The Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) form is a crucial document that outlines a patient's preferences for medical treatment in emergency situations. It is designed to ensure that healthcare providers understand and respect a patient's wishes regarding life-sustaining measures. Completing this form can provide peace of mind for both patients and their families, ensuring that care aligns with individual values and goals.
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The Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) form is a critical tool designed to communicate patients' treatment preferences in emergency situations. This standardized medical order form is intended for use by licensed healthcare providers, including physicians, nurse practitioners, and physician assistants. The MOLST form facilitates discussions between patients or their representatives and clinicians about end-of-life care, ensuring that the patient's wishes are clearly documented and respected. Key sections of the form address critical decisions, such as whether to attempt resuscitation, the use of ventilation, and transfer to a hospital. Additionally, it includes preferences for other medically indicated treatments, such as dialysis and artificial nutrition. The form becomes effective immediately upon signature and can be honored by emergency medical personnel statewide. Proper completion of the MOLST form is essential; it requires signatures from both the patient or their representative and the clinician to validate the orders outlined. This comprehensive approach aims to provide clarity and comfort to patients and their families during challenging times.
MASSACHUSETTS MEDICAL ORDERS for LIFE-SUSTAINING TREATMENT
(MOLST) www.molst-ma.org
Patient’s Name _________________________________
Date of Birth ___________________________________
Medical Record Number if applicable: ______________
INSTRUCTIONS: Every patient should receive full attention to comfort.
→This form should be signed based on goals of care discussions between the patient (or patient’s representative signing below) and the signing clinician.
→Sections A–C are valid orders only if Sections D and E are complete. Section F is valid only if Sections G and H are complete.
→If any section is not completed, there is no limitation on the treatment indicated in that section.
→The form is effective immediately upon signature. Photocopy, fax or electronic copies of properly signed MOLST forms are valid.
ACARDIOPULMONARY RESUSCITATION: for a patient in cardiac or respiratory arrest
Mark one circle
o Do Not Resuscitate
o Attempt Resuscitation
B
VENTILATION: for a patient in respiratory distress
o Do Not Intubate and Ventilate
o Intubate and Ventilate
o Do Not Use Non-invasive Ventilation (e.g. CPAP)
o Use Non-invasive Ventilation (e.g. CPAP)
CTRANSFER TO HOSPITAL
o Do Not Transfer to Hospital (unless needed for comfort)
o Transfer to Hospital
PATIENT
Mark one circle below to indicate who is signing Section D:
or patient’s
o Patient
o Health Care Agent
o Guardian*
o Parent/Guardian* of minor
representative
Signature of patient confirms this form was signed of patient’s own free will and reflects his/her wishes and goals of care as
signature
expressed to the Section E signer. Signature by the patient’s representative (indicated above) confirms that this form reflects
D
his/her assessment of the patient’s wishes and goals of care, or if those wishes are unknown, his/her assessment of the
Required
patient’s best interests. *A guardian can sign only to the extent permitted by MA law. Consult legal counsel with
questions about a guardian’s authority.
Mark one circle and
___________________________________________________________________
________________________________
fill in every line
Signature of Patient (or Person Representing the Patient)
Date of Signature
for valid Page 1.
_________________________________________________________
____________________________
Legible Printed Name of Signer
Telephone Number of Signer
CLINICIAN
Signature of physician, nurse practitioner or physician assistant confirms that this form accurately reflects his/her discussion(s)
with the signer in Section D.
E
Signature of Physician, Nurse Practitioner, or Physician Assistant
Date and Time of Signature
Fill in every line for
_______________________________________________________
valid Page 1.
Optional
Expiration date (if
any) and other
information
This form does not expire unless expressly stated. Expiration date (if any) of this form: ______________________
Health Care Agent Printed Name ___________________________________
Telephone Number ________________
Primary Care Provider Printed Name ________________________________
SEND THIS FORM WITH THE PATIENT AT ALL TIMES.
HIPAA permits disclosure of MOLST to health care providers as necessary for treatment.
