Monday, 3 February 2014

Liverpool Care Pathway - Making The MOLST Of Your POLST

The parallels abound. We have Yellow Folders; they have Hot-Pink Papers...

The MOLST, like the POLST, is a medical directive that records the patient's wishes on what treatments are desired and should proceed or not proceed in the event of a medical emergency. These forms are akin to the ‘My Wishes’ forms. My Wishes, 'Last Wishes' - Best Wishes! MOLST or POLST, it is all about withholding treatment.

There is no provision or order in the document to enable that the contrary position of a wish for treatment to be commenced/provided/continued should also be respected. Why do these forms not make such provision? It is not sufficient that, where an area is not completed, it is assumed that there is a wish for that treatment to proceed. There is no actual directive for that.

This document is what the US President has said the US Constitution is: it is a document of negations.

The physician will say that this is a medical decision. However, in the event that 'capacity' is lost, the POLST-maker may not wish the physician to make a 'best interests' decision on their behalf that deems any outcome resulting from treatment to be lacking in 'quality of life' and, therefore, futile.

May a POLST direct that life support shall not be withdrawn and over-ride a determination that the POLST-maker lacks life  or personhood?
What if a sick, elderly patient requests full treatment in case of a medical emergency, but they seem unlikely to survive CPR? How can you carefully relay this information to the patient and their family? This is a conversation that is extremely vital, as a recent study showed that 11% of care provided in the ICU is futile 

Dr. Boughton, an ACP Hospitalist blog contributor, says it is very important to both make a personal connection with a patient as well as focus on the patient’s facial expression and body language. One of the most important points of discussion is whether or not a patient would want to receive CPR. It’s good to lead into the discussion by first asking about what matters to them? What are their hopes and goals? What do they fear? A conversation on values can lead seamlessly into a conversation about CPR.
- ACP Decisions
The section has been left blank, but the physician will still step in to downsize care...

And the grooming shall commence.

They are a dignified person and deserve a dignified death. The chances of success of CPR are, according to Prof Lakhani, so small as to be insignificant...

But to the starfish that survived, it was VERY significant.

Pertinent reading -
Liverpool Care Pathway - The Bee Wee Tool

Liverpool Care Pathway – Communitarian Inevitabilities
There are circumstances that might occur - accidents that may befall - that are many and so diverse that such circumstances may not occur or enter consideration to the person at the time that they may make their POLST and would have affected their decision. These forms are dangerous. Their prime purpose and consideration is always the demographics of cost to the healthcare system; not the care of the patient.

This is the POLSTest with the MOLSTest. From January the 1st, hospitals and nursing homes have been required to offer these 'Last Rites' forms to patients upon admission...

This is the Providence Journal 

Rhode Island’s MOLST law passed in 2012, but it took until this past September to get the regulations in place, effective Oct. 1. And starting Jan. 1, hospitals and nursing homes have been required to offer;the form to patients upon admission — although, importantly, there is no requirement to fill it out.

Both the patient and the clinician must sign the order, which the law specifies should be printed on hot-pink paper. It then is supposed to travel with the patient into any medical setting. A patient having second thoughts can void it instantly, by writing “void” across the page or simply by telling the staff verbally. And ideally, the form should be updated frequently as circumstances change.
People of disability may live their lives only because such interventions as these forms will disavow and disallow permit them to. People of disability may rightly and justly feel their lives threatened by such forms...
Some people with disabilities fear that MOLST laws, already in place in several states, could result in denial of life-saving treatment to those who want it. Although MOLST is supposed to be voluntary, these activists say some nursing homes have presented it as mandatory. And when emergency personnel see that pink sheet tacked to the wall, will they read all its details or will they assume it means “do not resuscitate”?

Some nursing homes have made it mandatory; most will make it a 'must do'.

Yellow pages, not yellow folders... this is a sample POLST from Wisconsin -

And more on the POLST...

The Journal Sentinel 
Advocates consider the POLST, or Physician Orders for Life-Sustaining Treatment, an important tool that gives chronically and terminally ill patients greater control of their care in the final moments of their lives.
Critics, including some physicians and Wisconsin's Catholic bishops, fear it can be abused to expedite death and advance euthanasia.
The debate raises moral and ethical questions that lie at the heart of end-of-life care, including what constitutes living, what medical care is normal and what is extraordinary, and who decides how and when life should end.

This is from IHA 

This is the Surprise Question aka the Barton Method!
So, who borrowed from whom...?

Last POLST or Last Post...?

This really is the Last POST! And the POSTest with the MOSTest!

They come in many colours...

New Think...

...And New Speak!

Further reading - 
Liverpool Care Pathway - The POLST Is Being Delivered

Liverpool Care Pathway - "Let Your Fingers Do The Walking..."?

Liverpool Care Pathway - Integrating The Death Lists

Liverpool Care Pathway - The QP EoL Pathways

When death confronts us, life may be just a leap away...
From The Progress of POLST Programs Across the Nation

But will you make it past the POLST?

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