Massachusetts Molst Form – Fill Out and Use

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