Decisions by Default: Incomplete and Contradictory MOLST in Emergency Care

What patients intend when they make health care choices and whether they understand the meaning of orders for life-sustaining treatment forms is not well understood. The purpose of this study was to analyze the directives from a sample of emergency department (ED) patients' MOLST forms.

MOLST forms that accompanied 100 patients who were transported to an ED were collected and their contents analyzed. Data categories included age, gender, if the patient completed the form for themselves, medical orders for life-sustaining treatment including intubation, ventilation, artificial nutrition, artificial fluids or other treatment, and wishes for future hospitalization or transfer. Frequencies of variables were calculated and the associations between them were determined using chi-square. An a priori list of combinations of medical orders that were contradictory was developed. Contradictions with Orders for CPR (cardiopulmonary resuscitation) included the choice of one or more of the following: Comfort care; Limited intervention; Do Not Intubate; No rehospitalization; No IV (intravenous) fluids; and No antibiotics. Contradictions with DNR orders included the choice of one or more of the following: Intubation; No limitation on interventions. Contradictions with orders for Comfort Care were as follows: Send to the hospital; Trial period of IV fluids; Antibiotics. The frequencies of coexisting but contradictory medical orders were calculated using crosstabs. Free text responses to the "other instructions" section were submitted to content analysis.

Sixty-nine percent of forms reviewed had at least one section left blank. Inconsistencies were found in patient wishes among a subset (14%) of patients, wherein their desire for "comfort measures only" seemed contradicted by a desire to be sent to the hospital, receive IV fluids, and/or receive antibiotics.

Patients and proxies may believe that making choices and documenting some, but not all, of their wishes on the MOLST form is sufficient for directing their end-of-life care. The result of making some, but not all, choices may result in patients receiving undesired, extraordinary, or invasive care.