OFFICIAL SECTION OF THE

National Gerontological Nursing AssociationOFFICIAL SECTION OF THE

National Gerontological Nursing Association

Knowledge and Attitudes of HealthCare Workers Regarding MOLST

(Medical Orders for Life-SustainingTreatment) Implementation inLong-Term Care Facilities

Hieu Vo, MDRenee Pekmezaris, PhD

Howard Guzik, MDChristian Nouryan, MACharito Patel, RN, MS

Brinder Vij, MDJulia Tai, MA

Gisele Wolf-Klein, MD

We studied the impact of knowledge and atti-

tudesof physicians, nurses, and socialworkers

in nursing facilities of the Medical Orders for

LifeSustainingTreatment (MOLST) implemen-

tation. The results indicate that in the case of

advance directives, knowledge influences

care. (Geriatr Nurs 2011;32:58-62)

Background

The POLST (Physician Orders for Life-SustainingTreatment) Paradigm Program was developed inOregon to improve end-of-life care by addressingmany of the limitations of traditional advance di-rectives. It was created to transform patient pref-erences for life-sustaining treatments intoactionable medical orders for cardiopulmonaryresuscitation, medical interventions, artificialnutrition, and antibiotics. The POLST programdocuments conversations among health careprofessionals with the patient and/or healthcare proxy onto an easily identifiable, brightlycolored form that provides specific treatment or-ders. The POLST form is specifically recommen-ded for persons who have advanced chronicillness, who might die in the next year, or whowish to clearly specify treatment preferences.1

The unique POLST paradigm combines 2 key fea-tures into 1 document: a review of the patient’swishes regarding life-sustaining treatment andcomfort care with a physician order regarding in-terventions that providers should follow at endof life.

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POLST program requirements differ from stateto state; at this time, some states (New York, Cal-ifornia, Hawaii, West Virginia) require a physi-cian’s signature to be valid. Others (Oregon,Washington, Wisconsin) accept the signaturesof nurse practitioners, and 2 accept physician’sassistant signatures (Oregon, Washington). Itshould be noted that state POLST proceduresare revised regularly.

Although New York’s POLST paradigm re-quires that the physician ultimately sign the or-der, a health care professional can complete orchange the POLST form prior to physician signa-ture, based on the patient’s medical condition,values, and wishes.2 Nurses, particularly thosewith advanced training and those practicing inthe long-term care (LTC) setting, clearly havea critical leadership role in ensuring that thePOLST paradigm is applied.

Since the POLST Paradigm Initiative’s begin-nings in 1991, 34 states have implementedPOLST or are developing similar programs, tai-loring their approaches to state laws and regula-tions.3,4 It should be noted, however, that statelegislative processes used to create advancedirectives and out-of-hospital Do Not Resusci-tate (DNR) protocols have complicated effortsto achieve the goal of national implementation.Although the forms may vary somewhat by statein content, design layout, and name (e.g., in NewYork, it is called Medical Orders for Life Sus-taining Treatment, or MOLST), POLST ParadigmPrograms share common core elements andform design.3 Hickman et al conducted a nation-wide study to identify potential barriers toPOLST implementation through the examinationof state laws and regulations. The study identi-fied several statutory and regulatory barriers, in-cluding highly detailed state requirements forout-of-hospital DNR orders and witnessing re-quirements.3 Until recently, New York law, forexample, stipulated that family members couldnot make decisions refusing life-sustaining treat-ments beyond the DNR unless there was asigned proxy.

In New York State, the MOLST was initially pi-loted in New York State in 2006 by the RochesterHealth Commission for use in Onondaga andMonroe Counties. In 2008, Public Health Law

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No. 2977 was signed, making the MOLST state-wide and permanent in New York.5 As a result,an executed MOLST form presented by a patientmust be accepted by any facility in the state, func-tioning as the legal equivalent of an inpatientDNR form, in addition to conveying patientwishes regarding intubation, artificial nutrition,artificial hydration, hospitalization, and otheradvance-care orders. The Family Health Care De-cisions Act, which became law in New York inJune 2010, enables a patient’s family memberdincluding his or her domestic partnerdto makehealth care decisions when the patient is notable to do so.6 This change addressed a majorstatutory barrier identified by the Hickman andcolleagues’ 2008 study (New York’s default surro-gate statute applied only to out-of-hospital DNRorders).

