• New Maryland Procedures for End-Of-Life Decision-Making
  • October 24, 2011 | Author: Sigrid C. Haines
  • Law Firm: Lerch, Early & Brewer, Chartered - Bethesda Office
  • Maryland has a new procedure designed to enhance the consistency of decision-making regarding end-of-life decisions across health care settings, such as when a patient moves from a nursing home to a hospital.

    In 1993, following much public attention to the case of Nancy Beth Cruzan and related discussions about the “right to die,” Maryland passed the Health Care Decisions Act. The Act addressed a number of procedures regarding health care decision-making, particularly for patients who are incapacitated and thus unable to make their own decisions. Perhaps most significantly, Maryland established a form called an “Advance Directive Appointing an Agent” whereby a person could designate someone to make decisions on his or her behalf if the person became incapacitated; the document also allowed its maker to express his or her views about care if the maker became terminally ill, had an end-stage condition, or was in a persistent vegetative state.

    Medical Orders for Life-Sustaining Treatment
    Since that time, Maryland has continued to refine its procedures for health care decision-making for incapacitated persons. In particular, Maryland developed a “Do Not Resuscitate” form for emergency responders and a “Patient’s Plan of Care” form (later called a “Life-Sustaining Treatment Options” form), generally used to document the wishes of a patient or family at the time of admission to a nursing home. Maryland has now joined several other states by replacing these two documents with a new form called “Medical Orders for Life-Sustaining Treatment” or “MOLST.” (Other states substitute “Physician” for “Medical” and thus have “POLST” forms.)

    Effective October 1, 2011*, the MOLST form must be completed (or at least offered to the patient) at the time of a patient’s admission to a nursing home, assisted living facility, home health care program, dialysis center, or hospice program. The form also must be completed if a hospital inpatient is transferred to another institutional setting. Unlike an advance directive, the MOLST form must be signed by a physician or nurse practitioner, and it thus becomes a medical order. Also, unlike an advance directive, it must be completed by practitioners following discussions with patients, surrogate decision-makers and health care agents appointed under advance directives. One hoped-for advantage of the MOLST form is that it will transfer between health care settings (e.g., accompany a nursing home resident to a hospital), thus ensuring consistent decision-making.

    MOLST Designed to Enhance Provider-Patient Dialogue
    The MOLST form is several pages long and complex. The physician or nurse practitioner is responsible for the accuracy of the form. Patients or health care surrogates should not complete the form, particularly without discussion with the health care provider, but the MOLST form is designed to enhance the dialogue between the providers and the patient or surrogate regarding the patient’s wishes. If a patient transfers between health care settings, the receiving facility is responsible for asking about the existence of a MOLST form. A copy of a completed MOLST form must be given to the patient, health care agent, or surrogate within 48 hours of its completion (or sooner if the patient is transferred or discharged). A newer form supersedes a prior form. The MOLST form must be reviewed annually, as well as when the patient transfers between facilities or has a change in health status.

    The MOLST form should facilitate discussions between patients, surrogate decision-makers and providers regarding the patient’s treatment wishes. However, because it is a medical order rather than a legal document such as an advance directive, it remains to be seen whether it will significantly change patient treatment, and which document will prevail if there are any conflicts.