BY ERIC REINES, MD, FACP, COMMITTEE ON GERIATRIC MEDICINE
Dr. Eric Reines
The Massachusetts Medical Society has long supported the Commonwealth’s shift to the national Physician Orders for Life-Sustaining Treatment (POLST) paradigm — a standardized approach that translates care and treatment preferences into medical
orders recognized across states that honor POLST. Unlike the state’s current Medical Order for Life Sustaining Treatment (MOLST) form, which lacks a structured "Medical Interventions" section and includes only general questions, the POLST
form provides clear guidelines that improve understanding and effectiveness in honoring patients’ wishes.
In 2021, the Department of Public Health convened a group of experts representing organizations across Massachusetts, including the Society, as the MOLST to POLST Advisory Group. This group critiqued the existing MOLST form, considering the POLST
paradigm to ensure a powerful and meaningful medical order for patients and physicians. Their efforts focused on ensuring the transition process was efficient, effective, economic, and transparent.
Like the paper-only MOLST, the POLST is intended for individuals of any age with serious and advancing illness. As will be the case with the POLST, physicians may propose a MOLST order with patients, but it is ultimately the patients’ decision
to complete the form. The physician, nurse practitioner, or physician assistant and the patient and their family discuss the patient’s goals of care, responding to questions to understand the likely outcomes of treatment choices.
Currently, the bright pink MOLST form stays with the patient to be made available should emergency services be called or when entering a health care facility. As the Advisory Group worked with the Executive Office of Elder Affairs (EOEA), surveys
and focus groups were conducted to determine positive aspects and areas for improvement. It became clear that most MOLST forms are not readily available and that clinicians and emergency responders do not always know if a MOLST exists or how
to access the form. Further, many MOLST forms are completed hastily, for example, with older patients in an emergency department or any patient entering a skilled nursing facility. This negates any knowledge of the patients’ values or an understanding
of their treatment choices and goals of care.
In 2022, legislation passed granting the EOEA responsibility for the POLST transition. As the Commonwealth moves toward the standardized POLST, the focus is on best practices learned from research and from existing POLST programs around the country.
The secure, single sign-on electronic registry (e-registry) will be integrated within the most used electronic health record systems in the state, or within a stand-alone platform so that first responders, emergency department clinicians,
and long-term care facility professionals will be able to search for existing documents. A paper copy of the completed POLST is also provided to the patient. The POLST e-registry will also allow for reciprocity with other states using the
national POLST.
Priscilla M. Ross, RN, POLST program director, explains that “we are engaging with stakeholders across the care continuum in a variety of ways to ensure that the POLST Program development is based on best practices and the real-world experiences
of our health care providers.” The e-registry will also have a consumer portal where the patient can access their POLST form and upload their health care proxy or other advance directive.
Regulations will be developed and informed by the pilot program at Fairview Hospital in Great Barrington, Cooley-Dickinson Hospital in Northampton, and long-term care and emergency services within those communities. POLST leadership envisions
a soft, controlled launch tentatively scheduled Transition from the MOLST to the National POLST Paradigm continued from page 3 for 2026, with continuous improvement post launch. Eventually, the MOLST form will be retired.
The POLST Steering Committee will create extensive training modules on serious illness conversations, discussing the POLST with patients, understanding the various fields within the POLST, and documentation. There will also be a campaign for the
general public geared toward individuals and their loved ones who may want to complete a POLST order.
Three advisory groups will participate in the next phase of the POLST e-registry, the membership of which includes physicians, technicians, faith leaders, nurses, social workers, and several state agencies. The groups include a chief information
officer/chief medical officer cohort of clinical and technical leaders who will test the e-registry and a Continuum of Care group, within which the Society will be represented. This group of clinicians, social workers, hospice, clergy, and
others directly involved with serious illness will advise on workflow, protocol, policy impact of transition, system access and integration. A consumer advisory group is already up and running.
Dr. Reines is a past chair and current advisor to the Committee on Geriatric
Medicine. He is the MMS representative to the MOLST to POLST Continuum of
Care group and previously served on the Department of Public Health’s MOLST
to POLST Advisory Group. Dr. Reines is chief medical director of PACE at Element
Care (a program of all-inclusive care for the elderly) on the North Shore.
