Maryland Medical Orders For Life Sustaining Template (Page 3 of 3) in pdf

INSTRUCTIONS

Completing the Form: 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. Use Section 9 to document any other orders

related to life-sustaining treatments. The order form is not valid until a physician or nurse practitioner signs and dates it. Each page that

contains orders must be signed and dated. A copy or the original of every completed MOLST form must be given to a competent patient

or authorized decision maker within 48 hours of completion of the form or sooner if the patient is discharged or transferred.

Selecting CPR (Resuscitation) Status: EMS Option A-1 – Intubate, Option A-2 – Do Not Intubate, and Option B include a set of

medical interventions. You cannot alter the set of interventions associated with any of these options and cannot override or alter the

interventions with orders in Section 9.

No-CPR Option A: Comprehensive Efforts to Prevent Cardiac and/or Respiratory Arrest / DNR if Arrest – No CPR. This

choice may be made either with or without intubation as a treatment option. Prior to arrest, all interventions allowed

under The Maryland Medical Protocols for EMS Providers. Depending on the choice, intubation may or may not be utilized to

try to prevent arrest. Otherwise, CPAP or BiPAP will be the only devices used for ventilatory assistance. In all cases, comfort

measures will also be provided. No CPR if arrest occurs.

No-CPR Option B: Supportive Care Prior to Cardiac and/or Respiratory Arrest. DNR if Arrest Occurs – No CPR. Prior to

arrest, interventions may include opening the airway by non-invasive means, providing passive oxygen, controlling external

bleeding, positioning and other comfort measures, splinting, pain medications by orders obtained from a physician (e.g., by

phone or electronically), and transport as appropriate. No CPR if arrest occurs.

The DNR A-1, DNR A-2 (DNI) and DNR B options will be authorized by this original order form, a copy or a fax of this form, or a bracelet

or necklace with the DNR emblem. EMS providers or medical personnel who see these orders are to provide care in accordance with

these orders and the applicable Maryland Medical Protocols for EMS Providers. Unless a subsequent order relating to resuscitation has

been issued or unless the health care provider reasonably believes a DNR order has been revoked, every health care provider, facility,

and program shall provide, withhold, or withdraw treatment according to these orders in case of a patient’s impending cardiac or

respiratory arrest.

Location of Form: The original or a copy of this form shall accompany patients when transferred or discharged from a facility or

program. Health care facilities and programs shall maintain this order form (or a copy of it) with other active medical orders or in a

section designated for MOLST and related documents in the patient’s active medical record. At the patient’s home, this form should be

kept in a safe and readily available place and retrieved for responding EMS and health care providers before their arrival. The original, a

copy, and a faxed MOLST form are all valid orders. There is no expiration date for the MOLST or EMS DNR orders in Maryland.

Reviewing the Form: These medical orders are based on this individual’s current medical condition and wishes. Patients, their

authorized decision makers and attending physicians or nurse practitioners shall review and update, if appropriate, the MOLST orders

annually and whenever the patient is transferred between health care facilities or programs, is discharged, has a substantial

change in health status, loses capacity to make health care decisions, or changes his or her wishes.

Updating the Form: The MOLST form shall be voided and a new MOLST form prepared when there is a change to any of the orders. If

modified, the physician or nurse practitioner shall void the old form and complete, sign, and date a new MOLST form.

Voiding the Form: To void this medical order form, the physician or nurse practitioner shall draw a diagonal line through the sheet,

write “VOID” in large letters across the page, and sign and date below the line. A nurse may take a verbal order from a physician or

nurse practitioner to void the MOLST order form. Keep the voided order form in the patient’s active or archived medical record.

Revoking the Form’s DNR Order: In an emergency situation involving EMS providers, the DNR order in Section 1 may be revoked at

any time by a competent patient’s request for resuscitation made directly to responding EMS providers.

Bracelets and Necklaces: If desired, complete the paper form at the bottom of this page, cut out the bracelet portion below, and place

it in a protective cover to wear around the wrist or neck or pinned to clothing. If a metal bracelet or necklace is desired, contact Medic

Alert at 1-800-432-5378. Medic Alert requires a copy of this order along with an application to process the request.

How to Obtain This Form: Call 410-706-4367 or go to

□

Use of an EMS DNR bracelet is

DNR A-1 Intubate

DNR A-2 Do Not Intubate

DNR B

OPTIONAL and at the discretion of

Pt. Name _______________________________________ DOB __________________

the patient or authorized decision

Phys./NP Name __________________________________ Date __________________

maker. Print legibly, have physician or NP sign,

Phys./NP Signature ______________________________ Phone __________________

cut off strip, fold, and insert in bracelet or

necklace.

Maryland Medical Orders For Life Sustaining Template Page 3

Related Articles

Related forms

Related Categories