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The Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) form plays a crucial role in ensuring that patients receive care aligned with their personal wishes during critical medical situations. This standardized medical order form is intended for use by licensed healthcare providers, including physicians, nurse practitioners, and physician assistants. It facilitates meaningful conversations about end-of-life care and treatment preferences, allowing patients or their designated representatives to articulate their goals clearly. The form consists of several sections that address specific medical interventions, such as resuscitation efforts, ventilation options, and transfer to a hospital. Importantly, the MOLST form becomes effective immediately upon signature and must be completed thoughtfully, as incomplete sections may lead to unintended treatment decisions. It is essential for healthcare providers to engage in thorough discussions with patients to ensure that the signed orders genuinely reflect their wishes. Additionally, the MOLST form must be printed on bright pink paper for visibility and is valid in both physical and electronic formats, underscoring its importance in emergency medical situations.

Massachusetts Molst Example

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

 

 

Mark one circle

o Do Not Intubate and Ventilate

o Intubate and Ventilate

 

 

 

Mark one circle

o Do Not Use Non-invasive Ventilation (e.g. CPAP)

o Use Non-invasive Ventilation (e.g. CPAP)

 

 

 

 

 

 

 

CTRANSFER TO HOSPITAL

Mark one circle

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)

signature

with the signer in Section D.

 

 

 

E

___________________________________________________________________

________________________________

Required

Signature of Physician, Nurse Practitioner, or Physician Assistant

 

Date and Time of Signature

 

 

 

 

 

Fill in every line for

_______________________________________________________

____________________________

valid Page 1.

Legible Printed Name of Signer

 

 

Telephone Number of Signer

 

 

 

 

 

 

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 ________________________________

Telephone Number ________________

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

Mark one circle

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)

 

Mark one circle

O Refer to Section B

on

 

O Use non-invasive ventilation as marked in

 

O Undecided

 

 

 

 

 

Page 1

 

 

Section B, but short term only

 

 

O Did not discuss

 

 

DIALYSIS

 

 

 

 

 

 

 

 

Mark one circle

O No dialysis

 

 

O Use dialysis

 

 

 

O Undecided

 

 

 

 

O Use dialysis, but short term only

 

 

O Did not discuss

 

 

 

 

 

 

 

 

 

ARTIFICIAL NUTRITION

 

 

 

 

 

 

 

Mark one circle

O No artificial nutrition

 

O Use artificial nutrition

 

 

O Undecided

 

 

 

 

 

 

 

 

 

O Use artificial nutrition, but short term only

 

O Did not discuss

 

 

ARTIFICIAL HYDRATION

 

 

 

 

 

 

 

Mark one circle

O No artificial hydration

 

O Use artificial hydration

 

 

O Undecided

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

O Use artificial hydration, but short term only

 

O Did not discuss

 

 

Other treatment preferences specific to the patient’s medical condition and care

________________________________

 

 

_______________________________________________________________________________________________

 

 

_______________________________________________________________________________________________

 

 

 

 

 

 

 

PATIENT

Mark one circle below to indicate who is signing Section G:

 

 

 

 

or patient’s

o Patient

o Health Care Agent

o Guardian*

o Parent/Guardian* of minor

 

representative

 

 

 

 

 

 

 

 

 

 

signature

Signature of patient confirms this form was signed of patient’s own free will and reflects his/her wishes and goals of care as

 

 

expressed to the Section H signer. Signature by the patient’s representative (indicated above) confirms that this form reflects

 

G

his/her assessment of the patient’s wishes and goals of care, or if those wishes are unknown, his/her assessment of the

 

patient’s best interests. *A guardian can sign only to the extent permitted by MA law. Consult legal counsel with

 

Required

 

questions about a guardian’s authority.

 

 

 

 

 

 

 

 

 

 

 

Mark one circle and

_______________________________________________________

____________________________

 

Signature of Patient (or Person Representing the Patient)

 

 

Date of Signature

 

fill in every line

 

 

 

 

 

 

 

 

 

 

 

 

for valid Page 2.

_______________________________________________________

____________________________

 

 

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

 

signature

discussion(s) with the signer in Section G.

 

 

 

 

 

H

_______________________________________________________

____________________________

 

Signature of Physician, Nurse Practitioner, or Physician Assistant

 

 

Date and Time of Signature

 

 

 

 

 

Required

_______________________________________________________

____________________________

 

Fill in every line for

 

Legible Printed Name of Signer

 

 

 

 

 

Telephone Number of Signer

 

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.

