Medical Orders For Life Sustaining Treatment (Molst)
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1
2HIPAA PERMITS DISCLOSURE OF MOLST TO OTHER HEALTH CARE PROFESSIONALS AS NECESSARY.
MOLST IS VOLUNTARY. NO PATIENT IS REQUIRED TO COMPLETE A MOLST FORM.
Medical Orders for Life Sustaining Treatment (MOLST)
Follow these orders, then contact a MOLST-Qualified Health Care Provider. This is a
Medical Order Sheet based upon the person’s wishes in his/her current medical condition. Any
section not completed implies full treatment. This MOLST remains in effect unless revised.
Patient’s Last Name
Patient’s First Name
/
/
Gender:
c
M
c
F
Patient’s Date of Birth
Date/Time Form Prepared
A
CARDIOPULMONARY RESUSCITATION (CPR): Person has no pulse and is not breathing.
c Attempt Resuscitation/CPR
c Do Not Attempt Resuscitation/DNR (Allow Natural Death)
CHECK
ONE
• No defibrillator (including automated external defibrillators) should be used on a person who has chosen
“Do Not Attempt Resuscitation.”
• When not in cardiopulmonary arrest, follow orders in sections B and C.
B
*
MEDICAL INTERVENTION: Patient has a pulse and/or is breathing.
c Comfort Measures Only:
Use medication by any route, positioning, wound care and other measures to relieve pain and suffer-
CHECK
ing. Use oxygen, suction and manual treatment of airway obstruction as needed for comfort. Use antibiotics only to promote comfort.
ONE
c Limited Additional Interventions:
Includes care described above. Use medical treatment, antibiotics, and IV fluids as
indicated. Do not intubate. May use non-invasive positive airway pressure. Generally avoid intensive care.
c Full Treatment:
Includes care described above in Comfort Measures Only and Limited Additional Interventions, as well as additional
treatment, such as intubation, advanced airway interventions, mechanical ventilation, and defibrillation/cardioversion as indicated.
C
TRANSFER TO HOSPITAL
c Do not transfer to hospital for medical interventions.
c Transfer to hospital if comfort measures
CHECK
cannot be met in current location.
ONE
D
ARTIFICIAL NUTRITION (For example a feeding tube): Offer food by mouth if feasible and desired.
c No artificial nutrition
c Defined trial period of artificial nutrition
CHECK
c Long-term artificial nutrition, if needed
c Artificial nutrition until not beneficial or burden to patient
ONE
E
ARTIFICIAL HYDRATION: Offer fluid/nutrients by mouth if feasible and desired.
c No artificial hydration
c Defined trial period of artificial hydration
CHECK
c Long-term artificial hydration, if needed
c Artificial hydration until not beneficial or burden to patient
ONE
F
ADVANCE DIRECTIVE (if any): Check all advance directives known to be completed.
c Durable Power of Health Care
c Health Care Proxy
c Living Will
c Documentation of Oral Advance Directive
Discussed with:
c Patient
c Health Care Decision Maker
c Parent/Guardian of Minor
c Court-Appointed Guardian
c Other:
G
SIGNATURE OF MOLST-QUALIFIED HEALTHCARE PROVIDER (Physician, RNP, APRN, or PA)
My signature below indicates to the best of my knowledge that these orders are consistent with the person’s medical condition and preferences.
/
/
Signature (required)
Phone Number
Date/Time
Print Name
Rhode Island License #
SIGNATURE OF PATIENT, DECISION MAKER, PARENT/GUARDIAN OF MINOR, OR GUARDIAN
By signing this form, the patient or legally-recognized decision maker acknowledges that this request regarding resuscitative measures is consistent with
the known desires of, and with the best interest of, the individual who is the subject of the form.
Signature (Required)
Phone Number
Relationship (if patient, write self)
Print Name and Address
SEND MOLST FORM WITH PERSON WHENEVER TRANSFERRED OR DISCHARGED.
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