The Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) form is a critical document designed to ensure that patients' preferences regarding life-sustaining medical treatments are understood and respected. The form is to be completed through conversations between a patient (or the patient’s representative) and the signing clinician, covering crucial decisions such as resuscitation, ventilation, and hospital transfer. To make an informed choice and ensure that wishes are accurately represented in medical situations, individuals are encouraged to fill out the Massachusetts MOLST form by clicking the button below.
When navigating the delicate and often complex terrain of end-of-life care decisions in Massachusetts, the Medical Orders for Life-Sustaining Treatment (MOLST) form emerges as a crucial document designed to ensure that patients' healthcare preferences are understood, respected, and followed. Created to bridge the gap between patients, healthcare agents, and healthcare providers, the MOLST form is a beacon of patient autonomy, enabling individuals to articulate their desires regarding CPR, ventilation, hospital transfer, and other life-sustaining treatments in situations of severe health crises. By establishing a clearly communicated directive that is both signed by the patient or a legally authorized representative and a licensed clinician, the MOLST seeks to honor the patient’s goals and values regarding end-of-life care. Furthermore, it's designed to be readily recognizable and actionable across different healthcare settings, from emergency services through to ongoing care environments, provided it's printed on the distinctive Astrobrights® Pulsar Pink paper for maximum visibility. This document stands as a testament to the Massachusetts Department of Public Health's commitment to patient-centered care, ensuring that even in the most critical moments, a patient's healthcare preferences are front and center.
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
Completing the Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) form is an important step in ensuring that an individual's healthcare preferences are understood and respected, especially in situations where they may not be able to communicate these preferences themselves. This standardized medical order form must be completed following a detailed conversation about care decisions between the patient (or the patient’s representative) and the healthcare provider. To fill out the MOLST form accurately, it’s crucial to follow these steps carefully.
It's important for healthcare professionals to review the patient's goals for care and treatment preferences regularly, especially when there is a shift in the patient's condition or care setting. The form is designed to respect the patient’s healthcare decisions and to ensure those decisions are known and honored across different healthcare settings.
What is a Massachusetts MOLST form?
The Massachusetts MOLST (Medical Orders for Life-Sustaining Treatment) form is a legal document that outlines a patient's preferences regarding treatments that are life-sustaining. This includes instructions on resuscitation, intubation, ventilation, and other forms of medical intervention. The form is designed to ensure that healthcare professionals understand and respect the patient's wishes concerning end-of-life care.
Who can fill out a Massachusetts MOLST form?
The MOLST form should be filled out during a detailed conversation between the patient and a licensed healthcare provider, such as a physician, nurse practitioner, or physician assistant. The patient can also have a health care agent, guardian, or, in the case of minors, a parent or guardian fill out the form on their behalf, provided they have legal authority to do so.
Is the MOLST form legally binding?
Yes, the MOLST form is a legally binding document in Massachusetts once it is properly filled out and signed. It gives clear medical orders that healthcare providers are expected to follow regarding the patient's treatment preferences at the end of life.
Does the MOLST form replace a living will or health care proxy?
No, the MOLST form does not replace a living will or health care proxy. While both documents allow individuals to specify their preferences for end-of-life care, the MOLST form is a medical order meant for individuals with serious health conditions. It complements a living will or health care proxy by providing specific instructions for immediate use by medical professionals.
How can a MOLST form be changed or revoked?
A MOLST form can be changed or revoked at any time by the patient or their healthcare agent, provided the patient is unable to do so themselves. To make changes, the current form must be voided, and a new form must be filled out, signed, and dated. Revocation can be done verbally or in writing, but communicating this to healthcare providers and ensuring it is documented is crucial.
What happens if a section of the MOLST form is left blank?
If any section of the MOLST form is left blank, it is assumed that there are no limitations on the treatment for that section. Healthcare providers may provide full treatment for any item not explicitly addressed in the form.
Are photocopies of the MOLST form valid?
Yes, photocopies, faxed copies, and electronic copies of a properly signed and completed MOLST form are valid. However, for ease of recognition, it is recommended to use the form printed on bright or fluorescent pink paper.
What should be done with the completed MOLST form?
The completed MOLST form should be kept with the patient at all times and provided to healthcare providers whenever the patient seeks or receives treatment. This ensures that the patient's wishes are respected across different care settings.
When it comes to the Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) form, it's vital to complete it correctly to ensure that an individual's health care preferences are followed accurately. However, mistakes can happen. Here's a look at 10 common errors people make when filling out the Massachusetts MOLST form:
Not having a comprehensive discussion with the patient or their representative about the patient's wishes and goals for care before signing the form. This conversation is crucial to make informed decisions.
Failing to complete all required sections of the form. Sections A-C and sections F-H must be filled out completely for the form to be valid.
