**EP52: Wishes At End Of Life**
**Dr. Warwick:** Welcome to Dr. Warwick's podcast channel. Warwick is a practicing cardiologist and author with a passion for improving care by helping patients understand their heart health through education. Warwick believes educated patients get the best health care. Discover and understand the latest approaches and technology in heart care and how this might apply to you or someone you love.
My name is Dr. Warwick Bishop, and I'd like to welcome you to my consulting room. Today, I'd like to talk about something which is a real chestnut for me, and I may well have raised it in podcasts before, but I think it's so important it is worth raising again. What I'm going to talk about is end-of-life wishes and end-of-life orders, and I'm going to discuss a particular form called a MOLST.
M-O-L-S-T stands for Medical Orders for Life Sustaining Treatment, MOLST. Now, this is a form that really is available just about in every hospital, and it's so that there can be documentation of the wishes of a patient and their family if that patient were to come into the hospital and become critically unwell. There are real pluses and minuses to this, and I want to articulate those as best I can for you so that you understand a little bit about that process.
One of the pluses that's really important is a MOLST form can reflect the patient and family wishes. There may be a real desire for there not to be resuscitation, or there may be particular things that that individual is adamant they don't want. A very simple example could be Jehovah's Witnesses who are adamant they don't want blood products. So, in a MOLST order, documentation could be made that resuscitation measures can be undertaken, but no blood products used. What a great thing to document within the patient notes so that those wishes for the patient and the family can be met.
One of the other things that's really useful for the MOLST form is that it gives some clarity to the staff. The staff know exactly what the expectations of that patient are without having to ask on a regular basis. Well, nothing's perfect. My own observation is that the MOLST form is a form. And forms, by virtue of the fact that they're the way they're produced, are brittle. They're not subtle. They don't reflect nuances. And so there may be specific situations around an individual person which can't be reflected easily in that form.
Well, that's no surprise, and that is one of the issues of trying to be broad-based in an approach. One of the other things that I think a MOLST form seems to do, and I've observed this over and over, is change the perception of care that can be given by the ward that that patient is on. So, when a MOLST form appears in the notes, particularly if it says something like active resuscitation measures are not indicated for this individual for various reasons, they may be very elderly and close to the end of their life, or they may have other comorbidities going on. If their MOLST form suggests that they're not for resuscitation, there almost appears to be a subconscious step down in the care that those patients are given.
I'm not sure if that's documented or not. I'm not sure if there is any literature around that or not. But it's certainly what I seem to see, and it's what I seem to observe in patients I've had over the years. So, one of the things that makes me laugh about MOLST forms, I guess I laugh in a dark humor way, is that more often than not, these forms are trying to be filled out early on in the patient's stay.
So, you can imagine if someone elderly and unwell with a life-threatening illness comes into the hospital, in their first hours within the hospital, a junior doctor feels obliged to fill out the MOLST form because he's being pressured by other staff within the hospital because they need to know what's going on with this person and what their wishes are. Can you imagine a young doctor talking to a sick elderly person with their family saying, "Well, if this person gets worse, do you want us to resuscitate them or not?" What an incredibly uncomfortable conversation. What a very difficult place to put not only that young doctor but also the family and the patient involved.
My own feeling is that end-of-life conversations are very complicated, and really I'm only most comfortable in that situation if I've known the patient for a period of time. Often, it can be over a period of months or even years, particularly in my own practice since I've now been established for a number of years. I think the issues are often very complicated, and it's hard to know sometimes what situations are reversible and what are not. Sometimes there can be moment-to-moment changes which alter the way we view the scenario. This is really complicated.
My own experience is at trying to relate to patients and their families. Nearly 30 years of experience in this space of dealing with end-of-life decisions and management is almost impossible in a single discussion. In fact, it's almost impossible over the course of weeks or months. These issues are really difficult, and they're life and death without question. They are the most important decisions that people make, and we do need to be so sensitive and understanding around them.
In my own practice, I try and speak with the patient and the family together. I personally don't like using MOLST forms because of the limitations of constraint that they offer and because of that impact of perception for the care of the patient. I think it is really important to recognize the wishes of the patient, and in general terms, what my observation is that people don't want to be resuscitated or don't want emergent care if it's going to bring them to a position of being sub-functioning, a vegetable, or reliant on other people. This makes common sense.
Sometimes families want people to live no matter what, and this doesn't make common sense. So, the discussions have to be very balanced about trying to give enough therapy to the reversible, but not so much therapy that we really have unrealistic expectations. My general hope when I speak with people is to say, "Look, I really want to make these decisions as the challenges arise," understanding that your wish would be to die in dignity, to not be left with a situation where you're a vegetable or on a machine or fully dependent on someone else.
That these moment-to-moment decisions are complex, and based on 30 years of experience I've had in dealing with these situations, I want to let you know that my hope will be to do the very best for you and your family, respecting your wishes, but trying to make the process as understanding and comfortable, and with as much dignity and care as possible.
I think this is a really important space, and really, for those listening, I hope you have a chance to speak with your family broadly about the issues that may be important to you at this time of life because it does come for everyone, bar none. I think if you can live a long life, that's a plus. If you can be cared for in your last days with care, compassion, and maintain some dignity, then I think that is a reasonable objective.
I think if you can fill out a MOLST form in a way that allows some flexibility and some understanding, then that's terrific. This is such a difficult area, though. Don't be afraid to ask questions, and don't be afraid to ask your doctor to help you through that process because no one can expect you to know exactly what you want at a time you've never been through before.
With all my care and concern and passion, I do wish you the best. Until next time, good health, and thank you for joining me on a podcast. Goodbye.
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