In the nursing home setting, the POLST para-digm may be especially relevant: a recent multi-state study found that residents of nursinghomes participating in a program that used thePOLST to record their wishes for end-of-life treat-ment are much less likely to receive unwantedmedical interventions (including hospitaliza-tions) than are other patients.7 The POLST formhas been found to document patient treatmentwishes reliably and accurately and effectivelydirect treatment.8,9 This research supportsearlier work that documents the importance ofspecificity in advance directives.7,10 In contrastto traditional DNR orders, which only focuson whether to resuscitate the patient, thePOLST paradigm allows patients to directand document a variety of care preferences,such as whether they want to be hospitalized orreceive artificial nutrition (e.g., percutaneousendoscopic gastrostomy [PEG] tube feeding).3

In 2006, the National Quality Forum recommen-ded nationwide implementation of the POLSTParadigm.11

Because of the recent changes in legislation re-garding MOLST implementation in New YorkState and the mounting evidence of its effective-ness in nursing facilities,7 we chose to examinethe relationship between the rate of prevalenceof MOLST among nursing facilities affiliatedwith the North Shore-LIJ Health System(NSLIJHS), New Hyde Park, New York and theknowledge and attitudes of health care workerstoward MOLST in these facilities. NSLIJHS isthe largest nonprofit secular health care systemin New York State.

Geriatric Nursing, Volume 32, Number 1

Method

Participants

Registered nurses (RNs), medical attendings,residents/fellows, licensed practical nurses(LPNs), social workers, and nurse practitioners(NPs) employed at the 6 targeted health systemaffiliates were recruited to participate in theanonymous survey during regularly scheduledmeetings at the respective nursing facilitiesacross all shifts. Following internal review boardapproval for this project, between 75 and 100 sur-veys were distributed in each facility. Each par-ticipating facility was either a high or lowprevalence facility, as described subsequently.

Nursing Facility Utilization: MOLST

Prevalence

MOLST utilization statistics within NSLIJHS in-dicate that there was significant discrepancy inimplementation among its 16 nursing home affili-ates in 2008e2009. Whereas 1 facility achieved anaverage 73.8% implementation rate over a 1-yearperiod, others maintained a zero prevalencerate of the MOLST.

Between July 2008 and June 2009, an averagemonthly MOSLT completion rate was computedfor each facility. The average monthly rates andtheir corresponding tertiles (3 evenly dividedgroups of data) were computed as 0% to lessthan 5% (lower tertile), 5% to less than 44% (mid-dle tertile), and 44% and above (upper tertile). Weexamined provider-reported barriers affectingimplementation of the MOLST at institutionswith high and low MOLST prevalence to under-stand factors that may have an impact on theproper use of this form.

Procedure

Site Selection. We used the tertiles from thequality improvement initiative reported aboveto define “low” and “high” prevalence nursing fa-cilities in the current study. Low prevalence (LP)nursing facilities were defined as any facility withan average monthly MOLST completion rate ofless than 5%; high prevalence (HP) nursing facili-ties were defined those with a rate of 44% orgreater. The 16 facilities ranged between 100and 606 beds, approximately 75% of which areLTC beds.

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Table 1.Nursing Home (NH) Employee Anonymous SurveydSample Questions

o How often in the past 12 months have you been asked to fill out or administer a DNR or MOLST?

o How often in the past 12 months have you been asked to ignore an existing DNR, MOLST, or an other

advance directive by a surrogate decision maker or family member?

o How often in the past 12 months have you met with a family member regarding EOL decisions?

o How often in the past 12 months have you met with a patient regarding EOL decisions?

o Have you received an in-service about the MOLST form?

Please circle the answer that best describes your feelings.

o Patients who have filled out DNR and MOLST forms have better pain management.

Agree Strongly Agree Neutral Disagree Disagree Strongly

o All long-term nursing home residents should have a MOLST form executed.

Agree Strongly Agree Neutral Disagree Disagree Strongly

o It is the responsibility of social workers to discuss the MOLST with patients at EOL.

Agree Strongly Agree Neutral Disagree Disagree Strongly

o It is the responsibility of nurses to discuss the MOLST with patients at EOL.

Agree Strongly Agree Neutral Disagree Disagree Strongly

o It is the responsibility of doctors to discuss the MOLST with patients at EOL.

Agree Strongly Agree Neutral Disagree Disagree Strongly

DNR 5 do not resuscitate; EOL 5 end of life; MOLST 5 Medical Orders for Life Sustaining Treatment.

From each of the LP and HP facilities, we se-lected the 3 that were geographically closest tothe principal investigator’s research office:Recruitment. The principal investigator distrib-uted the anonymous surveys at regularly sched-uled staff meetings at each of the 6 facilities. Forthose staff members not in attendance at thesemeetings, surveys were left with a supervisor oneach shift. To keep the sample representative,we surveyed day, night, and evening staff.Measures and Survey Content. The 31-question survey contained 11 questions about ex-perience and knowledge, 11 questions aboutattitudes, and 9 questions about demographics.Table 1 contains a sampling of survey items.Data Analysis Plan. For categorical variables,comparisons of the high- and low-performing fa-cilities were carried out using the chi-squaretest. The Spearman rank correlation was used todescribe correlations between ordinal variables.

