Standardizing Protection of Patients' Rights From POLST to MOELI (Medical Orders for End-of-Life Intervention)

Use of conditional medical orders to minimize moral, ethical, and legal risk in critical care

Risk managers and ethicists monitor adherence to codes of conduct in the delivery of medical services and proactively participate with providers to create protocols that minimize the moral, ethical, and legal risks inherent in many commonly used medical protocols. "Code/no code" medical orders work well for patients at the extremes who always or never want to undergo a procedure, but they create troubling uncertainties for others by preventing them from expressly requesting procedures under some circumstances but not others. Obeying binary orders such as DNAR (Do Not Attempt Resuscitation) can allow deaths that a patient might want to delay or can expose patients to prolonged suffering they wish to avoid. These risks can be reduced by: (1) fully explaining the nature of proposed interventions and their possible beneficial and adverse effects in varying circumstances; and (2) replacing the traditional dichotomy with a continuum of options from always, through conditionally sometime, to never orders adapted to a range of situations and preferences. The Conditional Medical Orders (CMO) form summarizes patients' preferences regarding resuscitation, ventilation, and artificial hydration and nutrition (ANH) is an efficient way to increases the chance that patients will undergo only the treatments they want.

Conditional Permission to Not Resuscitate: A Middle Ground for Resuscitation

Every decision to perform or withhold cardiopulmonary resuscitation (CPR) has ethical implications that are not always well understood. Value-based decisions with far-reaching consequences are made rapidly, based on incomplete or possibly inaccurate information. For some patients, skilled, timely CPR can restore spontaneous circulation, but for others, success may either be unobtainable or bring serious iatrogenic consequences. Because CPR is an aggressive process yielding mixed results, patients must be informed about the likelihood of its positive and adverse outcomes. In considering whether to accept or refuse it, patients should also be given a realistic set of alternatives. Current protocols limit patients' options by restricting them to a choice between accepting or refusing CPR. Adding a "middle" code, DNAR-X (Do Not Attempt Resuscitation-Except), significantly expands patients' right to control what happens to their bodies by allowing them to stipulate CPR in some circumstances but not in others.