Most healthcare professionals agree that patients rarely document their wishes about end-of-life care before a crisis occurs. This often makes decision-making difficult for both clinicians and families. I have long advocated that everyone should have an advance directive in place. This may take two forms. The first is a living will, which specifies the kind of medical treatments you want if you have a life-threatening illness and cannot make decisions for yourself. Better yet is a durable power of attorney for health care (DPAHC), which legally designates a surrogate decision-maker, typically a spouse or child, who can make decisions for you, knowing your values and acting in your best interests.
For the very sick, especially those unlikely to live more than a year, a newer document has arisen in over 20 states, called MOLST (Medical Orders for Life-Sustaining Treatment) or POLST (Physician Orders for Life-Sustaining Treatment). Unlike a ‘do-not-resuscitate’ (DNR) order, MOLST documents address more than just CPR. They may also involve the use of a ventilator, a feeding tube, dialysis, antibiotics, or simple I.V. fluids. The purpose is to carry out the specifics of the patient’s advance directives in the form of a persistent medical order. In theory, this should be a better guarantee that a patient’s final wishes are carried out.
Advantages of MOLST:
- Can help protect dying patients from unwanted, intrusive, or disproportionate treatments (e.g., ventilators or CPR).
- May relieve the burden of decision-making for family members and other surrogates.
- Transferable as part of the medical record to various institutions.
Some Concerns about MOLST:
- It is a medical document, not a legal one. It is therefore more difficult to modify or revoke it.
- Advance directives (living wills and DPAHC) are enacted only when a patient loses decision-making capacity; a MOLST document is effective immediately. regardless of a patient’s capacity.
- On the form, the default is to limit treatments, which may imply a utilitarian agenda that devalues life for the elderly and infirm.
- Many pro-life groups oppose MOLST legislation, fearing that it paves the way for legalizing assisted suicide, and ultimately, euthanasia.
I have some reservations about MOLST, though the goal is to protect patients’ rights. Specifically, Ohio Right to Life is neutral on the proposed Ohio law, while other Ohio RTL groups oppose it.
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