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Maryland MOLST

Introduction

At various times in your life, you will need to make decisions about specific medical tests and treatments for your health care. It is important that you have a general knowledge of basic medical terms so that you more fully understand your options. The Maryland Medical Order for Life Sustaining Treatment (MOSLT) form is designed to speak for you at a time you may not be able to speak for yourself. The following talks about information you may want to discuss with you Doctor before signing a MOLST form.

Your decision about a medical test or treatment is based on your preferences, values, and goals. Sometimes you may want to talk to close family members or friends about a decision. Other times you may want to get a second opinion from another doctor. For every medical test or treatment, it is important for you to understand the benefits and risks for you. The benefits and risks may vary depending on your stage in life, and they will be different from one individual to another. Your doctor or nurse practitioner will help you understand how a test or treatment applies to your specific situation.

You should understand the purpose of a test before you agree or disagree to it. If a test will not change your medical treatment, then make sure you understand the reason that the test is being done. Things to consider when deciding on medical tests include:

  • Does the test rule out a medical condition? For example, you may get a blood test to see if you have diabetes or not.
  • Does the test monitor a treatment you are receiving? You may have your cholesterol checked to see if your cholesterol medicine is working.
  • Does the test check for side effects from a treatment? If you are taking a cholesterol medicine, you may get blood tests to see if the medicine is affecting your liver function.
  • Does the test help your doctor decide on treatment options? A sample of your urine may be sent to a lab to determine if you have a urinary tract infection and what antibiotics will effectively treat the infection.
  • Does the test check the function of an organ? Before surgery, you may get an EKG to check your heart or a blood test to check your kidney function.
  • Does the test hurt? If so, how will your pain be controlled? A blood draw is usually a single needle stick, but other tests are much more invasive and painful.
  • Will you be awake during the test? For some tests, like a colonoscopy, you are sedated.
  • Does the test expose me to radiation? A chest x-ray and a CT scan have different amounts of radiation.
  • Does the test screen for something that can be treated? Mammograms help to screen for breast cancer so that it can be identified and treated early.
  • What are your goals for your health care? What is most important to you?
  • Does the decision need to be made right away, like an emergency appendectomy, or do you have time to think about it, like a knee replacement?
  • What are the benefits for you? After a knee replacement, you may have less pain or walk better. A medicine to lower your blood pressure will control your hypertension.
  • What are the potential risks, complications, and side effects? Are the side effects temporary or will they be permanent? For example, some medicines may cause constipation, but the constipation goes away when the medicine is stopped.
  • Will a treatment cure a problem or just control a symptom? Antibiotics will cure an ear infection. Insulin controls your blood sugar, but it does not make your diabetes go away.
  • Does the treatment limit your activities? If you are on a blood thinner, you may not be able to participate in certain sports or activities. After some operations, you may not be able to drive or go up and down the stairs.
  • Where is the treatment done? A blood transfusion must be done in an infusion center or at the hospital.

Cardiopulmonary Arrest

To stay alive, both your heart and lungs need to be working. If your heart stops beating, it is called a cardiac arrest. If your lungs stop breathing, it is called a respiratory arrest. If your heart and lungs both stop, it is called a cardiopulmonary arrest. A cardiopulmonary arrest is the most serious medical condition that can happen. You will die if your heart and lungs do not start working again.

Cardiopulmonary resuscitation includes the steps that doctors take to help your heart and lungs if you have a cardiopulmonary arrest. These steps may include:

  1. Chest compressions to help circulate blood through your body
  2. Shocking your heart to restart it or to make it beat normally
  3. Using a machine called a ventilator to help your lungs move oxygen
  4. Giving medicines through an IV.

Even when all of these steps are taken, most people still die if their heart stops beating or they stop breathing. Even if you are still alive after being resuscitated, you may have serious medical problems because your brain, kidneys, and other organs did not get enough oxygen.

If you do not want resuscitation to be attempted, your doctor will write an order for DNR (Do Not Resuscitate). If you have a DNR order, then you will not be put on a ventilator, have chest compressions, or be shocked if you have an arrest. Death will be allowed to occur naturally. You may still receive pain medications and other treatments.

Whether you are at home or in a health care facility, if you do not have a Do Not Resuscitate (DNR) order, cardiopulmonary resuscitation (CPR) will be attempted. The Maryland MOLST order form tells health care professionals and EMS workers what medical treatments you want or do not want, including cardiopulmonary resuscitation and other life-sustaining treatments. Unless you have a Maryland MOLST order form or an older version of the EMS DNR form with an order not to be resuscitated, EMS providers (medics) must attempt resuscitation. Your doctor or nurse practitioner can complete a Maryland MOLST order form for you.

Respiratory Support

There are many ways to help you breath and to get oxygen into your body. As you look down the list, the options are more invasive. These include:

  1. Nasal cannula: A plastic tube with short tips that fit into your nose. It is attached to soft, flexible plastic tubing that wraps around your ears and under your chin. The tubing is connected to an oxygen tank or oxygen machine. The oxygen blows gently into your nose.
  2. Face mask and non-rebreather mask: A firm plastic mask that fits over your nose and mouth. It is held in place with an elastic strap around your head. The oxygen blows into your nose and mouth. It is hard to talk when wearing the mask. You can’t eat while the mask is in place.
  3. CPAP (Continuous Positive Airway Pressure) and BiPAP (Bi-level Positive Airway Pressure): Used for people who are still breathing on their own but need help to breath. This firm plastic mask fits tightly over your nose and/or mouth. It blows oxygen into your lungs. It keeps the small air sacs (alveoli) open to let oxygen get into your body.
  4. Intubation: If you are not breathing on your own, a hard plastic tube is put through your mouth and into your windpipe (trachea) at the top of your lungs. The tube is connected to a machine called a ventilator that helps you breath. The tube is taped to your face. You cannot talk or eat while the tube is in place. You may be sedated with medicines while on the ventilator.