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MOLST prevalence long term care facilities.

Results

Between 75 and 100 surveys were distributedin each facility, with an overall response rate of35%. Our results reflect the statistics derivedfrom 169 surveys (100 from 3 HP and 69 from3 LP facilities). Respondents included 9% medi-cal attending, 4% residents/fellows, 53% RNs,22% LPNs, 11% social workers, and 1% nursepractitioners. In an effort to protect anonymity

60

and increase survey participation, response ratesby worker type were not collected.

Analysis of gender, ethnicity, religion, and pro-fessional background revealed no statistical differ-ences between HP and LP facilities. However, LPemployees were generally older than HP (74.5%vs. 46.3% over age 40, P\ .008), had been in prac-tice longer (72.6% vs. 40.6%, over 11 years, P \.003), and had been employed longer at the samefacility (25.5% vs. 13.5% over 11 years, P\ .032)than HP employees (Figure 1). Years employedat the current facility was moderately correlatedwith both age and years in profession (Spearmanr 5 .29 and .35, respectively). Years in professionand age were more strongly correlated (Spearmanr 5 .70).

As expected, an overwhelming 77.4% of HP,compared with 37.2% of LP (P \ .0001), agreed

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85

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long term care facilities.

that all LTC residents should have aMOLST form.Half (46.8%) of HP agreed that residents withMOLST forms had better pain management;only 11.8% of LP concurred (P\ .0001; Figure 2).

With regard to barriers to completing MOLSTforms, twice as many LP employees (51.0%) feltthat the length and detail of the MOLST formmade it difficult to complete compared with HPstaff (26.1%; P \ .001). Only 19.6% of LP versus51.4% of HP group (P \ .0004) knew that theMOLST form does not have to be pink to be offi-cially accepted. In addition, 21.6% of LP versus7.2% of HP employees (P\ .02) had been askedto ignore an advance directive during their careers(Figure 2).

Both groups were aware that the MOLST formsneed to be signed by a physician to be valid (88.2%LP and 79.3% HP), but there was disagreementregarding the role of other members of the inter-disciplinary team in assisting with the actualhands-on process of the MOLST completion. Spe-cifically, significantly fewer HP staff reported thatsocial workers should be responsible for MOLSTdiscussions (37.8%), compared with LP staff(51.0%; P\ .0001). Compared to LP staff, a signif-icantly lower proportion of HP staff reported thatnurses should be responsible for MOLST discus-sions (27.3% HP and 31.4% LP; P\ .002). Finally,a much higher percentage of HP staff reportedthat physicians should be responsible for MOLSTdiscussions (96.4% HP and 78.5% LP; P\ .002).

Discussion

The survey indicated that younger employeesmay be more actively involved in the completion

Geriatric Nursing, Volume 32, Number 1

of the MOLST form, whereas employees whohave been practicing in the same facility fora long time continue to perpetuate past practiceswith regard to advance directive completion.

Compared with LP staff, employees in HP facili-tieswere twice as likely to report that LTC residentsshouldhaveaMOLST. Indeed,HPemployees recog-nized the benefit of executing the MOLST andminimized the potential limitations of theformdspecifically, its length and detail. As ex-pected, the HP group knew more specific details,such as the fact that the MOLST form does nothave to be pink to be officially accepted. Becausethe surveywasnot constructed to identify other fac-tors accounting for the variation in MOLST preva-lence, further studies need to be developed tobetter understand how to improve the prevalenceof advance directives within health care facilities.

It is interesting that uniformly, both HP andLP staff selected physicians as ultimately respon-sible for discussing the MOLST; this may be be-cause of the nature of the documentationprocess of the MOLST. As a medical order, pa-tient wishes must be authorized by a physician.This should be studied further, because clearly,although the physician has ultimate responsibil-ity for executing the order, both nursing and so-cial work staff members have an essential rolein discussing the MOLST.

Clearly, implementation of the MOLST has im-portant ramifications for patient care at the endof life, as reported by respondents. In our study,a striking 46.8% of HP respondents agreed thatresidents with MOLST forms had better painmanagement, compared with only 11.8% of LPemployees. Educational initiatives targeting staffawareness of the importance of documentingspecific advance directives may be helpful in im-proving quality of life in terminal patients.

It should be noted that even if nursing staff aretrained and fully knowledgeable about all of thechoices available, public knowledge must followsuit. Public outreach was a significant factor in thesuccessful implementation of the POLST inOregon.12

Limitations

As stated in the Methods section, we sampledfrom 6 LP and HP facilities, selected by geo-graphic proximity to the principal investigator’sresearch office. Also, this survey was created bythe researchers and has not been validated.

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Future research should replicate these findings,preferably with larger sample sizes.

