See EMS Instructor Resources / Information for EMS Instructors for MOLST Training Resources

 
Q:  What is the “Medical Orders for Life-Sustaining Treatment” form ?

A:  Written instructions on a medical order form about life-sustaining medical treatments from a clinician (physician, nurse practitioner or physician assistant) to other health professionals (e.g. nurses, EMTs), based on the patient's own preferences.

Q:  What is “life-sustaining treatment”?
A:  Medical treatments that attempt to keep a person alive. Cardiopulmonary resuscitation (CPR) is one example.  Health professionals are required to attempt CPR when a patient’s heart or breathing stops, unless they have medical orders (like a MOLST form) with other instructions.

Q:  What persons are most suitable for using MOLST forms? 
A:  Persons of any age (including children) with advanced illnesses or injuries, who want to express their preferences about life-sustaining medical treatments.

Q:  At what stage of illness is it appropriate to consider using the MOLST form?
A:  This depends on the person and the situation.  However, every person with advanced illness or injury should be offered the opportunity to fill out a MOLST form if:

• It is medically appropriate, based on the person's current health condition, and
• The person wants to express preferences about life-sustaining medical treatments.

Q:  What is the process for filling out a MOLST form? 
A:  It starts with a person (and/or their caregivers, family members) and a clinician (physician, nurse practitioner, physician assistant) talking about "advance care planning." These conversations should include talking about the person's health status, prognosis, personal values and goals of care, and the potential benefits and burdens of treatments. This may result in filling out a MOLST form, if one is medically indicated and desired by the person.

Q:  Who fills out the MOLST form?
A:  A clinician (physician, nurse practitioner, or physician assistant) and the person with advanced illness (or their health care agent, if the person lacks capacity).  If no health care agent is appointed, a guardian or the parent/guardian of a minor may fill out the MOLST form to the extent permitted by Massachusetts law. Seek legal counsel with questions about a guardian's authority. 

Q:  Can a person be required to use the MOLST form?
A:  No. Using MOLST is voluntary.

Q:  Can a person change his or her mind about treatment after they fill out the MOLST?
A:  Yes. They can ask for and receive needed medical treatment at any time, no matter what the MOLST form says. A person can also void the MOLST form and/or ask a clinician to fill out a new MOLST form with different instructions at any time.

Q:  Who honors MOLST instructions?
A:  Health care professionals (nurses, emergency responders, etc.) honor valid medical orders, including MOLST, in any setting where clinical care may be provided (including in the patient's home).

Q:  Do EMTs have to honor MOLST forms?
A:  Yes. The Massachusetts Department of Public Health's Office of Emergency Medical Services (OEMS) has jurisdiction over emergency medical services and instructs that MOLST forms must be honored by EMS personnel.  EMS personnel should call Medical Control if they have questions about MOLST instructions in the field.

Q:  Is MOLST the same as a "health care proxy" form?
A:  No. A health care proxy form is used to name a person's health care agent.  Only the health care agent is legally authorized to make medical decisions for another person if the person cannot make medical decisions themselves (e.g. because of unconsciousness, coma, dementia or other mental limitations).  Every adult age 18 and older in Massachusetts should fill out and sign a health care proxy form.  Print and sign a health care proxy form.

Q:  If a person has written “final wishes” or a “living will,” isn't that enough?
A:  No. Those are important forms that may be used as evidence of a person's wishes, but they are not authorized by law in Massachusetts.  They do not carry the same authority as a medical order like MOLST.

Q: Is MOLST an advance directive?

The MOLST form is not an advance directive because it contains actionable medical orders that are effective immediately based on a patient's current medical condition. Advance directives, including health care proxies and living wills, are legal documents that are effective only after the patient has lost capacity. In other words, a health care agent can make decisions for a person only after he or she has been determined to lack capacity; a living will is relevant only after the patient can no longer be consulted. A MOLST form, on the other hand, is a medical document signed by both the clinician and the patient, and is effective as soon as it is signed.

Q:  If a person already has a “Do Not Resuscitate” (DNR) order, can they still use MOLST?
A:  Yes. DNR orders can be written on the MOLST form.  The MOLST form also enables a person to express preferences about other types of life-sustaining treatments - and to either refuse or request certain treatments.

Q:  Who keeps the signed MOLST form?
A:  The person with advanced illness keeps the MOLST form with them, in a place where it is easy to locate (e.g. on the refrigerator, beside the bed, or on the door), and it should be carried with them outside the home.  Copies of MOLST forms are also valid and should be given to the person's health care agent and primary care provider

Q:  Will the MOLST form be honored outside of Massachusetts?
A:  The Massachusetts MOLST form might be honored in some states but not in others. However, the MOLST form is always a good record of a person’s treatment preferences and may be honored as evidence of those preferences outside of Massachusetts.

Q:  What are “Medical Orders for Life-Sustaining Treatment” (MOLST)?
A:  The MOLST form is a standardized form containing valid medical orders about life-sustaining treatment. It stays with the patient and is honored by health professionals across all health care settings.

Q:  How does MOLST impact current OEMS protocols for providing emergency care?
A:  MOLST does not change any current OEMS protocols for providing emergency care.