Approved by DPH
August 10, 2013
MOLST Form Page 1 of 2
Patient’s Name: ______________________ Patient’s DOB ___________ Medical Record # if applicable__________________
FStatement of Patient Preferences for Other Medically-Indicated Treatments
INTUBATION AND VENTILATION
O Refer to Section B
on
O Use intubation and ventilation as marked
O Undecided
Page 1
in Section B, but short term only
O Did not discuss
NON-INVASIVE VENTILATION (e.g. Continuous Positive Airway Pressure - CPAP)
O Use non-invasive ventilation as marked in
Section B, but short term only
DIALYSIS
O No dialysis
O Use dialysis
O Use dialysis, but short term only
ARTIFICIAL NUTRITION
O No artificial nutrition
O Use artificial nutrition
O Use artificial nutrition, but short term only
ARTIFICIAL HYDRATION
O No artificial hydration
O Use artificial hydration
O Use artificial hydration, but short term only
Other treatment preferences specific to the patient’s medical condition and care
_______________________________________________________________________________________________
Mark one circle below to indicate who is signing Section G:
expressed to the Section H signer. Signature by the patient’s representative (indicated above) confirms that this form reflects
G
for valid Page 2.
Signature of physician, nurse practitioner or physician assistant confirms that this form accurately reflects his/her
discussion(s) with the signer in Section G.
H
valid Page 2.
Additional Instructions For Health Care Professionals
→Follow orders listed in A, B and C and honor preferences listed in F until there is an opportunity for a clinician to review as described below.
→Any change to this form requires the form to be voided and a new form to be signed. To void the form, write VOID in large letters across both sides of the form. If no new form is completed, no limitations on treatment are documented and full treatment may be provided.
→Re-discuss the patient's goals for care and treatment preferences as clinically appropriate to disease progression, at transfer to a new care setting or level of care, or if preferences change. Revise the form when needed to accurately reflect treatment preferences.
→The patient or health care agent (if the patient lacks capacity), guardian*, or parent/guardian* of a minor can revoke the MOLST form at any time and/or request and receive previously refused medically-indicated treatment. *A guardian can sign only to the extent permitted by MA law.
Consult legal counsel with questions about a guardian’s authority.
MOLST Form Page 2 of 2
IMPORTANT INFORMATION ABOUT MASSACHUSETTS MOLST
The Massachusetts MOLST form is a MA DPH‐approved standardized medical order form for use by licensed Massachusetts physicians, nurse practitioners and physician assistants.
While MOLST use expands in Massachusetts, health care providers are encouraged to inform patients that EMTs honor MOLST statewide, but that systems to honor MOLST may still be in development in some Massachusetts health care institutions.
PRINTING THE MASSACHUSETTS MOLST FORM
⎯Do not alter the MOLST form. EMTs have been trained to recognize and honor the standardized MOLST form. The best way to assure that MOLST orders are followed by emergency medical personnel is to download and reproduce the standardized form found on the MOLST web site.
⎯Print original Massachusetts MOLST forms on bright or fluorescent pink paper for maximum visibility.
Astrobrights® Pulsar Pink* is the color highly recommended for original MOLST forms. EMTs are trained to look for the bright pink MOLST form before initiating life‐sustaining treatment with patients.
⎯Print the MOLST form (pages 1 and 2) as a double‐sided form on a single sheet of paper.
⎯Provide an electronic version of the downloaded MOLST form to your institution’s forms department or to personnel responsible for copying/providing forms in your institution.
FOR CLINICIANS: BEFORE USING MOLST
MOLST requires a physician, nurse practitioner, or physician assistant signature to be valid. This signature confirms that the MOLST accurately reflects the signing clinician’s discussion(s) with the patient. The MOLST form should be filled out and signed only after in‐depth conversation between the patient and the clinician signer.
Before using MOLST:
⎯Access the Clinician Checklist for Using MOLST with Patients at: http://www.molst‐ma.org/health‐ care‐professionals/guidance‐for‐using‐molst‐forms‐with‐patients.
⎯Listen to MOLST Overview for Health Professionals at: http://www.molst‐ma.org/molst‐training‐line.
⎯Access the MOLST website at: http://www.molst‐ma.org periodically for MOLST form updates.
⎯For more information about Massachusetts MOLST or the Massachusetts MOLST form, visit http://www.molst‐ma.org.
* Astrobrights® Pulsar Pink paper can be purchased from office suppliers, including:
Staples ‐ Item #491620 Wausau™ Astrobrights® Colored Paper, 8 1/2" x 11", 24 Lb, Pulsar Pink, in stores or at http://www.staples.com, and
Office Depot – Item #420919 Astrobrights® Bright Color Paper, 8 1/2 x 11, 24 Lb, FSC Certified Pulsar Pink, in stores or at http://www.officedepot.com.
MOLST Instructions Page 1 of 1
Filling out the Massachusetts MOLST form is an important step in ensuring that your medical treatment preferences are clearly communicated to healthcare providers. This form should reflect your wishes or those of your representative after thorough discussions with your clinician. It’s essential to complete the form accurately to avoid any misunderstandings regarding your care.
