Cincinnati Area Medical Orders For Life-Sustaining Treatment (Molst) Page 2
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2SEND FORM WITH PATIENT WHENEVER TRANSFERRED OR DISCHARGED
Other Contact Information
Surrogate
Relationship
Phone Number
Health Care Professional Preparing Form
Preparer Title
Phone
Date Prepared
Directions for Healthcare Professionals
Completing MOLST
The MOLST form must be completed by a health care professional based on patient preferences and medical
indications or decisions by the patient or a surrogate.
At the time a MOLST is completed, any current advance directive, if available, must be reviewed.
MOLST must be signed by a physician/PA/APRN and the patient or surrogate to be valid. Verbal orders are
acceptable with follow-up signature by physician/PA/APRN in accordance with facility/community policy.
Use of the original form is strongly encouraged whenever possible. Photocopies and faxes of signed MOLST
forms should be respected where necessary.
Using MOLST
If a person’s condition changes and time permits, the patient or surrogate must be contacted to assure that the
MOLST orders are reviewed and updated as appropriate.
If any section is not completed it implies full treatment. The healthcare provider should follow other
appropriate methods to determine ongoing treatment.
An automated external defibrillator (AED) should not be used on a person who has chosen “Do Not Attempt
Resuscitation”
Oral fluids and nutrition must always be offered if medically feasible.
When comfort cannot be achieved in the current setting, the person, including a person that designates
“comfort measures only,” should be transferred to a setting able to provide comfort
An IV medication or IV fluids to enhance comfort may be appropriate in some cases for a person who has
chosen “Comfort Measures Only.”
A person with decision-making capacity, or the authorized surrogate (if the person lacks capacity), can revoke
the MOLST at any time and request alternative treatment.
Review of MOLST
This form should be reviewed periodically (consider at least annually) and a new form completed when:
o
The person is transferred from one care setting or care level to another, or
There is a substantial change in the person’s health status, or
o
The person’s treatment preferences change.
o
Revoking MOLST
If the MOLST becomes invalid or is replaced by an updated version, draw a line through sections A through E
of the invalid MOLST, write “VOID” in large letters across the form, and sign and date the form.
If the person has a DNR-CC or DNR-CC Arrest Order, an Ohio DNR Identification
Form MUST be completed, and MUST be attached to this document whenever
the person is transferred from one site of care to another.
Version 10/10/2011
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