Q:  How is MOLST different from the Comfort Care/Do Not Resuscitate (CC/DNR) Verification Protocol?
A:  Both forms are valid. The Comfort Care form verifies (for EMTs only) the existence of a current valid DNR order.  The CC/DNR protocol also describes comfort care measures an EMT can provide to a patient with a valid CC/DNR form. The MOLST form is a medical order that may contain instructions to attempt or not attempt a range of life-sustaining treatments. The MOLST form is honored by health professionals in the MOLST demonstration sites and by EMTs throughout Massachusetts.  The MOLST form may eventually replace the CC/DNR form for EMS.

Q:  Where do I find a patient’s MOLST form?
A:  Ask at the scene about the existence of a MOLST form. In homes, check the refrigerator, backs of doors and bedside area. Check (or ask someone else to check) the patient’s wallet. Original MOLST forms are bright pink, but a copy of any color is valid.

Q:  What makes a MOLST form valid?
A:  Both Section D (patient info) and Section E (clinician info) must be complete before the EMT arrives for a MOLST form to be valid. EMTs should assume that all signatures on the form are valid.

Q:  Is a copy of only the front side of a MOLST form valid?
A:  If Sections D and E are fully complete and legible, instructions contained in a copy of the front side of the MOLST form are valid.

Q:  What if Sections D and E are complete, but some other section(s) of the form is blank?
A:  The form is still valid. If a section is blank, there is no limitation on the treatment indicated in that section.

Q:  What orders do I follow if the patient has both a CC/DNR form and a MOLST form?  
A:  For cardiac or respiratory arrest, follow the most recent orders. In all other situations, follow the MOLST instructions.

Q:  If the MOLST instructs “Do Not Intubate and/or Ventilate,” can I use CPAP?
A:  Maybe. To decide whether to use CPAP, look to the next row under "Do Not Intubate and Ventilate" in Section B on Page 1 of the MOLST form to find instructions about non-invasive ventilation (e.g. CPAP). 

Q:  Can I give treatment if the MOLST says “do not treat” but the person asks for treatment?
A:  Yes, a patient can request and receive previously refused, medically indicated treatment at any time.

Q:  What if the MOLST form says “give treatment” but the patient or family/health care agent says no?
A:  Treat and transport the patient. A new decision to withhold treatment is best made at the hospital and not at home.

Q:  What if a patient can’t communicate and the family or health care agent disputes the MOLST?
A:  Explain that the MOLST form contains the patient’s wishes and that EMTs are required to follow MOLST instructions. If a situation of conflict continues or escalates, treat and transport the patient, and then document what occurred.

Q:  Do I have to bring the MOLST form with the patient to the hospital? 
A:  Yes. The MOLST form should always stay with the patient and return home with the patient.

Q:  How do I document MOLST instructions and what occurred?
A:  Record the patient's name, the clinician’s name and contact information, the MOLST orders and what occurred.

Q:  Do all of the sections of the MOLST form have to be completed?

 A:  The MOLST form does not need to be completed in every section to be valid.  Each page can be valid independent of the other, and neither page needs to be fully completed to be valid.  

• For Page 1 to be valid, every part of Sections D and E must be filled in completely and legibly.  Page 1 can be used, for example, to provide resuscitation instructions only (Section A).  
• For Page 2 to be valid, every part of Sections G and H must be filled in completely and legibly.  Page 2 can be used, for example, to provide instructions only on parts of Section F.  

Q:  Is the goal to have all seniors/elders covered by a MOLST form?

A:  First, the MOLST form is not suitable for use by everybody; nor is it for use only with seniors/elders.  The MOLST form is typically most suitable for persons of any age with a current serious advanced illness.  If a patient's current medical condition would merit a conversation about DNR orders, or if it would not be surprising for the patient to die within the coming year from his/her advanced illness - then MOLST orders may be suitable.Second, all persons for whom the MOLST form is suitable, they are not required to use a MOLST form.  The goal is for MOLST be presented as an option for all suitable patients - but their choice to use the MOLST form must always be voluntary.

 Q:  Who can sign the MOLST form on a patient's behalf, if the patient has lost capacity and has not appointed a health care agent?

 A:  This question emphasizes the importance of encouraging all adults ages 18 and older, whether they are healthy or sick, to sign a health care proxy to appoint their health care agent.  Informal or default surrogates are not authorized to sign a patient's MOLST form.

Q:  If a patient has lost capacity to make medical decisions (per clinical assessment), and has not appointed a health care agent, can his or her guardian can sign the MOLST form on the patient's behalf?

 A:  Whether the guardian has authority to sign the MOLST form or not depends on the facts and circumstances. A court-appointed guardian who has been specifically granted the authority to sign a MOLST form has the authority to do so.  In other situations, consult legal counsel about the extent of the guardian's authority.

 Q:  If a patient has lost capacity to make medical decisions (per clinical assessment), and has both an appointed health care agent and a guardian, can either the health care agent or the guardian can sign the MOLST form on the patient's behalf?

 A:  The health care agent (not the guardian) is the one with the authority to make medical care decisions on the patient's behalf, including signing the MOLST form (unless the guardianship order expressly provides otherwise).