Once the form is completed and signed, it should be kept with the patient at all times. This ensures that healthcare providers can access it when needed. Remember, the MOLST form is effective immediately upon signature, and copies are valid.
The Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) form is a standardized medical order form designed for patients with serious illnesses. It is intended to ensure that patients' treatment preferences are clearly documented and respected by healthcare providers. The form outlines specific medical orders regarding life-sustaining treatments, including resuscitation, ventilation, and hospitalization. It serves as a critical tool for communication between patients, their families, and healthcare professionals.
The MOLST form can be signed by the patient themselves or by a representative if the patient is unable to do so. The representatives authorized to sign include a health care agent, a guardian, or a parent/guardian of a minor. It is essential that the individual signing the form does so with the understanding that it reflects the patient’s wishes regarding their care. If a guardian is signing, they must do so within the limits of Massachusetts law, and it may be prudent to consult legal counsel for clarity on their authority.
Emergency Medical Technicians (EMTs) are trained to recognize and honor the MOLST form in Massachusetts. The form must be printed on bright pink paper to ensure visibility. In emergency situations, the orders outlined in the MOLST form are followed to respect the patient's preferences regarding life-sustaining treatments. It is crucial that patients carry this form with them at all times to ensure their wishes are honored, especially in urgent care scenarios.
If any section of the MOLST form is left incomplete, there are no limitations on the treatment indicated in that section. This means that healthcare providers may provide full treatment, as the absence of a directive implies consent to proceed with standard care. Therefore, it is vital to ensure that all relevant sections are completed during discussions about the patient's goals of care.
Yes, the MOLST form can be revoked or changed at any time by the patient or their authorized representative. If a patient’s health status changes or if they wish to alter their treatment preferences, they can do so by revoking the existing MOLST form and completing a new one. To void the form, simply write "VOID" in large letters across both sides of the document. This ensures that healthcare providers are aware that the previous orders are no longer valid.
The MOLST form can be downloaded from the official Massachusetts MOLST website. It is important to use the standardized version to ensure that it is recognized by healthcare providers. The form should be printed on bright pink paper, as this color is specifically recommended for maximum visibility. Additionally, healthcare institutions may have their own processes for providing MOLST forms, so it may be beneficial to check with your healthcare provider for availability.
Not Completing All Required Sections: Each section of the MOLST form has specific requirements. If Sections D and E are not completed, the orders in Sections A–C are not valid. Ensure all relevant sections are filled out to avoid confusion about treatment preferences.
Failing to Sign the Form: The MOLST form must be signed by the patient or their representative. Without a signature, the form holds no legal weight. Always check that the signature is present before considering the form valid.
Using an Incorrect Version of the Form: It is crucial to use the most current version of the MOLST form. Outdated forms may not be honored by healthcare providers. Always download the latest version from the official MOLST website.
Not Discussing Goals of Care: The MOLST form should reflect a thorough discussion between the patient and the clinician. If these conversations do not occur, the form may not accurately represent the patient’s wishes.
Inadequate Clarity in Treatment Preferences: When marking options on the form, be clear and specific. Ambiguous choices can lead to misunderstandings about what treatments the patient does or does not want.
Ignoring the Need for Updates: Patient preferences may change over time. It is important to revisit and update the MOLST form as needed, especially if there are changes in the patient's health status or treatment goals.
The Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) form plays a crucial role in ensuring that patients' preferences regarding medical treatment are honored, especially in critical situations. However, it is often accompanied by other important documents that further clarify a patient’s wishes and legal rights. Understanding these documents can help patients, families, and healthcare providers navigate complex medical decisions more effectively.
By utilizing these documents alongside the MOLST form, patients can create a comprehensive plan that reflects their healthcare preferences. This proactive approach not only provides peace of mind but also fosters better communication among patients, families, and healthcare providers. Understanding and utilizing these forms can significantly impact the quality of care received during critical moments.
The Massachusetts MOLST form shares similarities with the Advance Directive, which allows individuals to outline their preferences for medical treatment in the event they become unable to communicate. Both documents serve as a way for patients to express their wishes regarding end-of-life care. While the MOLST form is a medical order that healthcare providers must follow, an Advance Directive is a legal document that can guide decisions but may require further interpretation by healthcare professionals.
The Do Not Resuscitate (DNR) order is another document that parallels the MOLST form. A DNR order specifically instructs medical personnel not to perform CPR if a patient stops breathing or their heart stops. Like the MOLST form, it is intended to respect the patient’s wishes regarding life-sustaining treatment. However, the DNR is typically more limited in scope, focusing solely on resuscitation efforts.
