Molst / Advance Directive Discussion Documentation Form printable pdf download

MOLST / Advance Directive Discussion Documentation Form

Patient Last Name/First/Middle I.: ______________________________________________________

Address__________________________ City/State/Zip_______________________________________

Family/Caregivers Present: ________________ Facility Name: _______________________________

DOB (mm/dd/yyyy): ______________Last 4 SSN: _________ Gender □ M □ F Date: ___________

Location of Review: □ Office □ Hospital □ Home □ Nursing Home □ Assisted Living

1) Prepare for Discussion: Review Current Medical Records

a. Current Health Status (Palliative Performance Scale):

□

Full function; self-care full; intake normal; mental status normal (80-100)

□

Reduced function; self-care full to occasional assist; intake normal or reduced; mental status normal (60-70)

□

Mainly lie, sit or in bed; considerable assistance; normal or reduced intake; normal or confused (40-50)

□

Bed-bound; total care; reduced intake; normal, drowsy, or confused (30)

□

Bed-bound; total care; minimal sips and bites; normal, drowsy, or confused; (10-20)

b. Estimated Prognosis:

□ Days to weeks □ Weeks to 3 months □ 3 Months to 6 months □ 6 Months to < 1 year □ > 1 year

c. Previously Completed Advance Directives:

Health Care Proxy (HCP) □ Yes □ No

Living Will (LW) □ Yes □ No

If has Health Care Proxy, Health Care Agent (HCA)’s name: ______________________

MOLST form □ Yes □ No

Nonhospital DNR □ Yes □ No

2) Assess Patient’s Decision-Making Capacity

a. Does the patient have capacity to make his/her medical decisions re life-sustaining treatment? □ Yes □ No

b. If no prior Health Care Agent has been identified:

i. Does the patient have capacity to choose a Health Care Agent? □ Yes □ No

ii. If yes, then complete health care proxy form and list HCA name________________

3) Discuss Goals of Care with patient and/or family

a. Reviewed what patient/family know about patient’s condition/prognosis □ Yes □ No

b. Reviewed what patient wants to know about their condition □ Yes □ No

c. Provided new information about patient’s condition/prognosis □ Yes □ No

d. Explored common understanding and differences □ Yes □ No

e. Determined next steps needed to resolve any differences □ Yes □ No □ N/A

Briefly summarize content of discussion and the patient’s goals of care on reverse side.

4) Complete/Review/Revise Traditional Advance Directives (HCP & LW) and MOLST

a. For prior completed directives, are there: □ No changes □ Updated □ Not yet done

b. If not completed previously, is patient interested in discussing? □ Yes □ No □ No, not capable

c. HCP discussed □ Yes □ No completed □ Yes □ No

d. Living Will discussed □ Yes □ No completed □ Yes □ No

e. Medical Orders for Life-Sustaining Treatment (MOLST) discussed □ Yes □ No completed □ Yes □ No

If MOLST already completed,

i. Were goals reviewed? □ Yes □ No

ii. Was content reviewed, updated and signed on page 3? □ Yes □ No

g. If MOLST not completed, is patient interested in discussing? □ Yes □ No

i. If interested, were wishes about CPR/DNR discussed? □ Yes □ No

ii. Were goals and wishes about other life sustaining therapies discussed? □ Yes □ No

iii. Was the main MOLST completed? (relevant for all patients) □ Yes □ No

iv. If patient lacks capacity, was the supplemental MOLST completed? □ Yes □ No □ N/A

v. If form not completed, was patient given a copy to take home? □ Yes □ No □ N/A

vi. Was a date set for a follow-up meeting? □ Yes (date:__________) □ No □ N/A

h. If directives not completed, summarize any identified barriers to completion on reverse side.

Total time spent in counseling around these issues: ____________ minutes

Start time(s) / Stop time(s): _____________________________________________________________

Signature: ______________________________ Print Name: __________________________________

Physician NPI: __________________________ Date: ________________________________________

B-

December 2008

MOLST-001-discussion documentation-1-1

Molst / Advance Directive Discussion Documentation Form

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