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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
Massachusetts Medical Orders For Life-Sustaining Treatment (MOLST) Form
Approved by DPH 1/1/2012 MOLST Page 1 of 2
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
patient’s clinician.
Sections AC are valid orders only if Sections D and E are complete. Section F is valid only if Sections G and H are complete.
If a 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.
A
Select one circle
CARDIOPULMONARY RESUSCITATION: for a patient in cardiac or respiratory arrest
o
Do Not Resuscitate
o
Attempt Resuscitation
B
Select one circle
Select one circle
VENTILATION: for a patient in respiratory distress
o
Do Not Intubate and Ventilate
o
Intubate and Ventilate
o Do Not Use Non-invasive Ventilation (e.g. CPAP) o Use Non-invasive Ventilation (e.g. CPAP)
C
Select one circle
TRANSFER TO HOSPITAL
o Do Not Transfer to Hospital (unless needed for comfort) o Transfer to Hospital
PATIENT
or patient’s
representative
signature
D
Required
Select circle and fill
in every line
for valid orders
Select one circle below to indicate who is signing Section D:
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 E 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
E
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 D.
___________________________________________________________________ __________________________________
Signature of Physician, Nurse Practitioner, or Physician Assistant Date of Signature
_______________________________________________________ ____________________________
Legible Printed Name of Signer Telephone Number of Signer
Optional
Expiration date and
other patient care
contacts
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.
Massachusetts Medical Orders For Life-Sustaining Treatment (MOLST) Form
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