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Lack of Understanding of MOLST Forms Can Lead to ED Overtreatment

BUFFALO, NY – Do patients presenting to emergency departments really understand the meaning of life-sustaining treatment forms, and how does that lack of comprehension affect the level of care actually delivered?

That was the question addressed in a new study published in the Journal of the American Medical Directors Association. To help answer it, University at Buffalo researchers analyzed directives from a sample of emergency department (ED) patients' medical orders for life-sustaining treatment (MOLST) forms.

For the study, the authors collected MOLST forms that accompanied 100 patients who were transported to an ED and analyzed their content, focusing on age, gender, if the patients completed the forms for themselves, medical orders for life-sustaining treatment including intubation, ventilation, artificial nutrition, artificial fluids or other treatment, and wishes for future hospitalization or transfer.

The study included the following assumptions:

  • Contradictions with orders for cardiopulmonary resuscitation (CPR) included the choice of one or more of the following: Comfort care; Limited intervention; Do Not Intubate; No rehospitalization; No IV (intravenous) fluids; and No antibiotics.
  • Contradictions with do-not-resuscitate (DNR) orders included the choice of one or more of the following: Intubation; No limitation on interventions.
  • Contradictions with orders for comfort care were as follows: Send to the hospital; Trial period of IV fluids; Antibiotics.

Results indicate that 69% of forms reviewed had at least one section left blank. In addition, study authors note that inconsistencies were found in patient wishes among 14% of patients whose expressed preference for “comfort measures only” appeared contradicted by a desire to be sent to the hospital, receive IV fluids, and/or receive antibiotics.

“Patients and proxies may believe that making choices and documenting some, but not all, of their wishes on the MOLST form is sufficient for directing their end-of-life care,” study authors conclude. “The result of making some, but not all, choices may result in patients receiving undesired, extraordinary, or invasive care.”

Commenting on the study, entitled “Decisions by Default: Incomplete and Contradictory MOLST in Emergency Care,” lead author Brian Clemency, DO, MBA, explained, “We called it ‘Decisions by Default’ to make patients aware that if they don’t make a decision about a specific life-sustaining treatment, then in an emergency, they will most likely get the most aggressive treatment available.”

“In emergency medicine, we are trained to do everything we can to prolong life,” Clemency pointed out in a University at Buffalo press release. “The goal of this paper is to help us as emergency medicine physicians honor our patients’ wishes as much as possible.”