Creation of medical orders for life sustaining treatment: Health care reform

The Affordable Care Act will alter the way that health care and public health serve the elderly. One significant way is through an expanded effort to deliver care on a more patient centered manner. Reimbursement will be available to counsel patients - particularly elderly patients– about the importance of considering the end of life and the types of services they would or would not want to receive under different conditions. The Massachusetts experience offers insight into what this might mean for the rest of country. As a component of the Massachusetts health care reform initiative which was implemented several years ago, there was an explicit requirement that an end of life commission be constituted to provide recommendations for action. One of those recommendations involved the creation of Medical Orders for Life Sustaining Treatment (or MOLST) initiative with a systematic approach to engaging patients and family members in a process to direct their own care. A pilot of a statewide MOLST program has been implemented in a county of the state and preliminary findings offer useful lessons regarding what is needed to expand such an effort throughout the state and the nation. A uniform state-endorsed form has been developed, training materials have been developed and utilized with a wide range of providers – including EMS, hospitals and nursing homes - and families. Preliminary efforts are underway to expand the program in Massachusetts, which would make it the largest government overseen effort of its type in the nation.