Most people who are near the end of life lack the ability to make their own decisions about the life-sustaining medical treatments they wish to receive or avoid. For patients with advanced illness and frailty, the most important means of ensuring their preferences are honored is to have a properly completed and accurate electronic version of Medical Orders for Life-Sustaining Treatment (eMOLST) available in their electronic medical records through connections with the New York state eMOLST Registry.

Peace of Mind For Those With Advanced Illness

eMOLST is for patients with serious health conditions who want to receive or avoid any or all life-sustaining treatment, who reside in a long-term care facility or require long-term care services, and/or who might die within the coming year. In New York state, eMOLST, and its predecessor, the hard copy MOLST, are the only authorized ways to legally document both nonhospital Do Not Resuscitate (DNR) and Do Not Intubate (DNI) orders that Emergency Medical Services can follow. eMOLST also documents additional specific medical orders that are recognized and honored in all health care settings, including preferences regarding hospitalization. In hospitals, hospice, nursing homes, and the community, eMOLST is used to issue orders concerning preferences for resuscitation and life-sustaining treatment.

COVID-19’s impact on the frail elderly illustrates the important role eMOLST has in the way preferences for care, recorded as medical orders, are communicated. The importance will be intensified if predictions for a second and third wave of the virus are realized. eMOLST allows frail older adults to write their own final chapter and relieve loved ones of any anxiety that comes with making end-of-life health care decisions on their behalf.

eMOLST is not intended for healthy people, or for people who have a chronic condition or multiple chronic conditions but have a long life expectancy. Those individuals should complete a health care proxy and discuss their wishes for care with family and loved ones.

How to Complete eMOLST

Patients should ask their providers if eMOLST is right for them, and if so, complete the electronic form. If a hard copy MOLST already exists, the COVID-19 crisis would dictate that it be reviewed and updated and converted to eMOLST so that it is in the registry. If a patient lacks the ability to make end-of-life decisions, the health care agent or surrogate should speak with the provider. The tools and features in the eMOLST system ensure that a standardized process is used for conversations, and the completed eMOLST is 100 percent accurate.

Licensed physicians and nurse practitioners have the authority and accountability for accurate completion of MOLST and eMOLST under the Public Health Law. As of June 17, 2020, physician assistants also will have that authority and accountability. Only licensed physicians can complete MOLST and eMOLST orders for patients with intellectual or developmental disabilities who lack capacity to make medical decisions and cannot complete a health care proxy.

When an authorized health care practitioner signs the eMOLST, a copy of the medical orders and the discussion automatically become part of the statewide eMOLST Registry that is available as a public health service in all settings, as patients move from one care setting to another across New York. The physician, nurse practitioner, or physician assistant also will print a copy of the eMOLST on prominent, bright pink paper that will physically travel with the patient.

Additional Resources and Education

Excellus BlueCross BlueShield led the development of two free community websites.  CompassionAndSupport.org has information on advance care planning, free downloadable health care proxy forms and instructional videos. MOLST.org has COVID-19 guidance on MOLST, how to have thoughtful MOLST discussions, and instructions for obtaining urgent access to eMOLST.

It was while I was lying awake at 3:00 a.m. again that I realized something was not right.  I am usually an early riser, but 3:00 a.m. is really early, even for me! The pandemic had brought about a lot of changes to my life, including a significant reduction in sleep!

A Vicious Cycle

I work as a Workplace Wellness Coordinator at Excellus BlueCross BlueShield. My job is to educate others on the importance of sleep, but I am not immune to having issues myself.  I know how detrimental inadequate sleep can be, with problems ranging from impaired memory, to obesity, to greater likelihood of car accidents. That knowledge only raised my stress levels! And like a vicious cycle, the more I stressed about not sleeping, the less I slept.

I decided to get help

One night, stuck in another vicious cycle of not sleeping, I decided to get help. I was already registered with MDLIVE, the telemedicine service affiliated with my health insurance. I decided to schedule an appointment with a Licensed Social Worker, who was available within a couple of days.