The Living Will is also similar to the MOLST form in that it allows individuals to specify their treatment preferences regarding life-sustaining measures. This document can cover a range of medical scenarios, including the use of mechanical ventilation or feeding tubes. While the MOLST form is more comprehensive and requires a clinician's signature, the Living Will may not have the same immediate legal weight in emergency situations.
The Physician Orders for Life-Sustaining Treatment (POLST) is a document used in several states, including Massachusetts, and is closely related to the MOLST form. POLST is designed for patients with serious illnesses and includes specific medical orders about treatment preferences. Both forms aim to ensure that patients' wishes are honored, but POLST may vary in format and requirements depending on the state.
The Health Care Proxy is another document that complements the MOLST form. It designates an individual to make healthcare decisions on behalf of the patient if they are unable to do so themselves. While the MOLST form outlines specific medical orders, the Health Care Proxy provides a broader authority for decision-making, allowing the appointed person to interpret the patient’s wishes in various situations.
The Durable Power of Attorney for Health Care is similar to the Health Care Proxy in that it grants another person the authority to make healthcare decisions. This document can include a wide range of medical decisions, not just end-of-life care. While both documents are important for ensuring that a patient’s wishes are respected, the MOLST form provides specific medical orders that must be followed by healthcare providers.
The Medical Power of Attorney also resembles the MOLST form by allowing individuals to appoint someone to make medical decisions on their behalf. This document can cover a variety of healthcare scenarios, while the MOLST form focuses specifically on life-sustaining treatments. Both documents aim to ensure that patients’ preferences are honored, but they serve different functions within the healthcare system.
The Treatment Preferences form is another related document. It allows patients to express their preferences regarding various medical treatments, similar to the MOLST form. However, the Treatment Preferences form may not carry the same legal authority as the MOLST form, which is a physician’s order. The MOLST form is actionable by healthcare providers, while Treatment Preferences may serve more as guidance.
The Patient Care Directive is also comparable to the MOLST form. It allows patients to outline their care preferences and treatment goals. Like the MOLST, it aims to communicate the patient’s wishes to healthcare providers. However, the Patient Care Directive may not have the same immediate effect in emergency situations as the MOLST form, which is specifically designed for use by medical personnel.
Lastly, the End-of-Life Care Plan is similar to the MOLST form in that it outlines a patient’s preferences for care as they approach the end of life. This document can include various treatment options and goals for care. While both documents are intended to ensure that patients’ wishes are respected, the MOLST form serves as a direct medical order, while the End-of-Life Care Plan may provide broader guidance for family and healthcare providers.
When filling out the Massachusetts MOLST form, there are important do's and don'ts to keep in mind to ensure that the process goes smoothly and accurately reflects the patient's wishes.
This is incorrect. The Massachusetts MOLST form is designed for any patient who wishes to express their preferences regarding life-sustaining treatment, regardless of their current health status. It can be used by individuals with chronic illnesses, those undergoing treatment, or even healthy individuals who want to plan for future medical care.
While it is true that certain sections of the MOLST form must be completed for specific orders to be valid, not every section needs to be filled out for the form to be effective. If a section is left incomplete, it does not automatically nullify the entire form; rather, it means there are no limitations on treatment for that particular section.
This misconception is misleading. Patients or their representatives have the right to revoke the MOLST form at any time. Additionally, if a patient's preferences change, the form can be updated to reflect new treatment goals. It is important for patients to communicate any changes in their wishes to their healthcare providers.
In fact, MOLST forms are recognized statewide by emergency medical technicians (EMTs) and other healthcare providers. This means that the form is intended to be honored in various settings, including at home, in nursing facilities, and during transfers between care settings. However, it is advisable for patients to ensure that their MOLST form is readily accessible and visible, such as by printing it on bright pink paper.
The Massachusetts MOLST form is a standardized medical order form that must be signed by a licensed clinician, such as a physician, nurse practitioner, or physician assistant. This signature confirms that the form accurately reflects the patient's wishes as discussed during a conversation.
Sections A–C of the MOLST form are only valid if Sections D and E are completed. Similarly, Section F is valid only if Sections G and H are filled out. Incomplete sections mean there are no limitations on treatment for those areas.
The form is effective immediately upon signature. It can be photocopied, faxed, or transmitted electronically, and all copies remain valid as long as they are properly signed.
To ensure visibility, print the MOLST form on bright or fluorescent pink paper. This helps emergency medical personnel recognize and honor the orders specified in the form.