Molst Form Massachusetts Details

The Massachusetts Molst form is an important document for anyone who wants to make clear their wishes about medical treatment in the event of a serious illness or injury. This form can help ensure that your loved ones know what you would want done in a difficult situation, and can help avoid any conflict or confusion. It is important to understand the basics of the Molst form before you fill it out, so you can be sure to include all the information you need. This blog post will provide an overview of the Massachusetts Molst form and explain how to complete it.

You may find information about the type of form you wish to complete in the table. It can show you the time you'll need to finish massachusetts molst form, what fields you need to fill in and some additional specific details.

QuestionAnswer
Form NameMassachusetts Molst Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesmass molst form, massachusetts molst form pdf, molst form pdf, molst form

Form Preview 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 DPHapproved 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 lifesustaining treatment with patients.

Print the MOLST form (pages 1 and 2) as a doublesided 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 indepth conversation between the patient and the clinician signer.

Before using MOLST:

Access the Clinician Checklist for Using MOLST with Patients at: http://www.molstma.org/healthcareprofessionals/guidanceforusingmolstformswithpatients.

Listen to MOLST Overview for Health Professionals at: http://www.molstma.org/molsttrainingline.

Access the MOLST website at: http://www.molstma.org periodically for MOLST form updates.

For more information about Massachusetts MOLST or the Massachusetts MOLST form, visit http://www.molstma.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