Leaving the signature fields blank. The form requires signatures from the patient or their representative and the physician, nurse practitioner, or physician assistant to be valid.
Using a photocopy or fax of the form that is not clear. While copies are valid, they must be legible to ensure the medical orders are understood correctly by health care providers.
Omitting the date and time when signatures were provided. This information is essential to determine the form's validity.
Not marking one of the choices in sections that require making a decision, such as CPR (Cardiopulmonary Resuscitation) or ventilation options. A choice must be marked to indicate the patient's preferences.
Forgetting to include the patient’s contact information and the signature of the person completing the form. Contact information is critical in case clarification is needed.
Not consulting legal counsel when a guardian is involved in signing the form, to ensure compliance with Massachusetts law regarding a guardian’s authority.
Changing or altering the form in unauthorized ways, which could compromise its validity. The MOLST form should be used as designed and any changes to patient preferences should lead to the completion of a new form.
Not providing the form to all health care providers and institutions involved in the patient's care. The form should accompany the patient at all times to ensure their wishes are respected across different care settings.
Avoiding these errors can help ensure that the MOLST form accurately reflects and respects the patient's health care preferences, guiding providers in delivering care aligned with the patient's wishes.
When managing the care of individuals with serious health conditions, particularly those nearing the end of life, Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) form plays a pivotal role. However, the MOLST form is often part of a larger group of legal and healthcare documents designed to ensure that a person's medical and personal wishes are respected and followed. Below is a list of other forms and documents commonly used alongside the MOLST form, each serving its unique purpose in comprehensive care planning.
The use of the Massachusetts MOLST form along with these associated documents ensures a more holistic approach to patient care, respecting the individual's health care preferences across different settings. They serve as critical tools in the planning and provision of care, particularly for those with serious, advanced illnesses. It is essential for both healthcare professionals and patients to understand the role of each document in ensuring that the patient's wishes are known, respected, and legally protected.
The Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) form is similar to other documents that address end-of-life decisions and patient preferences regarding medical treatments. These documents play a crucial role in ensuring that an individual's healthcare preferences are known and respected by healthcare professionals.
Advance Directive: An Advance Directive, often encompassing a Living Will and a Durable Power of Attorney for Healthcare, is the first document that shares similarities with the Massachusetts MOLST. Like the MOLST, an Advance Directive allows individuals to outline their preferences for medical treatments and interventions at the end of life. Both documents ensure that these critical decisions are discussed and made before they are needed. However, the primary difference lies in their legal and practical application. While the MOLST is a medical order effective immediately upon signing and recognized by healthcare professionals, an Advance Directive serves more as a guide for healthcare providers and may not always have immediate effect in emergency situations.
Do Not Resuscitate (DNR) Order: The MOLST form also resembles a Do Not Resuscitate (DNR) order in certain aspects. Both documents allow patients to declare their wish to forgo resuscitative measures in the event of cardiac or respiratory arrest. The specific section in the MOLST form dealing with cardiopulmonary resuscitation mirrors the purpose of a DNR order. While DNR orders are generally focused solely on the absence of resuscitation efforts, the MOLST provides a more comprehensive overview of a patient's wishes, including preferences on intubation, ventilation, hospital transfer, and other life-sustaining treatments.
POLST Form (Physician Orders for Life Sustaining Treatment): The Massachusetts MOLST form is most closely aligned with POLST forms used in other states. Both are designed to translate a patient's end-of-life preferences into medical orders that are immediately actionable. They address a range of life-sustaining treatments beyond resuscitation, such as ventilation and artificial nutrition. While the name and specifics of the document may vary from state to state, the core purpose remains the same: to ensure that patients receive medical treatment that aligns with their values and desires at the end of life. The POLST form, like the MOLST, is meant for patients with serious health conditions or those at a significant risk of death in the near term, ensuring that their treatment preferences are clear and can be acted upon by healthcare providers.
When completing the Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) form, it's important to follow guidelines carefully to ensure that the patient's wishes are accurately documented and respected. Here are some essential do's and don'ts to consider:
Understanding the Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) form is crucial for patients and their families to make informed healthcare decisions. However, several misconceptions can lead to confusion and distress. Here are six common misunderstandings about the Massachusetts MOLST form:
In summary, the Massachusetts MOLST form is an essential document for individuals facing advanced illness, as it communicates their treatment preferences. Dispelling these misconceptions can lead to better health outcomes and peace of mind for patients and their families.
The Massachusetts MOLST (Medical Orders for Life-Sustaining Treatment) form is a crucial tool for ensuring that a patient's preferences for life-sustaining treatments are known and respected. Here are key takeaways about filling out and using this form:
It's important for patients, healthcare agents, and family members to have open discussions about the patient's values and treatment preferences in the event of severe illness. Knowing how to properly complete and maintain the Massachusetts MOLST form is an important step in advocating for patient-centered care at the end of life.
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