title: Medical orders for life-sustaining treatment: is it time yet?
abstract: OBJECTIVE
  As the aging population faces complex end-of-life issues, we studied the intervals between long-term care admission and advance directive completion, and between completion and death. We also sought to determine the interdisciplinary team's compliance with documented wishes.
  
  
  METHODS
  A cross-sectional study of 182 long-term care residents in two facilities with and without completed medical orders for life-sustaining treatment (MOLST) in the New York Metropolitan area was conducted. Demographic variables included: gender, age, ethnicity, and diagnosis. Measures included: admission date, MOLST execution date, and date of death. Resident advance directive documentation was compared with clinical intervention at time of death, including intubation and mechanical ventilation.
  
  
  RESULTS
  Of the residents studied, 68.7% were female, 91% were Caucasian and 91.8% were ≥ 65 years of age (mean age: 83). The median time from admission to MOLST signing was 48 days. Median time from admission to MOLST signing for Caucasians was 21 days; for non-Caucasians was 229 days. Fifty-two percent of MOLST were signed by children, and 24% by residents. Of those with signed forms, 25% signed on day of admission, 37% signed within 7 days, and 47% signed within 21 days. Only 3% of residents died the day their MOLST was signed, whereas 12% died within a week, and 22% died within 30 days. Finally, among the 68 subjects who signed a MOLST and died, 87% had their wishes met.
  
  
  CONCLUSIONS
  In this era of growing time constraints and increased regulations, medical directors of long-term care facilities and those team members caring for residents urgently need a clear and simple approach to the goals of care for their residents. The MOLST is an ideal tool in caring for older adults at the end of life, providing concrete guidance, not only with regard to do not resuscitate (DNR) and do not intubate (DNI) orders, but also for practical approaches to daily care for the interdisciplinary team.
authors.affiliation: North Shore-LIJ Health System, Medicine/Geriatrics Department, New Hyde Park, New York.
authors.forename: Anna Clarissa
authors.initials: AC
authors.lastname: Araw
authors.affiliation: North Shore-LIJ Health System, Medicine/Geriatrics Department, New Hyde Park, New York.
authors.forename: Anna Marissa
authors.initials: AM
authors.lastname: Araw
authors.affiliation: North Shore-LIJ Health System, Health Services Research, New Hyde Park, New York.
authors.forename: Renee
authors.initials: R
authors.lastname: Pekmezaris
authors.affiliation: North Shore-LIJ Health System, Health Services Research, New Hyde Park, New York.
authors.forename: Christian N
authors.initials: CN
authors.lastname: Nouryan
authors.affiliation: North Shore-LIJ Health System, Department of Biostatistics, New Hyde Park, New York.
authors.forename: Cristina
authors.initials: C
authors.lastname: Sison
authors.affiliation: North Shore-LIJ Health System, Medicine/Geriatrics Department, New Hyde Park, New York.
authors.forename: Barbara
authors.initials: B
authors.lastname: Tommasulo
authors.affiliation: North Shore-LIJ Health System, Medicine/Geriatrics Department, New Hyde Park, New York.
authors.forename: Gisele P
authors.initials: GP
authors.lastname: Wolf-Klein
mesh_terms: D024362:Advance Directive Adherence / Q000706:statistics & numerical data*; D016223:Advance Directives / Q000706:statistics & numerical data*; D000368:Aged; D000704:Analysis of Variance; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D008134:Long-Term Care / Q000592:standards / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D009519:New York City; D012866:Skilled Nursing Facilities / Q000592:standards / Q000706:statistics & numerical data; D013997:Time Factors