Medical Orders For Life Sustaining Treatment (Molst) Page 2
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2HIPAA PERMITS DISCLOSURE OF MOLST TO OTHER HEALTH CARE PROFESSIONALS AS NECESSARY.
MOLST IS VOLUNTARY. NO PATIENT IS REQUIRED TO COMPLETE A MOLST FORM.
Review and Renewal of MOLST Orders on This MOLST Form (this MOLST form remains in effect unless
another MOLST form is executed.)
The MOLST-Qualified Health Care Provider may review the form from time to time as the law requires, and also:
• If the patient moves from one location to another to receive care; or
• If the patient has a major change in health status (positive or negative); or
• If the patient or other decision-maker changes his/her mind about treatment.
Date/Time
Reviewer’s Name
Location of Review
Outcome of Review
and Signature
(e.g., Hospital, Nursing Home,
Provider’s Office, Patient’s Residence)
c
No change
c
Form voided, new form completed
Form voided, no new form
c
c
No change
c
Form voided, new form completed
c
Form voided, no new form
No change
c
c
Form voided, new form completed
c
Form voided, no new form
Directions for MOLST-Qualified Health Care Providers Completing MOLST
• Must be completed by a MOLST-Qualified Health Care Provider based on patient preferences and medical indications.
A MOLST-Qualified Health Care Provider is defined as a physician, nurse practitioner, advanced practice registered nurse, or
a physician assistant.
• MOLST must be signed by a MOLST-Qualified Healthcare Provider (physician, nurse practitioner, advanced practice registered
nurse, or physician assistant) and the patient/decision maker to be valid. Verbal orders are acceptable with follow-up signature
by provider in accordance with facility/community policy and documentation that there was discussion with the patient or the
patient’s advocate about discontinuing the MOLST order.)
• This is the ONLY MOLST FORM that is acceptable for completion in Rhode Island. Do not make your own MOLST form.
Photocopies and faxes of signed MOLST forms are legal and valid.
• Any incomplete section of the MOLST form implies full treatment for that section.
*Section B:
• When comfort cannot be achieved in the current setting, the person, including someone with “Comfort Measures Only,”
should be transferred to a setting able to provide comfort (e.g., treatment of a hip fracture)
• IV medication to enhance comfort may be appropriate for a person who has chosen “Comfort Measures Only”.
• Non-invasive positive airway pressure includes continuous positive airway pressure (CPAP), bi-level positive airway pressure
(BiPAP), and bag valve mask (BVM) assisted respirations.
• Treatment of dehydration prolongs life. A person who desires IV fluids should indicate “Limited Interventions” or
“Full Treatment.”
Modifying and Voiding MOLST
• A patient with capacity can, at any time, void the MOLST form or change his/her mind about his/her treatment preferences
by executing a verbal or written advance directive or a new MOLST form.
• To void MOLST draw a line through Sections A through E and write “VOID” in large letters. Sign and date the line.
• A health care decision maker may request to modify the orders based on the known desires of the individual or, if unknown,
the individual’s best interests.
DEFINITIONS
“Medical orders for life sustaining treatment” or “MOLST” means a voluntary request that directs a health care provider
regarding resuscitative and life-sustaining measures. Rhode Island General Laws §23-4.11-2 (10).
“Qualified patient” means a patient who has executed a declaration in accordance with this chapter and who has been
determined by the attending physician to be in a terminal condition. Rhode Island General Laws §23-4.11-2 (16).
“Terminal condition” means an incurable or irreversible condition that, without the administration of life sustaining procedures,
will, in the opinion of the attending physician, result in death.” Rhode Island General Laws §23-4.11-3.1 (20).
This form is approved by the Rhode Island Department of Health. For more information or a copy of the form, visit
SEND MOLST FORM WITH PERSON WHENEVER TRANSFERRED OR DISCHARGED.
Rhode Island General Laws §23-4.11-3.1 authorizes this MOLST form.
(Rev. 9-2013)
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