During my appointment, she explained that I was feeling so stressed that my brain was too “busy” to shut down and sleep properly.  She gave me some activities to try such as meditation and breathing techniques.  She told me to work to make small improvements, even an extra 20 minutes at night is a start.

6 Habits for Better Sleep

Sleep problems are common, according to Greg Carnevale, M.D., chief medical officer and sleep specialist with Excellus BlueCross BlueShield. “There are 50-70 million people in the U.S. that suffer from one or several sleep disorders that result likely in not getting enough sleep. The cause and solution can vary for each person,” Carnevale said. Health experts recommend getting at least seven hours of sleep each night.

“As a society, we need to recognize the dangers of trying to get by with fewer hours of sleep and wake up to the health benefits of a good night’s rest,” Carnevale said. He offers the following tips for improved sleep:

• Keep bedroom quiet, dark and cool.
• Avoid large meals, caffeine, nicotine and alcohol before bed.
• Stick to a consistent sleep schedule, including on weekends.
• Exercise regularly.
• Establish a relaxing bedtime routine.
• Turn off electronic devices at least 30 minutes before bed.

Seek Help When You Need It

I’ve been listening to the advice of the social worker and thankfully, it is helping. I really wish I had called sooner. But, it is never too late to seek help.

“There are sometimes very easy and simple steps to improve on your sleep, and sometimes you need a professional, such as your doctor, to help,” Carnevale said. “Trying to navigate the misinformation out there alone can have deleterious effects to you and your health.  Don’t wait to seek help,” he added.

View and download an Excellus BlueCross BlueShield infographic on ways to improve sleep at ExcellusBCBS.com. For more help with sleep, talk with your doctor or sleep specialist.

The COVID-19 pandemic is shedding new light on the often-abstract concept of advance care planning. Advance care planning is where individuals document what matters most to them, and then select the right health care agent to make decisions on their behalf if they are unable to speak for themselves. During this pandemic, many people have had the heartbreaking experience of making medical decisions for loved ones who were unable to communicate.

Advance care planning gives patients peace of mind in knowing that health care decisions will be made on their behalf by a person they trust. For the person selected to be someone’s health care agent, advance care planning gives them the confidence to make decisions based on their loved one’s stated values and beliefs.

Advance Care Planning: For all Adults Ages 18 and Older

All adults ages 18 and older should start advance care planning conversations with their health care providers, family members and trusted friends. Then, they should complete a health care proxy to formally name a health care agent.

Completing or updating a health care proxy can be done at an office visit to the individual’s physician, nurse practitioner, or physician assistant. The practice of social distancing may require this to be done with a telehealth visit via telephone or by using video conferencing technology such as Skype.

The health care proxy form requires two witnesses to the signature. This can be accomplished in person, or by using video conferencing technology. A photo of the signed health care proxy can be mailed to the health care provider or uploaded to the medical practice’s secure patient portal. Individuals also should email a copy to family members.

If video conferencing is unavailable, speak with your health care provider about the process for verbal consent.

Read special considerations on how to complete a health care proxy during the pandemic by visiting CompassionandSupport.org.

MOLST: For those with an advanced illness

Individuals with an advanced illness or advanced frailty are advised to reach out to their physician or nurse practitioner to discuss the Medical Orders for Life-Sustaining Treatment (MOLST). MOLST reflects a patient’s preferences for treatment, including resuscitation, respiratory support on a ventilator, and hospitalization. It is based on a thoughtful discussion  about the patient’s current health status, prognosis and goals for care.

MOLST is not an advance directive and is not for healthy people. It is a set of medical orders signed by a physician or nurse practitioner that must be followed.

Learn More and Start The Conversation

Excellus BlueCross BlueShield led the development of a free community website, CompassionAndSupport.org, that includes information on advance care planning, free downloadable forms and instructional videos. MOLST.org has COVID-19 guidance on MOLST, eMOLST, and how to have thoughtful MOLST discussions.

