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

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Ohio Medical Orders For Life-Sustaining Treatment (MOLST) Form
Ohio Medical Orders For Life-Sustaining Treatment (MOLST) Form
Medical Orders for Life-Sustaining Treatment (MOLST) MODEL Ohio Form - Page 1 of 2
© 2011, Honoring Wishes Task Force, Columbus, Ohio.
Patient Name (Print): Date of Birth: _______________
These medical orders are based on the person’s current medical condition and advance directive/preferences. Any section not
completed does not invalidate the form and implies full treatment for that section. Use of this form is an option of the healthcare
facility. This form is not transferrable from one site of care to another.
Section A
CARDIOPULMONARY RESUSCITATION (CPR): Person has no pulse and is not breathing.
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Attempt Resuscitation/CPR. With full treatment and intervention including intubation, advanced airway
interventions, mechanical ventilation, defibrillation, and cardioversion as indicated.
Transfer to intensive care if indicated.
Do NOT Attempt Resuscitation/DNR No CPR
When not in cardiopulmonary arrest, follow orders in Sections B, C and D.
Section B
MEDICAL INTERVENTIONS: Person has a pulse and/or is breathing.
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Full Intervention. Includes care described below in this section. Use intubation, advanced airway interventions,
mechanical ventilation, and cardioversion as indicated.
Transfer to intensive care if indicated.
Additional Orders/Instructions:__________________________________________________________________________
Limited Additional Interventions. Includes care described below in this section. Use medical treatment, IV fluids, and
cardiac monitor as indicated. Do not use intubation, advanced airway interventions, or mechanical ventilation. May consider
airway support (e.g., CPAP, BiPAP).
Avoid intensive care.
Additional Orders/Instructions:__________________________________________________________________________
Comfort Measures Only. Use medication by any route, positioning, wound care and other measures to relieve pain and
suffering. Use oxygen, suction and manual treatment of airway obstruction as needed for comfort.
Do not transfer to higher
level of care for life-sustaining treatment.
Additional Orders/Instructions:__________________________________________________________________________
Section C
ANTIBIOTICS
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Use antibiotics if medically indicated.
Determine use or limitation of antibiotics when infection occurs.
No antibiotics. Use other measures to relieve symptoms.
Additional Orders/Instructions:__________________________________________________________________________
Section D
ARTIFICIALLY / MEDICALLY-ADMINISTERED NUTRITION / HYDRATION: Always offer by mouth, if feasible.
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one
in each
column
Long-term artificial nutrition by tube
Artificial nutrition by tube for a defined trial period
No artificial nutrition by tube
Additional Orders/Instructions:__________________________________________________________________________
Turn Over
Patient Name (print): Date of Birth: _______________
Ohio Medical Orders For Life-Sustaining Treatment (MOLST) Form
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