Approved by DPH

August 10, 2013

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.

August 10, 2013

MOLST Instructions Page 1 of 1
Click for Massachusetts Molst File

File Breakdown

Fact Name Description
Purpose The Massachusetts MOLST form is designed to communicate a patient's preferences for life-sustaining treatment.
Governing Law This form is governed by Massachusetts General Laws, Chapter 111, Section 70B.
Signature Requirement A valid MOLST form requires signatures from both the patient (or their representative) and a licensed clinician.
Effective Immediately The MOLST form becomes effective immediately upon being signed by the appropriate parties.
Copy Validity Photocopies, faxes, or electronic copies of a signed MOLST form are considered valid and should be honored by healthcare providers.

Guide to Using Massachusetts Molst

Completing the Massachusetts MOLST form is a crucial step in ensuring that a patient’s wishes regarding medical treatment are clearly documented and respected. This process involves gathering essential information about the patient and their treatment preferences. Below are the steps to fill out the form accurately.

  1. Start by writing the patient's name in the designated space.
  2. Enter the date of birth of the patient.
  3. If applicable, include the medical record number of the patient.
  4. In Section A, mark one circle to indicate the patient's preference for cardiopulmonary resuscitation (Do Not Resuscitate or Attempt Resuscitation).
  5. In Section B, mark one circle to indicate the preference for ventilation (Do Not Intubate and Ventilate or Intubate and Ventilate) and also indicate if non-invasive ventilation should be used.
  6. In Section C, mark one circle to indicate the preference regarding transfer to hospital (Do Not Transfer to Hospital or Transfer to Hospital).
  7. In Section D, indicate who is signing by marking one circle for the patient, health care agent, guardian, or parent/guardian of a minor.
  8. Have the patient or representative sign the form and write the date of signature.
  9. Print the legible name of the signer and provide their telephone number.
  10. In Section E, the clinician must sign to confirm that the form reflects their discussions with the signer. They should also include the date and time of their signature.
  11. In Section F, indicate the patient's preferences for other medically indicated treatments by marking the appropriate circles for intubation, non-invasive ventilation, dialysis, artificial nutrition, and artificial hydration.
  12. Repeat the steps in Section G for the patient or representative's signature, and ensure the clinician signs in Section H to confirm their discussions.
  13. Finally, ensure that the form is printed on bright or fluorescent pink paper for maximum visibility.

Once the form is completed, it is essential to keep it with the patient at all times. This ensures that healthcare providers can access and honor the patient's wishes regarding life-sustaining treatment as needed.

Get Answers on Massachusetts Molst

  1. What is the Massachusetts MOLST form?

    The Massachusetts MOLST (Medical Orders for Life-Sustaining Treatment) form is a standardized medical order that allows patients to communicate their preferences regarding life-sustaining treatments. It is designed to ensure that healthcare providers honor the wishes of patients, particularly in emergency situations.

  2. Who can sign the MOLST form?

    The MOLST form can be signed by the patient themselves or by a representative if the patient is unable to do so. This representative can be a healthcare agent, a guardian, or a parent/guardian of a minor. It is essential that the signer understands the patient’s wishes and goals of care.

  3. What happens if a section of the MOLST form is not completed?

    If any section of the MOLST form is left incomplete, there will be no limitations on the treatment indicated in that section. This means that healthcare providers may proceed with full treatment unless otherwise specified in the completed sections.

  4. How should the MOLST form be printed?

    To ensure maximum visibility, the MOLST form should be printed on bright or fluorescent pink paper. It is recommended to use Astrobrights® Pulsar Pink paper. The form should be printed double-sided on a single sheet of paper to maintain its integrity and ensure it is easily recognized by emergency medical personnel.

  5. When does the MOLST form take effect?

    The MOLST form becomes effective immediately upon signature. This means that once it is signed by the patient or their representative and the clinician, it should be honored by healthcare providers right away.

  6. Can the MOLST form be revoked or changed?

    Yes, the MOLST form can be revoked or changed at any time by the patient or their representative. If the patient's preferences change, it is important to revise the form to accurately reflect their current wishes. Any changes to the form require a new MOLST form to be completed.

