• Anita J Tarzian and Nadia B Cheevers.
• 1 Department of Family and Community Health, University of Maryland School of Nursing , Baltimore, Maryland.
• J Palliat Med. 2017 Sep 1; 20 (9): 939-945.

BackgroundAdvance directives (ADs) and Physicians Orders for Life-Sustaining Treatment (POLST) orders perform different but complementary functions in documenting a patient's treatment preferences and translating them into actionable orders that change in keeping with the patient's evolving clinical picture. Maryland's Medical Orders for Life-Sustaining Treatment (MOLST) form developed through a stakeholder-driven process that deviates from other POLST forms. While a patient or surrogate can decline discussing MOLST orders with a clinician, clinicians must write MOLST orders for certain patients (e.g., those admitted to a nursing home (NH), assisted living facility (ALF), hospice, home health (HH) agency, or dialysis center, discharged from a hospital to any of these facilities, or transferred between hospitals).ObjectiveTo gather data on Maryland MOLST form use to evaluate performance and inform future research and practice.DesignChart reviews (CRs).Setting/SubjectsMOLST forms and patient data collected from Maryland hospitals (adult nonpsych, nontrauma, nonobstetric patients), NHs, ALFs, hospices, HH agencies, and dialysis centers.MeasurementsFacility demographic tool and CR tools.ResultsA total of 1959 CRs were received from 137 facilities, including 2064 MOLST forms. Most patients required to have MOLST orders had them (84%); fewer had ADs (47%). Few patients or surrogates declined discussing MOLST orders (1%). Few MOLST orders were written based on medical ineffectiveness criteria defined in Maryland law (<1%). MOLST form completion error rates ranged from 1% to 3%. Non-white patients were about twice as likely to have a MOLST "Attempt CPR" order (62%) as white patients (32%).ConclusionsMOLST error rates are relatively low and consistent with other research. Areas for improvement include selecting one order option where required, avoiding contradictions between Page 1 and 2 orders, offering MOLST Page 2 options if relevant, and documenting in the medical record a summary of the discussion informing MOLST orders.

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