ECHO MOLST: Honoring Preferences at End-of-life. Crucial Conversations: Use Both Sides of Your Brain
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1 ECHO MOLST: Honoring Preferences at End-of-life Crucial Conversations: Use Both Sides of Your Brain
2 Presenter Patricia A. Bomba, MD, MACP Vice President & Medical Director, Excellus BlueCross BlueShield Chair, MOLST Statewide Implementation Team; emolst Program Director Founding Member, National POLST Paradigm Lead, ECHO MOLST The speaker has no significant financial conflicts of interest to disclose. 2
3 Learning Objectives Recognize MOLST is a communication process that requires both reason and compassion Apply the 8-Step Protocol Demonstrate effective communication skills
4 Crucial Conversations Require Wisdom When one prevents one s emotions from overtaking one s rationality it is called reason. When one prevents one s rationality from overtaking one s emotions it is called compassion. When one can do both, it is called wisdom. Ancient Chinese Proverb
5 8-Step MOLST Protocol 1. Prepare for discussion Understand patient s health status, prognosis & ability to consent Retrieve completed Advance Directives Determine decision-maker and NYSPHL legal requirements, based on who makes decision and setting 2. Determine what the patient and family know re: condition, prognosis 3. Explore goals, hopes and expectations 4. Suggest realistic goals 5. Respond empathetically 6. Use MOLST to guide choices and finalize patient wishes Shared, informed medical decision-making Conflict resolution 7. Complete and sign MOLST Follow NYSPHL and document conversation 8. Review and revise periodically Developed for NYS MOLST, Bomba, 2005; revised 2011 Bomba PA, Vermilyea D. JNCCN 2006;4(8):819-29; Bomba PA, Orem K. Ann Palliat Med 2015;4(1):10-21.
6 Step 1: Prepare for Discussion Understand patient s health status, prognosis & ability to consent (Be sure patient is appropriate for MOLST, as discussed in Session 1) Retrieve completed Advance Directives Determine decision-maker and NYSPHL legal requirements, based on who makes decision and setting (as discussed in Session 3 & 4) Invite important people to hear discussion (health care agent and family)
7 Effective Communication Skills Thoughtful MOLST Discussions Express yourself clearly Ask open-ended questions Actively listen Reflect: paraphrase the message and communicate understanding back Resolve conflicts
8 Step 2: Determine What the Patient & Family Know re: Condition & Prognosis What have you heard from other doctors about your condition? (Start from there.) Inform the patient they are appropriate for a MOLST discussion based on MOLST screening questions. Offer the opportunity to continue. (MOLST is voluntary. Patient may not ready to accept his condition and prognosis. Return to discussion at a future date) Respond with emotion and empathy.
9 Estimate and Communicate Prognosis Physicians markedly over-estimate prognosis Accurate information helps patient / family cope and plan Offer a range for average life expectancy days to weeks weeks to 3 months 3 6 months (PCIA, PCAA, Hospice*) 6 months to 1 year (MOLST**) > 1year (MOLST: e.g. persons of advanced age may have explicit wishes.) * Would it surprise you if this person died in the next 6 months? ** Would it surprise you if this person died in the next year?
10 Discussing Prognosis What sort of information about the future would help you? Most people want to know about their prognosis and don t want to know at the same time. What about you? Would it be best to talk about the best case, the worst case and the usual case?
11 Step 3: Explore Values, Beliefs, Goals and Expectations Identify patient s personal values and beliefs Recognize patient s personal goals for care What makes life worth living What matters most Personal goals align with Longevity Functional Preservation Comfort Care
12 Align Language with Person-centered Goals for Care Longevity: We want to ensure you receive the kind of treatment you want and needs in order to attend your son s wedding Functional Preservation: We ll do everything we can to help you maintain your independence Comfort Care: Your grandmother s comfort will be our top priority
13 Step 4: Suggest Realistic Goals Manage unrealistic expectations Clarify possibilities Negotiate goals
14 Managing Unrealistic Expectations: Clarify Possibilities. Negotiate Goals. What do you understand about your father s condition? What do you hope we can accomplish with our medical care? I wish for that too. Unfortunately, no medicine, surgery or all the love you have for him
15 Step 5: Respond empathetically When you notice an emotion, respond with Naming: put emotion into words Understanding: explain how you see it from their perspective Respecting: admire what you genuinely feel good about Supporting: offer your caring, expertise and presence Exploring: when you re not sure where to go, ask for more data
16 Key Points The patient and/or medical decision-maker and family must understand health status and prognosis before progressing with MOLST discussion Discussing values, beliefs and goals should precede virtually all discussions about preferences re: Resuscitation and other Life Sustaining Treatment Understanding a patient s goals and values has the potential to humanize the relationship and improve decision-making at all levels
17 References Thoughtful MOLST Discussions 8-Step MOLST Protocol Using the 8-Step MOLST Protocol Video Series Thoughtful MOLST Discussion: Hospital & Hospice Settings Video 43:52 Thoughtful MOLST Discussion: Nursing Home Setting (Residential/Custodial Care) Video 20:18 VitalTalk.org Vital Talk app available
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