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Massachusetts Medical Orders For Life-Sustaining Treatment (MOLST) Form

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Massachusetts Medical Orders For Life-Sustaining Treatment (MOLST) Form Page 2
Massachusetts Medical Orders For Life-Sustaining Treatment (MOLST) Form
Approved by DPH 1/1/2012 MOLST Page 2 of 2
Patient’s Name: ______________________ Patient’s DOB ___________ Medical Record # if applicable__________________
F
Select one circle
Select one circle
Select one circle
Select one circle
Select one circle
Statement of Patient Preferences for Other Medically-Indicated Treatments
INTUBATION AND VENTILATION
o
Refer to Section B on
Page 1
o
Use intubation and ventilation as checked
in Section B, but short term only
o
Undecided
o
Did not discuss
NON-INVASIVE VENTILATION (e.g. Continuous Positive Airway Pressure - CPAP)
o
Refer to Section B on
Page 1
o
Use non-invasive ventilation as checked
in Section B, but short term only
o
Undecided
o Did not discuss
DIALYSIS
o
No dialysis
o
Use dialysis
o Use dialysis, but short term only
o
Undecided
o Did not discuss
ARTIFICIAL NUTRITION
o
No artificial nutrition
o
Use artificial nutrition
o
Use artificial nutrition, but short term only
o
Undecided
o
Did not discuss
ARTIFICIAL HYDRATION
o
No artificial hydration
o
Use artificial hydration
o Use artificial hydration, but short term only
o
Undecided
o Did not discuss
Other treatment preferences specific to the patient’s medical condition and care ________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
PATIENT
or patient’s
representative
signature
G
Required
Select circle and fill
in every line
for valid orders
Select one circle below to indicate who is signing Section G:
o Patient o Health Care Agent o Guardian* o Parent/Guardian* of minor
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
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 to the extent permitted by MA law. Consult legal counsel with questions
about guardian’s authority.
_______________________________________________________ ____________________________
Signature of Patient (or Person Representing the Patient) Date of Signature
_______________________________________________________ ____________________________
Legible Printed Name of Signer Telephone Number of Signer
CLINICIAN
signature
H
Required
Fill in every line for
valid orders
Signature of physician, nurse practitioner or physician assistant confirms that this form accurately reflects his/her
discussion(s) with the signer in Section G.
_______________________________________________________ ____________________________
Signature of Physician, Nurse Practitioner, or Physician Assistant Date of Signature
_______________________________________________________ ____________________________
Legible Printed Name of Signer Telephone Number of Signer
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.
Massachusetts Medical Orders For Life-Sustaining Treatment (MOLST) Form
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