legislation “violates the POLST Paradigm's tenet that completion of a POLST is always voluntary.”11
While various state forms have many differences, one similarity is especially significant. Individual states may not require the completion of all the sections on the form, but many states note that an incomplete section indicates a preference for full treatment, and, unless indicated otherwise, all treatments will be provided to the full extent regarding that section.12 Varying perceptions between the nurses caring for patients with MOLST orders and the providers responsible for completing the form concerned the team involved in the research project described in this article.
A literature review was conducted to identify research regarding barriers and facilitators in the completion and comprehension of both MOLST and POLST forms.Although some relevant articles were identified in a literature review of life-sustaining treatments, these were inconclusive about the barriers and facilitators in completing the entire order form.13-16 Further research was warranted to explore the use of the form by nurses and providers.
The authors' survey was designed to evaluate facilitators and barriers related to MOLST orders, as well as the required education and resource needs to assist patients, authorized decision-makers, and families in completing the form. It was initiated in a healthcare system of three rural hospitals, two of which are recognized as Magnet® organizations. The project was exempted by the institutional review board, and informed consent was completed by participants within the online survey before they were prompted to answer the questions.
Healthcare providers who complete and sign the order form and nurses who care for patients with MOLST were eligible to complete the survey. Convenience sampling was used within the healthcare system initiating the research, and snowball sampling was used for healthcare providers and nurses in the state of Maryland.17 Snowball sampling refers to the practice of using those already taking part in research to identify other potential participants.18 Data were gathered based on participant feedback from hospitals, as well as healthcare organizations, associations, and other provider groups in the state.
The research team developed a survey that included yes-or-no, multiple-choice, and open-ended questions. Mary R. Lynn's procedures of data collection were followed to quantify content validity (CV).19 A six-member panel of content experts conducted a two-stage process to determine CV and generate a CV index (CVI). The item level CVI demonstrated the proportion of total items deemed valid, yielding an item level and scale CVI of 1.0.19,20 Experts included an oncology nurse practitioner; an ethics committee representative; and nurse leaders in emergency care, acute care, palliative care, and case management.
The 25-item validated survey had six parts:
- survey eligibility: one question
- demographics and work: four questions
- healthcare provider-related MOLST education and resource needs: three questions
- patient, authorized decision-maker (healthcare agents, legal guardians, or surrogates), and family-related MOLST education and resource needs: three questions
- MOLST hospital processes for healthcare providers: eight questions
- MOLST hospital processes for nurses: six questions.
Of 211 participants, 195 met the eligibility requirements. Those taking the survey were not required to answer every question, but five questions from the first two parts of the survey were mandatory for all participants. Of the remaining 20 questions, 6 applied only to nurses and 14 applied only to providers.
A conventional approach to content analysis was utilized to interpret qualitative data from the open-ended questions, codes were identified and aggregated into categories, and descriptive statistics were used to report these responses.21 The research team coded the qualitative comments data, reviewed findings, and resolved discrepancies independently to reach a final consensus. (See Participant feedback.)
Of 195 eligible participants, 165 were nurses (84.6%), followed by 14 physicians (7.2%), 12 NPs (6.2%), and 4 PAs (2.1%). In other words, the participants were comprised of 30 healthcare providers (15.4%) who sign MOLST forms and order care, and 165 nurses (84.6%) who provide care for the affected patients. Of the total eligible participants, 156 (80%) worked in the acute care setting and 137 (70.3%) were from the healthcare system initiating the research.
The responses from healthcare providers were reported for those from the health system initiating the survey, as well as those from different healthcare systems in Maryland. Similarly, findings from nurse participants were reported for the same group types.
A total of 113 eligible participants responded regarding the completion of both the first and second pages of the MOLST order form. The most commonly cited barriers included limited time to discuss and complete the form with the patient or family (54.9%) and uncertainty from the patient or family (53.1%). In this context, uncertainty referred to patients who were unsure of the care they did or did not want and lacked confidence in making a definite decision due to factors such as comprehension. The most common facilitators for completion included additional time to discuss and complete the form with patients and families (54.9%) and patient and family comprehension of the MOLST form (44.2%).
