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"Clinician Checklist for Using MOLST"

Fast Facts about MOLST

  • Filling out MOLST is one possible outcome of clinical discussions with patients* about life-sustaining treatment decisions.
  • The patient's* choice to use the MOLST form must be voluntary. 
  • The clinician's signature on MOLST confirms that the form accurately reflects the clinician's discussion(s) with the patient*.
  • The goal is to offer MOLST as an option for suitable patients of any age with a serious advancing illness, including:
    • Life-threatening illness or injury
    • Chronic progressive disease
    • Medical frailty
    • Any patient with whom you would discuss DNR orders

How to HONOR a patient's MOLST form:

 1.   Determine if the form is valid:

  • Two (2) patient identifiers are present
  • Patient signature box is complete
  • Clinician signature box is complete
  • Information is clear and legible
  • If able, verify with the patient that the MOLST is current.

2.  If valid, honor the decisions documented on the MOLST form as you would honor other medical orders.  If needed, contact the signing clinician for more information.

3.  If there is conflict related to honoring MOLST instructions, refer to your institution's policy or guidelines for dealing with conflict.

How to INTRODUCE the MOLST form to a patient*:

  1. When appropriate, discuss the patient's health status, prognosis, values and goals for care.
  2. When appropriate, discuss the benefits and burdens of the life-sustaining treatments in the context of the patient's current health status and treatment plan.
  3. Explain the use of the MOLST form to provide documentation and communication of the patient's decisions about life-sustaining treatments.
  4. If the patient chooses, proceed with filling out the MOLST form to document the patient's decisions reached in the context of your discussions.

How to COMPLETE the MOLST form with a patient*:

  1. Fill in the parts of the MOLST form that were discussed with the patient and are relevant to the patient's current clinical situation.
  2. Fill in boxes A, B, C on page 1 or Box F on page 2, to reflect the patient's decisions about the treatments discussed (not all boxes need to be filled in).
  3. Instruct the patient to fill in boxes D and G completely and legibly - including their signature, printed name, the date, and phone number.
  4. As the signing clinician, fill in boxes E and H completely and legibly - including your signature, printed name, the date and time, and phone number.
  5. Retain copies of the original MOLST form for the medical record.  Return the original MOLST form to the patient and follow your institutional procedure for documenting MOLST instructions in the patient's medical record/care plan.
  6. Educate the patient about the need to carry the MOLST form (or a copy) with them everywhere they go, and to inform their Health Care Agent, family members, caregivers, and other health care providers about the decisions they have documented.



How to CHANGE the MOLST form with a patient*:

  1. Rediscuss the decisions on the MOLST form with the patient whenever there is a change in health status, treatment preferences, goals of care, health care setting or level of care.
  2. If after discussions with a patient, the form needs changing, VOID the outdated MOLST form and fill out a new MOLST form if the patient wants one.
  3. Re-enter the new MOLST form and instructions in the medical record/care plan and remember to provide everyone who has copies of the outdated MOLST form with the updated new MOLST form.


NOTE: It is the responsibility of the signing clinician to know if the patient has capacity to sign the MOLST form.  If the patient's decision-making capacity is uncertain, the signing clinician should seek clinical counsel.  Only 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, consult legal counsel with questions about if anyone else can make MOLST decisions or sign MOLST on the patient’s behalf.