An educational poster “Who Will Speak For You If You Can’t Make Your Own Health Care Decisions?” is available to download at ExcellusBCBS.com.

Bob Russell was diagnosed with type 1 diabetes at age 25. Today, he is the Upstate New York Area Executive Director of the American Diabetes Association (ADA). He’s aware of the importance of managing the risks associated with diabetes.

Bob Russell, Upstate New York Area Executive Director of the American Diabetes Association

“Diabetes can affect anyone at any time,” Russell said. “Being aware, paying attention to your body and taking time to take care of yourself is even more important in our current environment.”

There are an estimated 1.6 million adults in New York living with diabetes, according to the New York State Department of Health. This chronic health condition, where the body doesn’t produce or properly use insulin to digest sugar (glucose), can cause serious illness and damage many parts of the body if it’s not managed properly.

People with diabetes can jeopardize their health by failing to take necessary steps to keep their chronic illness in check. Many risk factors for diabetes can be reduced by maintaining a healthy weight and diet, staying physically active and avoiding tobacco.

Managing Diabetes is Now More Important Than Ever

As diabetes affects the immune system, diabetics have an increased risk for infections, including respiratory viruses, that includes the family of coronaviruses and COVID-19.

“Managing our diabetes now is critically important,” he said. “This virus poses a challenge to those of us who are living with diabetes.”

Bob Russell, Upstate New York Area Executive Director of the American Diabetes Association

Take Time to Take Care of Yourself

While many of us are currently working from home and sheltering in place, our routines have changed. People living with diabetes need to continue to watch what they eat and monitor blood sugar levels.

“We’re home and not as active,“ said Russell. “We need to continue to keep our numbers in check. Making small changes can help you be more in control of what you’re dealing with and can help you in the long run. You don’t have to give up the things you love. You just have to do things differently.”

One of the things Russell is doing differently is substituting a big breakfast of bacon, eggs and toast each morning with a protein shake that has less than 10 grams of carbs. “It’s a nice, simple way to take care of yourself,” he says.

Bob mixing his daily shake (photo courtesy of Bob Russell)

“And we need to continue to stay active,” he adds. “The outdoors is still open to us, so go outside and take a walk around the block!”

Russell says everyone, and especially those with chronic disease, must be aware of their environment. “Social distancing is crucial. I limit where I put myself. I carry wipes and use hand sanitizer all the time.”

The Centers for Disease Control and Prevention also recommends wearing cloth face coverings when going into public settings where social distancing may be difficult to maintain.

A Focus on the Spirit and the Psyche

He also says that social interaction is as important as social distancing, especially for those with a chronic condition. “With what’s going on, it’s easy for us to get stressed or even panicked,” he said. “Turn off the news and connect with friends or loved ones. We have to focus on our spirit and our psyche. It’s good for our mental health.”

He encourages those with diabetes or any chronic condition to reach out to support organizations for help.

“The American Diabetes Association is available anytime to help our community,” Russell says. “We’re in this together.”

Additional resources:

• American Diabetes Association:
  • https://www.diabetes.org/coronavirus-covid-19/take-everyday-precautions-for-coronavirus
  • 1-800-Diabetes
• Centers for Disease Control and Prevention:
  • https://www.cdc.gov/diabetes/index.html
  • https://www.cdc.gov/coronavirus/2019-ncov/
• Ask your doctor or health insurer about telemedicine for medical or behavioral health conditions
• Excellus BCBS Behavioral Health Care Management: 1-800-277-2198 (TTY 1-800-662-1220) weekdays, 8 a.m. to 5 p.m.
• Counseling is also available over the phone through telehealth. Ask your doctor or health insurer about telehealth options.

In honor of National Nurses Week, we’re sharing stories that celebrate the compassion, empathy and kindness demonstrated by nurses and other medical professionals throughout our upstate New York communities.

The Call That May Have Saved A Life

When Grace (pseudonym) felt uneasy and scared about her husband’s worsening health condition, she turned to a nurse for guidance.

