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PALLIATIVE CARE
This form is aimed at the group of people in
is the group of patients for which the answer from their experienced health care provider to the “surprise question” (Would you be surprised if the patient died within the next year?) would be “no.”8 The DMOST form is voluntary, actionable as a medical order, and portable. It travels with the patient through health care settings. A big difference from ADs is that DMOST must be completed
by patient/surrogate AND a health care provider. It can be facilitated with a range of health care providers, but must be signed by a physician, APN or PA. The patient must also sign it and — different from an AD — a surrogate can sign in place of the patient if the patient has lost decisional capacity.
DMOST is the most recent version of
the Physician Orders for Life-Sustaining Treatment (POLST) form that started in Oregon in 1991. Over the last 25 years, other states have developed their versions of POLST so that now there are active forms in 46 states and an increasing body of evidence of the form’s effectiveness for aligning medical care to a person’s wishes near the end of life.9
The conversations and decision making
quality of these conversations is crucial.
At this stage of life and illness, it is often a more detailed discussion of the diagnosis, prognosis, treatment options, and likelihood
is often about what goals are achievable and at what cost or burden. Similar to an AD, completing a DMOST is about informing/ empowering a patient/surrogate to choose the best path forward.
DMOST has been available since April 2016. The Delaware Academy of Medicine (DAM) is responsible for implementing DMOST, including education and training to both the public and providers, monitoring its use, and measuring its impact.
The website Delawaremost.org has a registration process, as well as a training module for health care providers. The training module is strongly recommended for any provider who might be facilitating or completing a DMOST form with a patient/ surrogate. It is the obligation of all health care providers to recognize and honor a properly completed DMOST. The form should be printed out on regular paper and placed in
a pink envelope that can be obtained from DAM. Copies can be scanned into an EMR. The original should travel with the patient at all times. All health care settings should consider creating a DMOST policy that describes how the form will be handled within the boundaries of that setting.
ADs and DMOST are only tools in the ACP process and only as effective as the people who use them. It is time for health care providers and our health care system to “up our game” for the 21st century
in terms of encouraging, facilitating, documenting, and utilizing the ACP process to deliver on the promise of true person-centered care and the best outcome for every patient every time.
CONTRIBUTING AUTHOR
■ JOHN GOODILL, MD is Director of Supportive and Palliative Care Education and Outreach at Christiana Care Health System.
REFERENCES
1. Institute of Medicine report. Dying in America: Improving Quality and Honoring Individual Preferences near the End of Life. Wash, DC. 2014.
2. Singer PA. Quality end of life care: patients’ perspectives. JAMA 1999;281:163-168.
3. Gawande A. Being Mortal: Medicine and What Matters in the End. New York, NY. Metropolitan Books; 2014.
4. Kalanithi P. When Breath Becomes Air. New York, NY. Random House; 2016.
5. Romer AL, Hammes BJ. Communication, trust, and making choices: advance care planning four years on. J Pall Med. 2004;7:335-340.
6. Five Wishes. Aging with Dignity website. Available at: https://www.agingwithdignity.org/ five-wishes.
7. UCLA poster, Center to Advance Palliative Care, November 2016, Oregon Health Science Center, Session at American Academy of Hospice and Palliative Medicine, 2017.
8. Moss AH. Prognostic significance of the ‘surprise’ question in cancer patients.
J Pall Med. 2010; 13:837-840.
9. National POLST Paradigm website. Available at: http://polst.org/.
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