Massachusetts Medical Orders For Life-Sustaining Treatment
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2MASSACHUSETTS MEDICAL ORDERS
Patient’s Name _________________________________
for LIFE-SUSTAINING TREATMENT
Date of Birth ___________________________________
Medical Record Number if applicable: ______________
(MOLST)
INSTRUCTIONS: Every patient should receive full attention to comfort.
→ This form should be signed based on goals of care discussions between the patient (or patient’s representative signing below) and the
patient’s clinician.
→ Sections A–C are valid orders only if Sections D and E are complete. Section F is valid only if Sections G and H are complete.
→ If a section is not completed, there is no limitation on the treatment indicated in that section.
→ The form is effective immediately upon signature. Photocopy, fax or electronic copies of properly signed MOLST forms are valid.
CARDIOPULMONARY RESUSCITATION: for a patient in cardiac or respiratory arrest
A
o
o
Select one circle
Do Not Resuscitate
Attempt Resuscitation
VENTILATION: for a patient in respiratory distress
B
o
o
Select one circle
Do Not Intubate and Ventilate
Intubate and Ventilate
o
o
Select one circle
Do Not Use Non-invasive Ventilation (e.g. CPAP)
Use Non-invasive Ventilation (e.g. CPAP)
C
TRANSFER TO HOSPITAL
o
o
Select one circle
Do Not Transfer to Hospital (unless needed for comfort)
Transfer to Hospital
Select one circle below to indicate who is signing Section D:
PATIENT
o Patient
o Health Care Agent
o Guardian*
o Parent/Guardian* of minor
or patient’s
representative
Signature of patient confirms this form was signed of patient’s own free will and reflects his/her wishes and goals of care as
signature
expressed to the Section E signer. Signature by the patient’s representative (indicated above) confirms that this form reflects
D
his/her assessment of the patient’s wishes and goals of care, or if those wishes are unknown, his/her assessment of the
patient’s best interests. *A guardian can sign to the extent permitted by MA law. Consult legal counsel with questions
Required
about guardian’s authority.
Select circle and fill
___________________________________________________________________
___________________________________
in every line
Signature of Patient (or Person Representing the Patient)
Date of Signature
for valid orders
_______________________________________________________
_____________________________
Legible Printed Name of Signer
Telephone Number of Signer
Signature of physician, nurse practitioner or physician assistant confirms that this form accurately reflects his/her discussion(s)
CLINICIAN
with the signer in Section D.
signature
___________________________________________________________________
__________________________________
E
Signature of Physician, Nurse Practitioner, or Physician Assistant
Date of Signature
Required
_______________________________________________________
____________________________
Fill in every line for
Legible Printed Name of Signer
Telephone Number of Signer
valid orders
This form does not expire unless expressly stated. Expiration date (if any) of this form: ______________________
Optional
Health Care Agent Printed Name ___________________________________ Telephone Number ________________
Expiration date and
other patient care
Primary Care Provider Printed Name ________________________________ Telephone Number ________________
contacts
SEND THIS FORM WITH THE PATIENT AT ALL TIMES.
HIPAA permits disclosure of MOLST to health care providers as necessary for treatment.
Approved by DPH 1/1/2012
MOLST Page 1 of 2
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