Prevalence, Management and Outcomes Related to Preoperative Medical Orders for life Sustaining Treatment (MOLST) in an Adult Surgical Population.

Objective To determine prevalence of documented preoperative code status discussions and post-operative outcomes (specifically mortality, readmission and discharge disposition) of patients with completed Medical Orders for Life-Sustaining Treatments (MOLST) forms before surgery. Summary of background data A MOLST form documents patient care preference regarding treatment limitations. When considering surgery in these patients, preoperative discussion is necessary to ensure concordance of care. Little is known about prevalence of these discussions and post-operative outcomes. Methods A retrospective cohort study was conducted consisting of all patients having surgery during a one-year period at a tertiary care academic center in Boston, Massachusetts. Results Among 21787 surgical patients meeting inclusion criteria, 402 (1.8%) patients had preoperative MOLST. Within the MOLST, 224 (55.7%) patients had chosen to limit cardiopulmonary resuscitation and 214 (53.2%) had chosen to limit intubation and mechanical ventilation.Code status discussion was documented pre-surgery in 169 (42.0%) patients with MOLST. Surgery was elective or non-urgent for 362 (90%), and median length of stay [Q1, Q3] was 5.1 days [1.9, 9.9]. The minority of patients with preoperative MOLST were discharged home (169 [42%]), and 103 (25.6%) patients were readmitted within 30 days. Patients with preoperative MOLST had a 30-day mortality of 9.2% (37 patients) and cumulative 90-day mortality of 14.9% (60 patients). Conclusions Fewer than half of surgical patients with preoperative MOLST have documented code status discussions before surgery. Given their high risk of post-operative mortality and the diversity of preferences found in MOLST, thoughtful discussion before surgery is critical to ensure concordant perioperative care.