Cardiac Support

There are different ways to support your heart if it is not beating normally or stops beating. They include:

  1. Chest compressions: Someone presses down on your chest to compress your heart to help pump blood through your body.
  2. Cardioversion: A small electrical shock is given to try to get your heart beating normally again.
  3. Defibrillation: An electrical shock is given to try to get your heart beating normally again.
  4. Pacemaker: A pacemaker sends small electrical signals to your heart to help it beat normally. It can be used on a short-term basis outside of your body and on a long-term basis inside your body.

Transfusing Blood Products

A transfusion is when a blood product is taken from one person and given to another person. All blood products are very carefully screened so that diseases are not passed from one person to another. You only receive blood types that your body will accept. Whole blood, packed red blood cells, plasma, and platelets can be transfused.

  1. Red blood cells carry oxygen to your lungs and throughout your body. If you have severe anemia (a low red blood cell count), you may get a transfusion of packed red blood cells.
  2. Plasma contains clotting factors that help your blood to clot. If you have difficulty clotting your blood and are low in clotting factors, you may get a plasma transfusion.
  3. Platelets are particles in blood that help blood to clot. If you have difficulty clotting your blood and are low in platelets, you may get a platelet transfusion.

Common Ways to Take Medicines

The most common ways to get medicines into your body are:

  1. Oral: The tablet, capsule, or liquid is swallowed.
  2. Sublingual: A very small amount of liquid or small tablet is put in your mouth and absorbed through the mucous membranes.
  3. Subcutaneous: A small needle is placed just under your skin, but not in a vein. Small doses of some medicines, like insulin, are given this way.
  4. Rectally: Medicine is put into your rectum and gets absorbed into your body.
  5. Intravenous: There are several types of IVs:
    • IV catheter: A small needle and catheter are put into a vein in your arm. The catheter (a flexible tube) is left in place to give medicines or fluids. The needle is removed. Usually it is used short term to give medicines like antibiotics.
    • PICC (Peripherally Inserted Central Catheter): A long, slender, flexible tube that is put into a vein in the upper arm. The tip of the catheter is pushed in until it is in a large vein near the heart. You may be able to go home with a PICC line if nurses monitor it. It can stay in for several weeks or months.
    • Central Line: A large catheter that goes into a large vein, such as the femoral, subclavian, or jugular vein. It is a large IV that is used in the hospital. It can stay in place for about a week.
    • Indwelling Port: A special reservoir that is surgically placed inside your body. It is used to give chemotherapy or other special drugs. It can stay in your body for many months.

Artificially Administered Feeding and Hydration

Sometimes a person cannot take in enough fluids and food through his or her mouth, so other ways are used to get nutrition into the body. It is called “artificial” because the food is not swallowed by the person naturally. Your physician or nurse practitioner will explain which of these options may be appropriate for you. There are several types of artificial feeding and hydration:

  1. Subcutaneous: A very small needle connected to a catheter (flexible tube) is put into your upper arm or thigh, but not in a vein. Small amounts of fluid, but not food, are given through the catheter. When fluids are given this way, it is called hypodermoclysis.
  2. Intravenous: A small needle and catheter (a flexible tube) are put into your vein. The needle is removed and the catheter is left in place for several days. Fluids and some nutrition can be given through the IV for a short period of time. If you are dehydrated or elderly, it is harder for the nurse to put in an IV.
  3. Nasogastric Tube: This plastic tube about the diameter of a woman’s smallest finger goes through your nose and into your stomach. It is used for food, fluids, and medicines. It is very uncomfortable to get it placed, but once it is in you will get more used to it. The tube is in the back of your throat, so some people are bothered by it. It is held in place by taping it to your nose and face. It is a short-term way to get nutrition while in the hospital.
  4. G (Gastric) Tube or PEG (Percutaneous Endoscopic Gastric) Tube: These flexible plastic tubes are smaller than the diameter of a woman’s smallest finger. The tube goes through the side of your abdomen directly into your stomach. You are sedated when it is placed during an endoscopy. It is used for food, fluids, and medicines. It stays in place for many months. It can be changed in a doctor’s office or other health care facility.
  5. TPN (Total Parenteral Nutrition): Special liquid nutrition is given through a PICC line or central line. Generally, it is only for short-term use. It requires regular blood tests for adjustment.

Dialysis

Dialysis is done when your kidneys are not working well enough to filter waste products out of your blood. These waste products are like salt, they are dissolved in the blood stream. There are two types of dialysis - hemodialysis and peritoneal dialysis. The type of dialysis that is done is decided by the patient and the doctor.

  1. Hemodialysis: A hemodialysis machine filters waste from your body and adds some normal products back into your body. Because hemodialysis directly filters the blood, a surgeon must make a special connection between an artery and vein in your arm. The dialysis machine is connected to this AV (arteriovenous) fistula or graft. Hemodialysis is done at a dialysis center, three days a week for a few hours each day.
  2. Peritoneal dialysis: Peritoneal dialysis cleans the blood differently. It may be better for some people because it can be done at home, but it requires a lot of attention. Every night a patient uses a peritoneal catheter (tube) to flush the inside of the abdomen with a special clean peritoneal fluid. The waste products move from the blood into the clean peritoneal fluid, and then the dirty fluid empties into a plastic bag. Peritoneal dialysis requires a surgeon to place a flexible catheter (tube) into the abdomen, below the belt line. Using a special machine, this process is done every night and usually lasts eight hours.

For More Information

Website: marylandmolst.org