By Patrick Connole
There is an interesting new development in the end-of-life planning space, with some experts in the field saying they back changes to the existing system to ensure that the wishes of patients are adhered to in a more organized and efficient manner.
Called MOELI (Medical Orders for End-of-Life Intervention), this new model is an improvement on the existing Physician’s Orders for Life-Sustaining Treatment (POLST) because it allows for more flexibility and acts as a more effective way to document and communicate patient wishes in institutional and community settings, according to Richard Stuart from the Department of Psychology at the University of Washington in Seattle.
He helped write an editorial in the September issue of JAMDA (Journal of the American Medical Directors Association) explaining how MOELI is an upgrade to the POLST Paradigm because it fills in gaps to increase the range of patients who can use the model. Stuart and others hope to spur a national conversation among various POLST organizations and collaborate with them to create a standardized national form for end-of-life patient wishes.
One major change would be to relax when POLST is offered. Currently, it is offered to patients with those of a life expectancy not exceeding 12 months due to a terminal illness or extreme frailty. MOELI would extend the offering to those who are 80 years or older, regardless of the life expectancy issue.
In the JAMDA piece, Stuart and company also recommend the development of a national evaluative database, creation of organizational policies and resources that support the paradigm’s use, and increased efforts to educate health care professionals and the general public about MOELI.
“Many patients get more invasive, expensive, and often harmful end-of-life treatment than they want, while others get fewer life-prolonging efforts than they want,” Stuart said. “The POLST program, and the MOELI that enhances it, are designed to help patients convey their treatment choices to providers who enter patients’ wishes in their medical records to increase the likelihood that care desired equates with care received.”
The enhanced end-of-life program would also assist long term care providers, considering that many patients are admitted to centers because of frailty, which can of course lead to declines in cognitive capacity.
“Facilitating the completion of a MOELI upon admission would allow patients to enter their treatment preferences in their electronic medical records. Doing so could save patients, their families, and the institutions that care for them a considerable amount of money due to the extraordinary unreimbursed cost of caring for patients with dementia,” the article said.
In a talk with Provider, Stuart days he does a lot of work in helping patients create living wills, but they are meaningless unless wishes are translated into medical orders. One of the problems is the lack of standardization across care settings. “A lot of patients are mobile so they go from place to place, and wishes validated in one setting may not be accepted in another,” he says.
Some of the other major changes MOELI would bring include what Stuart calls “middle” options in end-of-life planning. “POLST arbitrarily allows people to address certain options, but … the existing POLST system [doesn’t allow] people to choose or designate their preference for all of them. So, I try to make the menu complete so they indicate the kind of care that they would like,” he says.
There are also technical fixes Stuart would like to see made. One involves first responders. An example would be that as a first responder arrives to treat someone who is in shock, for example, that person may have a do-not-resuscitate order (DNR) in place. This means in a strict sense the first responder should not treat them and conceivably let them die.
“I want to put in a middle category if someone’s heart stops beating because of a treatable short-term event, then of course they want to be rescuitated. This is an example of why people in the past have been reluctant to make commitments because they realized they don’t want an absolute DNR order, which makes that middle category so important,” Stuart says.
Another example of a middle category in MOELI being an improvement from POLST is that many individuals who do plan for end-of-life voice their concerns about medical requests being taken out of context.
“It is often the case that patients are asked if they want active care or comfort care only,” Stuart says. With a middle category, people would be asked if they want to have active care as long as they can preserve their identity as the person they are now. “That middle category is extremely important. It gives people rational options,” he says.