Maryland Medical Orders For Life Sustaining Template
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3MM 2 2012
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Maryland Medical Orders for Life-Sustaining Treatment (MOLST)
Patient’s Last Name, First, Middle Initial
Date of Birth
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Male
Female
This form includes medical orders for Emergency Medical Services (EMS) and other medical personnel regarding cardiopulmonary resuscitation and
other life-sustaining treatment options for a specific patient. It is valid in all health care facilities and programs throughout Maryland. This order form
shall be kept with other active medical orders in the patient’s medical record. The physician or nurse practitioner must accurately and legibly complete
the form and then sign and date it. The physician or nurse practitioner shall select only 1 choice in Section 1 and only 1 choice in any of the other
Sections that apply to this patient. If any of Sections 2-9 do not apply, leave them blank. A copy or the original of every completed MOLST form must
be given to the patient or authorized decision maker within 48 hours of completion of the form or sooner if the patient is discharged or transferred.
CERTIFICATION FOR THE BASIS OF THESE ORDERS: Mark any and all that apply.
I hereby certify that these orders are entered as a result of a discussion with and the informed consent of:
________ the patient; or
________ the patient’s health care agent as named in the patient’s advance directive; or
________ the patient’s guardian of the person as per the authority granted by a court order; or
________ the patient’s surrogate as per the authority granted by the Heath Care Decisions Act; or
________ if the patient is a minor, the patient’s legal guardian or another legally authorized adult.
Or, I hereby certify that these orders are based on:
________ instructions in the patient’s advance directive; or
________ other legal authority in accordance with all provisions of the Health Care Decisions Act. All supporting
documentation must be contained in the patient’s medical records.
________ Mark this line if the patient or authorized decision maker declines to discuss or is unable to make a decision
about these treatments. The patient’s or authorized decision maker’s participation in the preparation of
the MOLST form is always voluntary. If the patient or authorized decision maker has not limited care, except
as otherwise provided by law, CPR will be attempted and other treatments will be given.
CPR (RESUSCITATION) STATUS:
EMS providers must follow the Maryland Medical Protocols for EMS Providers.
Attempt CPR:
________
If cardiac and/or pulmonary arrest occurs, attempt cardiopulmonary resuscitation (CPR).
This will include any and all medical efforts that are indicated during arrest, including artificial ventilation
and efforts to restore and/or stabilize cardiopulmonary function.
[If the patient or authorized decision maker does not or cannot make any selection regarding CPR status,
mark this option. Exceptions: If a valid advance directive declines CPR, CPR is medically ineffective, or
there is some other legal basis for not attempting CPR, mark one of the “No CPR” options below.]
____________________________________________________________________________________________________________________________________________
No CPR, Option A, Comprehensive Efforts to Prevent Arrest:
Prior to arrest, administer all
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medications needed to stabilize the patient. If cardiac and/or pulmonary arrest occurs, do not attempt resuscitation
(No CPR). Allow death to occur naturally.
Option A-1, Intubate:
________
Comprehensive efforts may include intubation and artificial ventilation.
Option A-2, Do Not Intubate (DNI):
________
Comprehensive efforts may include limited ventilatory
support by CPAP or BiPAP, but do not intubate.
_____________________________________________________________________________
__________________________________________________________
_______ No CPR, Option B, Palliative and Supportive Care:
Prior to arrest, provide passive oxygen for
comfort and control any external bleeding. Prior to arrest, provide medications for pain relief as needed,
but no other medications. Do not intubate or use CPAP or BiPAP. If cardiac and/or pulmonary arrest
occurs, do not attempt resuscitation (No CPR). Allow death to occur naturally.
PHYSICIAN’S OR NURSE PRACTITIONER’S SIGNATURE (Signature and date are required to validate order)
Practitioner’s Signature
Print Practitioner’s Name
Maryland License #
Phone Number
Date
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