Medical Orders for Scope of Treatment
This week let’s jump into What Matters with a discussion about Medical Orders for Scope of Treatment (MOST). MOST is a concept used in many states for advance care planning, and usually has an associated document. MOST forms can also be called Physician Orders for Life Sustaining Treatment (POLST) forms. The idea for MOST/POLST begun in the 1990s in Oregon where it was recognized that traditional advanced directives did not always encompass What Matters to those with advanced illness or frailties.
MOST/POLST forms have slight variations state to state, but in general are an excellent start to guide advance care discussions. They take us through certain life/death scenarios so we can make informed decisions and document the care we want if and when we are not able to speak for ourselves. They are divided up into 4 boxes labelled A through D.
Box A has to do with cardiac resuscitation, or when I am speaking with patients I say “What do you want someone to do if you have already passed away?” The options here are fairly straightforward, either “Attempt Resuscitation” or “Do Not Resuscitate.” It can be difficult to select Do Not Resuscitate (DNR), so I will also describe this as to “allow a natural death” as it empowers a person to make a more active choice about their end-of-life rather than a passive “Do Nothing” option. To help people make informed decisions I also try to be up to date regarding statistics of out of hospital cardiac arrest (OHCA) survival, and the most up to date research I have found is that of people who have OHCA and receive CPR, only ~8-9% will live to hospital discharge.
Box B is a little more complicated and it is directives of what to do if a person is critically ill but cannot express their wishes, maybe because they are too ill or confused to effectively communicate. There are three options in box B, “Full Scope,” “Selective Scope,” and “Comfort Scope.” Full scope is the most aggressive and includes things such as life support (breathing tube, ventilator, feeding tube, etc). Selective scope is a somewhat nebulous, but I describe it as “OK with going to the hospital, but NOT being on life support.” And finally, comfort scope is what it sounds like - no hospital transfers, no life support, just ensure “I am not experiencing pain or anxiety even if I pass away.”
Box C is a little sibling to box B and it asks what to do regarding feeding tubes. I explain to people that feeding tubes are a form of life support to try to help clarify it, and there are some times when we will need feeding tubes to sustain life. Common examples are neurodegenerative diseases such as Amyotrophic Lateral Sclerosis (ALS or “Lou Gehrig’s Disease”) or after a stroke. Use of a feeding tube in persons with advanced dementia is NOT AN OPTION and can prolong suffering and add new venues of pain.
Box D is the formality of disclosing who filled the form out, whether it be the patient, MDPOA, or guardian.
Regarding the things I do on a day to day basis, helping people understand that death is a guarantee and we should plan for it is high on my priority list. Death plans do not look the same for everyone and should change. MOST/POLST forms are not written in stone and can/should be changed when What Matters to a person changes. And finally advance care plans will not do a person any good if they are not communicated with the people that are important to that person’s care. Caregivers, loved ones, and healthcare providers should all be included to help protect a person’s primacy and authority over their own life.
Key Points:
MOST and POLST forms are easy guides to start an advance care discussion
Advance care plans change as What Matters changes
Be open and communicate What Matters to those important to you!