Results: Healthcare providers
A total of 25 eligible healthcare providers weighed in on the most common education and resources they use to complete the first and second pages of the MOLST order form. These included the Maryland MOLST Health Care Decision Making Worksheet (52%) and the Maryland information sheet entitled Ten Things Health Care Professionals Should Know About Maryland MOLST (48%).6,22,23
Regarding the most effective MOLST education and resource needs used by patients and families, the most commonly identified preferences were as follows: 9 participants (42.9%) cited palliative care consultation, 9 (42.9%) cited the Maryland MOLST Health Care Decision Making Worksheet, and 6 (28.6%) cited the Maryland information sheet.22,23
The healthcare providers reported caring for a weekly average of 14.4 patients with a MOLST order form and 8.0 patients who need but do not have one. The average time required to discuss and complete the first page of the form was 9.2 minutes versus 16.2 minutes to complete both pages. On average, only the first page was completed by 39.5% of the participants.
With 11 of 20 (55%) participants identifying each option, the data on top barriers were split between lack of time, lack of certainty, and overwhelmed patients and families. In comparson, the top facilitators for completing both MOLST pages were identified as follows: of 20 total participants, 10 cited certainty among patients and families, 8 cited comprehension among patients and families, and 8 cited additional time to discuss and complete the form with patients and families.
A total of 89 nurse participants specified that, on average, 30.7% of patients have a MOLST form with only the first page completed, requiring the nursing staff to contact a healthcare provider regarding the second page. However, 14 nurses (15.7%) responded that they had not needed to contact a provider due to an incomplete second page. Only 22 nurses (32.8%) responded that both pages of the MOLST order form were complete upon their initial review.
Of 93 eligible nurse participants who responded that they had to contact a healthcare provider to clarify the MOLST form, 42 nurse participants (45.2%) specified that the most common reason for doing so was to verify an existing form. Approximately 31 participants (33.3%) cited an invalid order form, such as multiple selections in sections on either the first or second page. Additionally, 35 nurses (37.6%) stated that they had never contacted a healthcare provider to clarify issues related to the MOLST form.
When analyzed according to top barriers to MOLST form completion, 89 nurses responded. Of those, 51 nurses (54.8%) cited a lack of time for healthcare providers to discuss and complete the form with patients and families. Similarly, 49 nurses (52.7%) specified a lack of certainty among patients and families. When asked to specify the most common facilitators in completing the entire MOLST order form, 54 nurses (58.1%) mentioned the importance of additional time to discuss and complete it with patients and families and 51 participants (54.8%) noted improved comprehension.
Discussion and limitations
Some findings from this survey study, such as barriers to completing the MOLST form and the need for education and resources for patients and families, were consistent with the literature. While many states do not require each section of the order form to be completed, this study identified time as a common factor contributing to incomplete forms. Previous research demonstrated that 69% of MOLST orders have at least one blank section.13
One limitation of this study is that the findings may not be universally applicable to order forms for life-sustaining treatment used in other healthcare settings or in nonrural environments. Additionally, self-selection bias may exist due to the convenience and snowball sampling methods utilized during the recruitment process. Further research is warranted regarding best practices for life-sustaining treatment order completion.
Feedback on the barriers and facilitators to the MOLST form highlighted effective strategies to ensure adequate time to discuss and complete the order. Patient completion of the MOLST order form before hospitalization would be beneficial.
Innovative techniques are needed for MOLST education-related information and resources for healthcare professionals as they review patient options. Healthcare facilities have the opportunity to evaluate any MOLST resources currently available. This may present opportunities to discuss how to make these data more readily available and user-friendly at multiple entry points such as provider offices, community clinics, ambulatory settings, rehabilitation facilities, long-term-care facilities, and inpatient settings.
State websites can also provide comprehensive information and resources pertaining to orders for life-sustaining treatment for healthcare professionals, patients, and families alike. The same is true for healthcare systems, regardless of state-specific order forms. Similarly, healthcare providers should be included in the design and execution of any potential tools for life-sustaining treatment orders.
The goal is to support, encourage, and assist in initiating communication with family members regarding the patient's wishes; to further guide discussions with healthcare professionals; and to create greater clarity and comprehension of the options available for patients and families. Additional time is required for healthcare professionals, patients, and families to clarify treatment preferences. Introducing order forms for life-sustaining treatment, as well as the appropriate resources by state, before a patient is hospitalized will improve the overall process.
Introducing the department coordinator
Nursing has an impressive legacy of inspiring change in healthcare, and nurses currently serve as instrumental members and leaders on performance improvement projects. Among other patient safety indicators, nurses have helped to reduce incidents of patient harm, championed quality improvement initiatives, and served as educators to improve care. With these thoughts in mind, I embrace my new role as the department coordinator for the Inspiring Change department in Nursing2020.