  7. Where can I find more information about the MOLST form?

    For additional information about the Massachusetts MOLST form, you can visit the official MOLST website at www.molst-ma.org . This site provides resources for both patients and healthcare professionals, including guidance on using the MOLST form effectively.

Common mistakes

When completing the Massachusetts MOLST form, there are several common mistakes that individuals often make. These errors can lead to confusion about a patient’s wishes regarding life-sustaining treatment. Understanding these pitfalls can help ensure that the form accurately reflects the patient’s preferences.

One frequent mistake is failing to complete all required sections of the form. Sections A through C are only valid if Sections D and E are filled out. If any section is left incomplete, it may lead to unintended treatment decisions. For instance, if the resuscitation section is not marked, it could imply that the patient wishes to receive full resuscitation efforts, which may not align with their actual wishes.

Another common issue is not ensuring that the signatures are provided by the appropriate individuals. The form requires the signature of the patient or their representative, such as a health care agent or guardian. If the wrong person signs the document, it may not hold legal weight. Additionally, a guardian can only sign within the limits set by Massachusetts law, which can lead to complications if not understood properly.

People sometimes overlook the importance of discussing treatment preferences in detail with the clinician. The MOLST form should reflect a thorough conversation about the patient’s wishes and goals of care. If this discussion is not comprehensive, the signed form may not accurately represent the patient’s desires, leading to potential conflicts in treatment.

Another mistake involves using outdated or altered versions of the MOLST form. The form must be the most current version approved by the Massachusetts Department of Public Health. Alterations can cause confusion for emergency medical personnel, who are trained to recognize the standardized form. Using the correct, unaltered form ensures that the patient’s preferences are honored.

Additionally, individuals may forget to print the MOLST form on the recommended bright pink paper. This specific color is essential for visibility and recognition by emergency medical technicians (EMTs). If the form is printed on regular paper, there is a risk that it may not be easily identified in urgent situations.

Finally, not providing copies of the completed MOLST form to all relevant parties is a common oversight. It is crucial that copies are given to the patient, their health care providers, and any family members involved in decision-making. This ensures that everyone is aware of the patient’s wishes and can act accordingly in case of an emergency.

Documents used along the form

The Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) form is an essential document that ensures patients' treatment preferences are respected during medical emergencies. In addition to the MOLST form, there are several other important documents and forms that can help clarify a patient’s wishes regarding medical care. Understanding these documents can provide peace of mind for both patients and their families.

  • Health Care Proxy: This document allows a person to designate another individual to make medical decisions on their behalf if they become unable to do so. It is crucial for ensuring that a patient's preferences are honored even when they cannot communicate them directly.
  • Advance Directive: An advance directive is a legal document that outlines a person’s wishes regarding medical treatment in situations where they are unable to express their preferences. This can include instructions about life-sustaining treatments and other healthcare choices.
  • Do Not Resuscitate (DNR) Order: A DNR order is a specific request not to receive cardiopulmonary resuscitation (CPR) if the heart stops beating. This document must be signed by a physician and is often used in conjunction with the MOLST form to ensure clarity in a patient's wishes.
  • Living Will: A living will is a type of advance directive that provides guidance on the types of medical treatments a person would or would not want in the event of a terminal illness or irreversible condition. It can help family members and healthcare providers understand the patient's wishes.
  • Patient Identification Bracelet: This is a physical bracelet worn by patients that contains critical information about their medical history and preferences. It can alert healthcare providers to a patient's MOLST orders or other important directives in emergency situations.
  • Medication List: A current list of medications can be vital in emergencies. This document helps healthcare providers understand what treatments the patient is currently receiving and can prevent harmful drug interactions or complications.

By familiarizing yourself with these forms, you can better navigate the complexities of medical care preferences. Each document serves a unique purpose and collectively, they help ensure that a patient's voice is heard, even in challenging circumstances. Taking the time to complete these forms can provide both patients and their families with reassurance and clarity about their healthcare decisions.

