Prevalence, Management, and Outcomes Related to Preoperative Medical Orders for Life Sustaining Treatment (MOLST) in an Adult Surgical Population

Abstract

Objective: To determine prevalence of documented preoperative code status discussions and postoperative outcomes (specifically mortality, readmission, and discharge disposition) of patients with completed MOLST forms before surgery. Summary of Background Data: A MOLST form documents patient care preference regarding treatment limitations. When considering surgery in these patients, preoperative discussion is necessary to ensure concordance of care. Little is known about prevalence of these discussions and postoperative outcomes. Methods: A retrospective cohort study was conducted consisting of all patients having surgery during a 1-year period at a tertiary care academic center in Boston, Massachusetts. Results: Among 21,787 surgical patients meeting inclusion criteria, 402 (1.8%) patients had preoperative MOLST. Within the MOLST, 224 (55.7%) patients had chosen to limit cardiopulmonary resuscitation and 214 (53.2%) had chosen to limit intubation and mechanical ventilation. Code status discussion was documented presurgery in 169 (42.0%) patients with MOLST. Surgery was elective or nonurgent for 362 (90%), and median length of stay (Q1, Q3) was 5.1 days (1.9, 9.9). The minority of patients with preoperative MOLST were discharged home [169 (42%), and 103 (25.6%) patients were readmitted within 30 days. Patients with preoperative MOLST had a 30-day mortality of 9.2% (37 patients) and cumulative 90-day mortality of 14.9% (60 patients). Conclusions: Fewer than half of surgical patients with preoperative MOLST have documented code status discussions before surgery. Given their high risk of postoperative mortality and the diversity of preferences found in MOLST, thoughtful discussion before surgery is critical to ensure concordant perioperative care.

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“…In our cohort, 77% of patients had a discussion on assigning or confirming a designated HCP, and 15% of patients had a MOLST form completed during the visit. Although these rates are lower than other domains discussed in the CGA, it was higher than expected, as a recent study showed that less than 2% of older patients undergoing elective surgery had a completed MOLST form documented 40 . This further emphasizes the importance of discussing and documenting patients' preferences, trade‐offs, priorities, and expected treatment goals, 41–43 specifically, as the American College of Surgeons and the American Geriatric Society have launched the Geriatric‐Surgery Verification program, requiring these discussions to be explicitly documented in the EHR 44 …”

“…Although these rates are lower than other domains discussed in the CGA, it was higher than expected, as a recent study showed that less than 2% of older patients undergoing elective surgery had a completed MOLST form documented. 40 F I G U R E 2 Distribution of the length of stay (LOS) among those without and with frailty.…”

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“…Our own work shows that there are significant discrepancies in the documentation of code status restrictions, and in some cases, the clinical care provided may not align correctly with what the patient actually wants. 14 We found that fewer than half of surgical patients with preoperative MOLST (Medical Orders for Life Sustaining Treatment) had documented code status discussions before surgery. Ensuring compliance with ACS GSV standards could go a long way toward ensuring appropriate documentation of code status, limitations on resuscitation, and discussions regarding perioperative management of patients with restrictions on resuscitation.…”

“…The impact of the ACS GSV on cancellations and delays of surgery, as well as validation of alignment of patient goals and values with surgical goals also is an important area of future investigation. Our own work shows that there are significant discrepancies in the documentation of code status restrictions, and in some cases, the clinical care provided may not align correctly with what the patient actually wants 14. We found that fewer than half of surgical patients with preoperative MOLST (Medical Orders for Life Sustaining Treatment) had documented code status discussions before surgery.…”