Conclusions

This study suggests that LTC facilities with highlevels of MOLST implementation tend to employyounger health care professionals, with a betterunderstanding of the importance of the MOLSTform. Employees of HP facilities also believe thattheuseof theMOLSTandadvancedirectives resultinbetterpainmanagement andconsiderend-of-lifediscussions to be the responsibility of physicians.

These results indicate that in the caseof advancedirectives, knowledge influences care. Nursing fa-cility staff who knew more about the MOLST rec-ognized its role in improving patient care at endof life, supporting the importance of widespreaddissemination of educational initiatives at nursingfacilities, as well as the need for continuing educa-tion. It is crucial that health careprofessionalswhocare for patients at end of life, at all levels, shouldbe targeted for educational initiatives about the im-portance of documenting specific advance direc-tives in improving quality of life for theirchronically ill patients.

References

1. Omnibus Budget Reconciliation Act of 1990, HR5835, 4

USC, SEC 4751. Subpart EdMiscellaneous.

Requirements for Advance Directives Under State Plans

for Medical Assistance. Public Law No. 101e508.2. New York State Department of Health form # DOH-5003

(6/10) Medical Orders for Life-Sustaining Treatment

(MOLST). Available at www.compassionandsupport.

org/pdfs/professionals/molst/DOH-5003_06.10_.

FINAL__.pdf. Cited September 14, 2010.

3. Hickman SE, Sabatino CP, Moss AH, et al. The POLST

(Physician Orders for Life-Sustaining Treatment)

Paradigm to improve end-of-life care: potential state legal

barriers to implementation. J Law Med Ethics 2008;36:

119-40.

4. New study shows impact of program allowing patients to

document wishes for end-of-life treatment:medical order

program available in New York state is linked to lower

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rates of unwanted hospitalization. Available at www.

compassionandsupport.org/pdfs/homepage/07.22_.

2010_MOLST_-_news_release_concerning_new_

study_7_.01_.10_.pdf. Cited September 14, 2010.

5. New York State Law # 2977. Available at www.

compassionandsupport.org/pdfs/legislation/MOLST%

20Legislation%202008.pdf. Cited July 14, 2010.

6. Family Health Care Decisions Act. S.03164 or A.07729.

Available at http://assembly.state.ny.us/leg/?

default_fld5&bn5S03164%09%09&Summary5Y.

Cited July 14, 2010.

7. Hickman SE, Nelson CA, Perrin NA, et al. A comparison

of methods to communicate treatment preferences in

nursing facilities: traditional practices versus the

physician orders for life-sustaining treatment program.

J Am Geriatr Soc 2010;58:1241-8.

8. Meyers JL, Moore C, McGrory A, et al. Use of the

physician orders for life-sustaining treatment (POLST)

form to honor the wishes of nursing home residents for

end of life care: preliminary results of a Washington state

pilot project. J Gerontol Nurs 2004;30:37-46.

9. Lee MA, Brummel-Smith K, Meyer J, et al. Physician

orders for life-sustaining treatment (POLST): outcomes

in a PACE program. J Am Geriatr Soc 2000;48:1-7.

10. Pekmezaris R, Breuer L, Zaballero A, et al. Predictors of

site of death of end-of-life patients: the importance of

specificity in advance directives. J Pall Med 2004;7:3-17.

11. NQF: A National Framework and Preferred Practices for

Palliative and Hospice Care Quality. Available at

.qualityforum.org/Publications/2006/12/A_National_

Framework_and_Preferred_Practices_for_Palliative_

and_Hospice_Care_Quality.aspx. Cited August 31, 2010.

12. Tolle S, Tilden V. Changing end-of-life planning: the

Oregon experience. J Pall Med 2002;5:311-7.

HIEU VO, MD, Postdoctoral Fellow, Division of Geriatric

Medicine, New Hyde Park, NY. RENEE PEKMEZARIS,

PhD, Vice President, Health Services Research, Great

Neck, NY. HOWARD GUZIK, MD, Chief, Division of Geriat-

ric and Palliative Medicine, Manhasset, NY. CHRISTIAN

NOURYAN, MA, Analyst, Health Services Research, Great

Neck, NY. CHARITO PATEL, RN, MS, Nurse Manager, De-

partment of Nursing, Manhasset, NY. BRINDER VIJ, MD,

Postdoctoral Fellow, Division of Geriatric Medicine, New

Hyde Park, NY. JULIA TAI, MA, Analyst, Feinstein Institute,

Manhasset, NY. GISELE WOLF-KLEIN, MD, Director of

Geriatric Education, Division of Geriatric Medicine, New

Hyde Park, NY.

0197-4572/$ - see front matter

� 2011 Published by Mosby, Inc.

doi: 10.1016/j.gerinurse.2010.11.002

Geriatric Nursing, Volume 32, Number 1