Similar forms

  • Advance Directive: Similar to the MOLST form, an advance directive outlines a person's preferences for medical treatment in case they become unable to communicate their wishes. Both documents require a discussion with healthcare providers and can guide treatment decisions.
  • Durable Power of Attorney for Health Care: This document designates a person to make healthcare decisions on behalf of someone else. Like the MOLST form, it is based on the patient's wishes and can be activated when the patient is unable to make decisions.
  • Do Not Resuscitate (DNR) Order: A DNR order specifically instructs medical personnel not to perform CPR in the event of cardiac or respiratory arrest. The MOLST form includes similar instructions but encompasses a broader range of treatment preferences.
  • Living Will: A living will specifies the types of medical treatments a person does or does not want in the event of a terminal illness. The MOLST form serves a similar purpose but is more comprehensive in addressing various medical interventions.
  • Physician Orders for Life-Sustaining Treatment (POLST): The POLST form, like the MOLST, is a medical order that reflects a patient's preferences for life-sustaining treatment. Both are designed to be honored by healthcare providers and emergency personnel.
  • Health Care Proxy: This document appoints someone to make healthcare decisions for another person. Similar to the MOLST form, it is based on the patient's values and wishes, ensuring their preferences are respected.
  • Emergency Medical Services (EMS) Protocols: EMS protocols guide first responders in providing care during emergencies. The MOLST form complements these protocols by providing clear instructions on a patient's treatment preferences.
  • Patient Self-Determination Act Documentation: This federal law requires healthcare providers to inform patients of their rights to make decisions about their medical care. The MOLST form embodies this principle by allowing patients to articulate their treatment preferences.
  • Care Plan: A care plan outlines the medical care and services a patient will receive. While the MOLST form focuses on immediate treatment preferences, both documents work together to ensure comprehensive patient care.

Dos and Don'ts

When filling out the Massachusetts MOLST form, it is essential to approach the process with care and attention. Below are some important dos and don'ts to consider.

  • Do ensure that the form is completed after thorough discussions between the patient and the clinician.
  • Do use bright or fluorescent pink paper for printing the MOLST form to ensure visibility.
  • Do sign the form only when you are confident that it accurately reflects the patient’s wishes and goals of care.
  • Do keep a copy of the signed form with the patient at all times.
  • Don't alter the MOLST form in any way, as this may invalidate it.
  • Don't leave any sections incomplete, as this can lead to unintended treatment decisions.
  • Don't forget to review and update the form as the patient's condition or preferences change.
  • Don't assume that the form is valid without the necessary signatures from both the patient and the clinician.

Misconceptions

  • MOLST is the same as a living will. Many people believe that MOLST serves the same purpose as a living will. However, while a living will outlines a person's wishes regarding medical treatment, MOLST is a medical order that must be signed by a healthcare professional. It provides specific instructions for emergency medical personnel.
  • MOLST is only for terminal patients. Some assume that MOLST is only applicable to individuals who are terminally ill. In reality, anyone with serious health conditions or who wishes to specify their treatment preferences can benefit from a MOLST form.
  • Once signed, the MOLST form cannot be changed. It is a common misconception that the MOLST form is permanent. Patients or their representatives can revoke or revise the MOLST at any time, especially if their health status or treatment preferences change.
  • All healthcare providers must follow MOLST orders. While MOLST is designed to guide treatment, not all healthcare providers may be familiar with it. In some cases, healthcare institutions may still be developing systems to honor MOLST. It is crucial for patients to ensure that their MOLST is recognized by their specific healthcare providers.
  • EMTs are not required to honor MOLST. Some individuals mistakenly believe that emergency medical technicians (EMTs) do not have to follow MOLST orders. However, in Massachusetts, EMTs are trained to recognize and honor valid MOLST forms statewide.
  • The MOLST form is valid regardless of its color. Many people think that any color of paper can be used for the MOLST form. In fact, the Massachusetts Department of Public Health recommends using bright or fluorescent pink paper for maximum visibility. This ensures that EMTs can easily identify the form in emergencies.

Key takeaways

Key Takeaways about the Massachusetts MOLST Form

  • The MOLST form is designed for patients to express their wishes regarding life-sustaining treatment.
  • It must be signed by both the patient (or their representative) and a clinician to be valid.
  • Sections A–C are valid only if Sections D and E are completed.
  • The form is effective immediately upon signature, and copies are valid.
  • Health care providers must honor the orders listed in Sections A, B, and C until a clinician reviews them.
  • Changes to the form require it to be voided, and a new form must be signed.
  • The MOLST form should be printed on bright pink paper for visibility, as EMTs are trained to recognize it.
  • Patients or their representatives can revoke the MOLST form at any time.
  • Clinicians should engage in thorough discussions with patients before completing the form.