Sample of the Massachusetts MOLST Form

The Massachusetts MOLST form is a working draft for use during the 2010 demonstration program. 

It was designed with input from more than 100 local experts and consumers to function in the unique health care system and legal environment of Massachusetts. 

It will change in 2011 based on what was learned during the demonstration period. 

Original Massachusetts MOLST forms are printed on hot pink-paper, but photocopies, faxes, electronic copies and forms printed on any color paper are valid if they are completed and signed in a valid way.

A *sample* Massachusetts MOLST form is provided here. It is not intended for actual use.

Patients and families - if you think MOLST may be suitable for you, talk with your doctor about "advance care planning" and MOLST. (Because MOLST is a new form, you may want to show your doctor the sample MOLST form).

Attending clinicians - for information about getting usable MOLST forms, please call the MOLST program at 508-856-5890.