Clinician Checklist for Using MOLST Forms with Patients
Successful MOLST implementation requires that physicians, nurse practitioners and physician assistants are trained and able to conduct end-of-life and goals of care conversations with patients and their families.
1) BEFORE talking about MOLST:
□ Talk to all patients, healthy or sick, aged 18 and older about the importance of signing a health care proxy
□ When medically indicated, initiate advance care planning conversations with the patient
□ Determine if a patient may be suitable for MOLST based on his or her current medical status and prognosis
2) To INTRODUCE the option of using MOLST: *
□ Engage in discussions with the patient and his or her loved ones and/or representatives about the patient’s health condition, prognosis, values and goals of care
□ Discuss the burdens and benefits of CPR, ventilation, hospitalization and other life-sustaining treatments; explain the potential outcome of each treatment based on the patient’s current medical condition
□ Explore the patient’s expectations and hopes for treatment – especially what the patient would consider to be a successful or acceptable outcome of treatment, and discuss the patient’s treatment preferences
□ Clarify that MOLST is a voluntary way to express preferences about life-sustaining treatments
□ Explain that all patients are made as comfortable as possible as they are nearing the end of life
3) FILLING OUT the MOLST form with a patient: *
On Page 1
□ Fill in Sections A, B, and C to reflect the patient’s preferences
□ Instruct the patient, health care agent, or authorized representative* to fill in Section D completely
□ Fill in Section E yourself (Both Sections D and E must be fully compete and legible for Page 1 to be valid).
□ Fill in optional information as instructed at the bottom of Page 1, if appropriate for the patient
On Page 2
□ For Section F, explain the uses, benefits and burdens of each treatment and mark the patient’s treatment preferences (or mark “Undecided” or “Did not discuss”)
□ Talk with the patient about what “other treatment preferences” to include if appropriate (e.g. use of blood products, antibiotics, hospice care)
□ Instruct the patient, health care agent, or authorized representative to fill in Section G completely
□ Fill in Section H yourself (Both Sections G and H must be fully compete and legible for Page 2 to be valid).
□ Explain that the MOLST form should be: 1) kept with the patient; 2) put where it is easy to find (e.g. on the refrigerator, door, at bedside), and 3) taken with the patient (e.g. in a purse or wallet) outside the home
□ Discuss decision-making about calling 911 in an emergency, based on the patient’s MOLST preferences
□ Copy the MOLST form for the patient’s record and discuss who else needs a copy (e.g. health care agent)
□ Re-discuss the contents of the MOLST form with the patient whenever there is a significant change in the patient’s health status, treatment preferences or goals of care, health care setting, or level of care
□ Void the MOLST form and fill in a new MOLST with updated instructions if one is desired by the patient
* If a patient is declared incapacitated, the health care agent can make decisions about and sign MOLST for the patient. If no health care agent was appointed, a guardian or the parent/guardian of a minor can make decisions about and sign MOLST to the extent permitted by Massachusetts law. Consult legal counsel with questions about a guardian's authority.
