Cincinnati Area Medical Orders For Life-Sustaining Treatment (Molst)

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SEND FORM WITH PATIENT WHENEVER TRANSFERRED OR DISCHARGED
Person’s Last Name
CINCINNATI AREA
MEDICAL ORDERS FOR
First Name/Middle Initial
LIFE-SUSTAINING TREATMENT
Date of Birth
Last 4 numbers of SSN
(MOLST)
_____/______/___________
____
____
____
____
These orders are based on the person’s medical condition and wishes at the time the orders were issued. Any section not completed does not
invalidate the form and implies full treatment for that section. Everyone shall be treated with dignity and respect, with attention to their comfort needs.
Cardiopulmonary Resuscitation (CPR):
Person has no pulse and is not breathing.
A
Attempt Resuscitation/CPR with full treatment and intervention.
Do NOT attempt Resuscitation/DNR. No CPR (Attach Ohio DNR Form)
Check
one
When not in cardiopulmonary arrest, follow orders in Sections B, C, and D
Medical Interventions:
Person has a pulse and/or is breathing.
Full Intervention.
Includes care described below in this section. Use intubation, mechanical ventilation,
and cardioversion as indicated. Transfer to intensive care if indicated.
Additional Orders/Instructions: ________________________________________________________________
Limited Additional Interventions.
Includes care described below in this section. Use medical
B
treatment, IV fluids, and cardiac monitor as indicated. Do not use intubation or mechanical ventilation. May
consider airway support such as CPAP or BiPAP. Transfer to hospital if indicated. Avoid Intensive Care.
Check
Additional Orders/Instructions: _______________________________________________________________
one
Comfort Measures Only.
Use medication by any route, positioning, wound care, and other measures to
relieve pain and suffering. Use oxygen, oral suction, and manual treatment of airway obstruction as needed for
comfort. Do not transfer to hospital, unless comfort needs cannot be met in current location.
Additional Orders/Instructions: ________________________________________________________________
Antibiotics:
Artificially Administered Hydration/Nutrition:
Use antibiotics if clinically indicated
Always offer food and liquids by mouth if feasible
C
D
Determine use or limitation of antibiotics
Long-term hydration/nutrition by tube
when infection occurs
Trial period of hydration/nutrition by tube
Check
Check
No antibiotics. Use other measures to
one
one
No hydration/nutrition by tube
relieve symptoms of infection
Additional orders:
Additional orders:
BASIS FOR ORDERS AND SIGNATURES
These orders were discussed with:
These documents were reviewed / location of copies:
Patient
Living Will:
__________________________
(location of copy)
Health Care Agent (DPOA-HC)
Durable Power of Attorney-HC: _____________________
Next of Kin/Surrogate
Court-Appointed Guardian
Ohio DNR form (ATTACH A SIGNED COPY)
E
Parent of a minor
Other: _____________________
Other documents:_____________________________
Physician/PA/APRN printed name
Signature (required)
Date
Relationship (“self” if patient)
Patient/Surrogate printed name
Signature (required)

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