The NC MOST Project
Collaboration in Action
Susan Redding, MSN, APRN-C
NCNA NP Spring Symposium
April 20, 2008
Medical Orders for Scope of Treatment
Respecting Patients’ Wishes
for care at the End of Life
An Index Case
Mr. Jan (a pseudonym), a 71-year-old man with severe
chronic obstructive pulmonary disease and mild dementia,
was convalescing at a skilled-nursing facility after a hospital
stay for pneumonia. Mr. Jan developed increasing shortness
of breath and decreasing responsiveness over 24 hours. The
nursing facility staff called the emergency medical service,
who found the patient unresponsive, with a respiratory rate of
8 breaths/min and oxygen saturation at 85% on room air.
Although Mr. Jan had discussed his desire to forgo aggressive,
life-sustaining measures with his family and nursing
personnel, the nursing facility staff did not document his
preferences, inform the emergency team about them, or
mention his do-not-resuscitate order.
After the emergency team was unable to intubate him at the
scene, they inserted a nasal pharyngeal airway, administered
supplemental oxygen, and transported the patient to the
emergency department of a second hospital. Mr. Jan remained
unresponsive. He was afebrile, with a systolic blood pressure
of 190 mm Hg, a pulse of 105 beats/min, a respiratory rate of
8 breaths/min, and an oxygen saturation of 88% despite
supplemental oxygen. He had diminished breath sounds
without wheezes, and a chest X-ray showed large lung
volumes without consolidation. Arterial blood gases showed
marked respiratory acidosis. The emergency department
physician wrote, “full code for now, status unclear.” The staff
intubated and sedated Mr. Jan and transferred him to the
intensive care unit.
Lynn, et al. Ann Intern Med 2003;138:812-818.
What went wrong? – Could this
happen in your community?
Advance directives not documented
DNR order not communicated in transfer
Fragmentation in care (2 hospitals)
Overtreatment against patient’s wishes
Unnecessary pain and suffering
System-wide failure to respect pt’s wishes
– Failure to plan ahead for contingencies
– No system for transfer of plan of care
Why not rely on the
Advance Directive???
• AD may not be available when needed
• AD may not have prompted needed discussion and
may not be specific enough
– No provision for some specific treatments
– May not cover topics of most immediate need, i.e., site
of care
• May not be provider agreement that AD should be
effected – “is this person terminal??”
• AD does not immediately translate into a medical
Advance Care Planning
circa 2008
 Identification of Medical Power of Attorney
 Goals of treatment
 Cardiopulmonary resuscitation (CPR)
 Feeding tubes
 Mechanical ventilation
 Dialysis
 Organ and Tissue Donation
 Preferred site of death and those present at death
Purpose of MOST
• To provide a mechanism to
communicate patients’ preferences for
end-of-life treatment across treatment
• To improve implementation of advance
care planning
Why MOST Works
• By law MUST accompany patient
• Contains specifics
• It IS an order—no interpretation is
• Statute provides safe harbor for
Who benefits from a MOST?
• Persons who have advance chronic
progressive illness
• Those who might die in the next year
“Would you be surprised if this patient
died this year?”
• Anyone wishing to further define their
preferences for healthcare interventions
MOST in North Carolina
• 2004: North Carolina pilots POST
– Mission Hospitals in Asheville
– Physicians from Buncombe and Henderson County Medical Societies
ask NCMS to study POST
– NCMS agrees and assigns to NCMS E & J Affairs Cmte;
• Early 2005: NCMS Ethical and Judicial Affairs Committee
decides to pursue NC POST form and appoints subcommittee
• 2005 POST pilot begins in Pitt Co.
• 2006: POST Task Force formed to look at documents
• 2006-2007: MOST form modifications; legislation developed
and pursued (H 634/Session Law 2007-502)
• 2007: NC passed legislation recognizing MOST
• 2008: ongoing efforts to develop educational toolkit to
facilitate appropriate utilization of MOST
POST Task Force—March 4, 2006
Pilots (Buncombe, Pitt)
Home Health
Nursing Homes
• NCBA (health, elder &
estate law)
• Nursing
• Old North State M.S.
• NC Med. Dir. Assoc
• Family Policy Council
• Life Tree
• Catholic Medical
A Little Bit of History. . .
• Began with a journal article describing the work of
Dr.Alvin Moss of WVA r/t his development of
POST form
• Contacted Dr.Moss who facilitated contact with
Dr.David Blackmon who was already piloting
document in Western NC
• Collaborated with NH’s, local geriatrician,
geriatric RN/case manager and palliative care
team at area hospital
More History. . .
• Education provided to hospital ED, EMS,
case managers, NH staff, some area MD’s
and patients/families
• In Nov. 2005, began pilot in 3 Eastern NC
nursing facilities, utilizing forms/processes
already in use in Buncombe Co. pilot
Benefits of Collaboration on Pilot
• Identified common problem/need r/t
honoring patients desires for EOL care
• Identified tool with proven track record
• Willingness of all players to share expertise,
tools, experiences, etc.
Benefits of Collaboration
• POST task force attempted to identify all
players who might be impacted by form
• POST task force sought by-in from all who
would be needed to actualize form
(regulatory agencies/clinicians/legal
counsel/consumers, etc)
• Willingness to address ALL expressed
concerns and potential problems with form
What did we learn??
• Importance of listening to concerns of others
• Importance of recognizing that each player comes
with needs, with something to offer and with a
unique perspective on the project
• Importance of keeping the patient’s needs at the
center of what we were doing – honoring person’s
wishes for care at end of life
• That it “takes a village” – and then some. . .
What next??
• Develop educational materials
• Develop training programs for health care
professionals who work with patients and patient
representatives to learn to help prepare MOST
• Translate materials into Spanish and other
languages as needed
• Start collecting data on MOST for NC IOM
study to be issued in 2013 to assess if MOST has
improved EOL care in NC