Mrs. J had written "to complete do not resuscitate (DNR) forms" as the reason for her visit. She had copies of an official living will and an organ donation document with her. She and I had talked about emergency health situations before in general terms but neither in depth nor with details exclusive to her. I admit that I had never initiated a serious discussion with her on the topic.
At 77 years old, she lived alone and was in relatively good health with stable hypertension controlled by medication and lifestyle behaviors. Although a little eccentric, Mrs. J had not exhibited any cognitive impairment.
Her main concern was making sure that everyone, including her family, friends, and health providers-but particularly emergency personnel-would know that she did not want to receive CPR or intubation in the event she became seriously ill in her home and was not able to express her wishes. She had done her homework, and the paperwork she displayed included instructions and checklists required by New York to execute a Medical Orders for Life Sustaining Treatment (MOLST), specifically to document nonhospital DNR and DNI (do not intubate) orders.
End-of-life care
Medical orders, however, are not directed by the healthcare professional (HCP) alone. The MOLST is designed to honor patient preferences at end of life. Comprehensive discussions should take place between the patient and HCP, usually over time, to ensure that the HCP knows the patient well enough to determine medical decision-making capacity. The patient-HCP relationship is trusting so that discussions are honest and realistic. The patient must be comfortable addressing end-of-life care and willing to accept his or her own mortality. The MOLST is "intended for patients with serious health conditions." However, there is no rule that forbids a patient from completing one.
Most states provide detailed guidance for individuals and HCPs; some states require the use of their own forms, while others permit similar forms to be used. There are several checklists available depending on the medical decision-making capacity of the individual. The correct checklist must be used to be in compliance with the legal process. Currently, a physician's signature is required in New York, but regulations vary by state.
Final decisions
The nurse practitioner (NP) student working with me was completing the palliative care specialty in addition to adult-gerontology NP program. Therefore, she was familiar with the language to use, definitions to explain, options to present, forms to use, and the process to follow. Mrs. J was attentive to the student and asked questions appropriately. Details from her living will were useful in helping us clarify her wishes, provide additional information, and confirm her final decisions.
Once the MOLST form is completed, individuals are instructed to print the form on bright "pulsar" pink stock paper and to hang it in several prominent places in their home, such as near the front door and in the bedroom and bathroom. It must be clearly visible at all times; most emergency medical system (EMS) personnel are trained to look for the bright pink form when entering someone's home. State rules vary about how frequently the MOLST must be reviewed and resigned (and by whom) as well as other circumstances that mandate a review.
Respecting wishes
Initiating discussions with patients about end-of-life care can be difficult whether the patient's health is stable or terminal. The potential for a situation requiring a call to EMS probably crosses every patient's mind at some point. What care do they want? Mrs. J left the office that day with peace of mind that her wishes would at least be evident and hopefully, respected.
Jamesetta Newland, PhD, RN, FNP-BC, FAANP, DPNAP
EDITOR-IN-CHIEF [email protected]