I have spent the last 30 years as a nurse, paramedic, and hospital administrator. Much of my experience was gained at hospitals associated with the University of North Carolina (UNC), where I serve as president of Chatham Hospital and vice president for Hillsborough Hospital. Previously, I was the clinical nurse director for emergency services at UNC Medical Center. I also function in an adjunct capacity at UNC's Gillings School of Global Public Health and School of Nursing, as well as in an allied faculty role at the Tillman College of Business at the University of Mount Olive. Before taking on the department coordinator role, I was part of the editorial advisory board on Nursing and had also served on the editorial review boards for the Journal of Trauma Nursing and the Journal of Emergency Nursing.
Inspiring Change highlights great work in process redesign and quality improvement projects initiated by clinical nurses. These projects make a difference in patient care and experience and can be cost-effective to organizations. By focusing on the return on investment for such projects, nurses can show the value of such changes.
I encourage you to submit work on your own initiatives and the methods used to accomplish them. In doing so, others may duplicate your efforts and the nursing profession can improve patient care.
As nurses embrace home-care and travel nursing, their duties are increasingly being performed in unique environments. If you are practicing in these nontraditional roles, consider submitting an article. You never know how your efforts may affect the way others practice.
JEFFERY STRICKLER, DHA, RN, NEA-BC
1. Cruzan v. Director, Missouri Department of Health, et al. 497 U.S. 261. 1990. http://www.law.cornell.edu/supct/html/88-1503.ZS.html
2. Taub S. “Departed, Jan 11, 1983; At Peace, Dec 26, 1990”. Virtual Mentor
3. Patient Self Determination Act of 1990, HR 4449, 101st Cong, 2nd Sess (1989-1990).
4. Oregon POLST: Portable Orders for Life-Sustaining Treatment. Oregon POLST history. 2019. https://oregonpolst.org/history
5. Maryland MOLST: Medical Orders for Life-Sustaining Treatment. Maryland MOLST training task force. 2013. http://marylandmolst.org/pages/about_us.htm
6. Maryland Medical Orders for Life-Sustaining Treatment (MOLST). Maryland medical orders for life-sustaining treatment (MOLST) form. 2013. https://marylandmolst.org/docs/MOLST
MM3 2013 FINAL PROPOSED 72613 POSTED 21714-no-instructions.pdf.
7. National POLST Paradigm. National POLST paradigm program designations. 2019. http://polst.org/programs-in-your-state
10. Maryland Medical Orders for Life-Sustaining Treatment (MOLST). Summary of changes to the MOLST regulation. 2013. http://marylandmolst.org/docs/Summary
of Changes to the MOLST Regulation Revision.pdf.
11. National POLST Paradigm. National POLST paradigm program designations. 2019. https://polst.org/programs-in-your-state
13. Clemency B, Cordes CC, Lindstrom HA, Basior JM, Waldrop DP. Decisions by default: incomplete and contradictory MOLST in emergency care. J Am Med Dir Assoc
14. Hickman SE, Nelson CA, Moss AH, Tolle SW, Perrin NA, Hammes BJ. The consistency between treatments provided to nursing facility residents and orders on the physician orders for life-sustaining treatment form. J Am Geriatr Soc
15. McGough NN, Hauschildt B, Mollon D, Fields W. Nurses' knowledge and comfort levels using the Physician Orders for Life-sustaining Treatment (POLST) form in the progressive care unit. Geriatr Nurs
16. Turnbull AE, Hayes MM, Hashem MD, Needham DM. Interactive online module failed to improve sustained knowledge of the Maryland Medical Orders for Life-Sustaining Treatment form. Ann Am Thorac Soc
17. Polit DF, Beck CT. Nursing Research: Generating and Assessing Evidence for Nursing Practice
. 10th ed. Philadelphia, PA: Wolters Kluwer; 2017.
19. Lynn MR. Determination and quantification of content validity. Nurs Res
20. Polit DF, Beck CT, Owen SV. Is the CVI an acceptable indicator of content validity? Appraisal and recommendations. Res Nurs Health
21. Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res
22. Maryland MOLST: Medical Orders for Life-Sustaining Treatment. Ten things health care professionals should know about Maryland MOLST. 2014. http://marylandmolst.org/docs/Information
Sheet for Health Care Professionals_Revised_February 2014.pdf.
23. Maryland MOLST: Medical Orders for Life-Sustaining Treatment. Health care decision making worksheet instructions. http://marylandmolst.org/docs/Health
Care Decision Making Worksheet.pdf.