Physicians, Nurse Practitioners, Physician Assistants

Frequently Asked Questions about Using MOLST forms with patients

What are “Medical Orders for Life-Sustaining Treatment” (MOLST)?
The MOLST process and form is an appropriate way to meet the standard of care for communicating patients' life-sustaining treatment preferences across care settings in Massachusetts.

What patients should consider MOLST?
MOLST is used voluntarily by patients and is most suitable for patients of any age with a serious advancing medical condition including, but not limited to, the following: 

• Life-threatening illness or injury
• Chronic progressive disease
• Dementia
• Medical frailty
• Any patient with whom you would discuss DNR orders

Who is responsible for discussing MOLST with patients?
All clinicians should engage in advance care planning discussions with patients and document patient preferences as appropriate, in any care setting, medical specialty or length of relationship with a patient. This may result in a MOLST form, if one is medically indicated and desired by the patient.

What is the process for establishing MOLST with a patient?
Every patient and situation is unique; however, the following process is recommended:

BEFORE talking about MOLST with any patient:

• Encourage every patient aged 18 and older to appoint a health care agent.
• Initiate advance care planning discussions when medically indicated.
• Review the training module for clinician signers of MOLST
• Consider discussing MOLST with patients nearing the end of life based on their current medical condition, prognosis, values and goals of care. Determining which patients are suitable for MOLST may be more of an art than a science.

Introducing MOLST as an option:

• Anticipate that it may take more than one discussion to sign a MOLST.
• Have discussion(s) with the patient about his/her medical condition, prognosis, values and goals of care. Include loved ones and the health care agent when possible.
• If a patient lacks capacity, talk with his/her health care agent. Guardians can sign on patients' behalf to the extent permitted by Massachusetts law (consult legal counsel with questions about a guardian’s authority).
• Explain and discuss the burdens and benefits of CPR, intubation, ventilation, hospitalization and other medically indicated treatments.
• Explain that the patient will be made as comfortable as possible as they near the end of life, regardless of their choices about life-sustaining treatments.
• Clarify that using MOLST is voluntary for patients.

Using the MOLST form with a patient:

• Fill in sections of the form as appropriate to reflect the patient’s preferences.
• Ask the patient (or health care agent) to complete and sign Section D.
• Complete and sign all information in Section E yourself.
• The MOLST is only valid if Sections D and E are completed fully and legibly.
• Discuss and explain Section F treatments when appropriate. Mark "did not discuss" for treatments you did not cover (to alert other clinicians of discussion status).
• Explore other patient preferences to include in Section F (e.g., use of blood products, pain medications, pressors, hospice care).
• Ask the patient (or health care agent) to sign and date Section F. Section F is only valid if the signature box in Section F is fully completed.
• Print the health care agent name and phone number in Section G (optional).
• Instruct the patient to keep the MOLST form where it is easy to see (on the refrigerator, the back of a door, or near the bedside)
• Instruct the patient to carry a copy of the form if they go outside their home.
• Discuss results of calling 9-1-1, based on the patient’s MOLST instructions.
• Copy the MOLST for the patient’s record
• Discuss who else needs a copy (e.g. health care agent, others)
• Re-discuss the form with the patient when there is a significant change in health status, treatment preferences, health care setting or level of treatment.
• Void the patient’s MOLST form in the event of changes
• Complete a new MOLST if desired by the patient