A registered nurse with the Excellus BlueCross BlueShield 24/7 Nurse Call Line answered the call for help. The nurse provided guidance and support that ultimately resulted in a diagnosis that may have saved his life. What his wife thought was COVID-19 turned out to be a heart attack and pneumonia.

Marleen Rein (photo courtesy of Marleen Rein)

“To find out that the chest pain, cough and shortness of breath was due to a myocardial infarction (MI) and pneumonia was shocking to the member. This call may have saved this man’s life,” said Marleen Rein, RN, a care manager with Excellus BlueCross BlueShield.

Nurses Making a Difference

Knowledge, compassion and ability to listen are qualities that are instinctive for many nurses and other health care professionals. Frontline helpers are making a difference on the health and wellbeing of upstate N.Y. communities.

“The nurses who answer our 24/7 call line don’t often know what happens to these individuals after they call us,” said Michelle Borth, RN, Director of Health Care Improvement with Excellus BlueCross BlueShield. “Hearing these types of stories reinforces the important work that our nurses do and the impact they have on people’s lives.”

The 24/7 Nurse Call Line focuses on the health and well-being of Excellus BlueCross BlueShield members, providing support and education through specially trained registered nurses, who offer compassion, empathy, and kindness while ensuring members are directed to the most appropriate care setting.

Access to Medical Advice 24/7

Marleen says care managers, like herself, continue to work with the member after the initial call by following his or her recovery through education to help avoid any reoccurrences, and by bringing in expert advice on questions around medications, diet, and physical activity.

“The ultimate goal is to help the member have a good understanding of their current health conditions and know how to prevent this from happening again,” Marleen said.

The efforts 24/7 nurses make in creating a healthier, more secure community is supported each day through easy access for members to seek advice whenever they need it, day or night.  Thank you to the nurses and other medical professionals who are making a difference in our lives.

The 24/7 Nurse Call Line is a service provided to Excellus BlueCross BlueShield members to support their relationship with their health care providers. The information provided is intended to help educate members, not to replace the advice of a medical professional. If you are experiencing severe symptoms such as sharp pains, fever, loss of bodily function control, vomiting or any other immediate medical concern, dial 9-1-1 or contact a physician directly.

Many of us start the year by setting New Year’s resolutions or making plans for what we want to accomplish over the coming months. Maybe you signed up for your first 5K road race or had just enrolled in a professional development course. Perhaps you were planning a once-in-a-lifetime vacation or had resolved to finally pay off debt. If you’re feeling upset about not seeing your plans come together, you’re certainly not alone. During this time, it’s important to acknowledge your feelings so that you can start building toward what to do next.

Remember Your “Why”

Think about why you wanted to accomplish your goals in the first place. Maybe, the bigger goal of running that 5K was to improve your health. Perhaps the ultimate reason behind your vacation was the desire to spend quality time with your family. Start revisiting your goals by remembering why you set them in the first place. Remembering your “why” can help keep you grounded in your motivation for doing things and springboard new ideas for how you can still achieve what you ultimately want, even if it is in a new way.

Shift Your Focus to “How”

Once you’ve reflected on your bigger goals, think about ways you can shift your plan to still get what you want. If your professional development course is off the table, consider books or podcasts on similar topics to help you grow professionally. Enjoy the process of working towards fitness goals by being mindful of how the activity makes you feel. For example, maybe you’ve realized that going for a run gives you more energy throughout the day and lowers your stress. If your goal was a house project or renovation, consider doing a smaller project like organizing drawers, cleaning out the attic or planting flowers.

Recommit Where You Can

If the chaos of these uncertain times has made it hard for you to remain motivated, consider small adjustments you could make to recommit where you can. Perhaps you vowed to avoid screens after dinner but are finding yourself catching up from work in the evenings. Instead, consider taking a real break for lunch to spend time outside, away from the screens. If you struggle with getting consistent exercise without that 5K race, consider picking a date on the calendar to run your own race – you can even enlist family or neighbors to cheer from the sidelines.

