Massachusetts Medical Orders For Life-Sustaining Treatment (MOLST) Form
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Approved by DPH 1/1/2012MOLST Page 2of 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
Legible Printed Name of SignerTelephone 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 clinicianto 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 clinicallyappropriate 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 previouslyrefused medically-indicated treatment.