Make Short-Term, Realistic Plans For Now

After some reflection, you may find that you would benefit from some new goals altogether. When setting new goals, focus on short-term plans that are within your control. Plan to cook a special meal or get take-out from a favorite restaurant. Enjoy a themed movie night with your significant other (my suggestion, enjoy a double feature I call “Swayze Saturday” and watch both Dirty Dancing and Ghost). Find an obscure holiday to celebrate with your kids. For exercise, take advantage of working from home with a daily lunchtime walk. You’ll likely find many small ways you can set short-term, achievable goals that tie back to your “why.”

How You Want to Feel vs. Things You Want to Do

At the end of the day, remember the bigger picture. Think about how you ultimately want to feel or what impact you want to have on others. You may find that you’re well on your way to achieving your goals after all.

The same day she received her nursing degree from SUNY Brockport, Kathy Gorall RN, BSN, was commissioned as a 2^nd Lieutenant in the US Air Force, choosing the Air Force because it allowed her to experience all different areas of hospital nursing care.

Kathy Gorall (photo courtesy of Kathy Gorall)

After leaving the military, she put her Air Force experience to work in a hospital emergency room and cardiac catherization lab before joining the nursing team at Excellus BlueCross BlueShield. Kathy currently works as a medical specialty drug coordinator.

However, there was one Air Force experience she never expected to follow into her civilian career: preparing a mobile hospital.

On the Front Lines

In early March, Monroe County saw its first cases of the novel coronavirus, COVID-19, and local hospitals began implementing drive-thru test sites amid the outbreak.

“I work as a per diem nurse at an urgent care center to keep my patient skills sharp,” Kathy said. The urgent care center is located on the grounds of a local hospital, and when the hospital decided to put up test and triage tents outside of the urgent care, she volunteered to help, taking on additional shifts.

“It felt like I was back in the Air Force. They created a mobile hospital in a day. It’s what I would have needed to do in a war situation,” she said. “Training prepares you to be able to quickly assess who needed to be tested and who didn’t.”

She said working in the fast-paced setting, performing exams in a car, in a tent, outfitted in face shields and protective gear, standing all day in the cold, was challenging but worthwhile.  “We’re here to support the community. Patients don’t know what to expect and they need someone to say, ‘It’s ok, you’re going to be ok. Go home and take care.’ They need reassurance.”

Kathy on the front lines (photo courtesy of Kathy Gorall)

Did she have any fears about the risk of working with a contagious disease? “I had a little fear in the beginning, but once I got there, I felt protected. We wear protective gear, we’re cautious, constantly changing gloves, washing our hands. I feel good. It’s the right thing to do to be out there and seeing patients.”

We are All In this Together

Back at her day job with Excellus BlueCross BlueShield, Kathy supports members and providers from her home office. As a nurse coordinator for the medical specialty drug unit, Kathy works with doctors’ offices on drug reviews for patients with complex diseases. During this unprecedented time, Kathy and her team are working to make the drug review process as flexible and convenient as possible.

“For example,” said Kathy, “during this time of social distancing, our team offers guidance and assistance to providers who have patients who would benefit from receiving their medication infusion at home instead of in their doctors’ offices or hospitals.”

“I’ve also found that offices need to talk about the craziness of life. And, of course, I listen. It’s a scary time for everyone. I just try to be supportive and understand. We are all in this together.”

Service Before Self

Kathy believes her training and experience with the military and as a nurse are benefits during this time. “I am very thankful for that knowledge and mostly that I am able to help out where needed. This is a time where we all need to pull together for our world, and we’re gonna get through this,” she said. “That’s why we’re here, why we do this – to help people. I am proud to be part of that process.”

Kathy’s dedication to others demonstrates her commitment to another of her military experiences: the Air Force core value of “Service before Self.”

How have you or others helped the community as we adjust to our new normal? Share your stories in the comments below.