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Massachusetts
Medical Orders for
Life-Sustaining
Treatment
“MOLST Overview for Health Professionals”
The MOLST project is a collaboration of the:
• Massachusetts Department of Public Health
• Massachusetts Executive Office of Elder Affairs and
• Commonwealth Medicine at UMass Medical School
Presenters
picture
Christine McCluskey, RN, MPH
Director, MOLST Expansion Project
Commonwealth Medicine, UMass Medical School
Mary Valliere, MD
Medical Consultant, MOLST Expansion Project
Jena Bauman Adams, MPH
Training Consultant, MOLST Expansion Project
Central Massachusetts Area Health Education Center
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Goals of the Presentation
 Provide basic information about MOLST
 Provide a recorded version of the MOLST Overview for Health
Professionals that may be used for individual or group training
 Supplement the MOLST Overview for Health Professionals with
responses to Frequently Asked Questions about its content
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MOLST Overview for Health Professionals
Documenting and honoring patients’
preferences for life-sustaining treatment
MOLST is…

A “POLST paradigm” program (more info at www.polst.org)

A medical document that may be used in the context of
advance care planning

Suitable for patients of any age with an advanced illness

Based on a patient’s current health status

Valid medical orders for life-sustaining treatments

A portable document that is valid across care settings
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MOLST expands on the MA Comfort Care/DNR form
CC /
DNR
M
O
L
S
T
Documents
that a medical
order exists
Always
instructs DNR not to use CPR
Orders about
CPR only
Honored in
outpatient
settings
by EMTs
Is a medical
order form
May instruct to
use OR not use
treatments
Orders about
several types of
life-sustaining
treatments
Honored
across settings
by all health
professionals
The CC/DNR form remains valid in Massachusetts!
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MOLST is not an Advance Directive

Advance Directives are legal (not medical) documents.

Advance Directives specify who (e.g. health care agent) or
what (e.g. information on a living will) represents a
person’s preferences if the person loses capacity to make
medical decisions.

Advance Directives go into effect only after a patient is
declared incapable of making their own medical decisions.
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Advance Directives in Massachusetts

The only legally authorized Advance Directive in
Massachusetts is a health care proxy (HCP) form.

Health care proxy forms specify who (the health care
agent) represents an incapacitated patient during
shared decision-making.
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What about “Living Wills”?

A “living will” is written documentation of a person’s
preferences – to guide surrogates and clinicians if the
person loses capacity to make medical decisions.

Living wills are not legally binding in Massachusetts, but
can be important sources of information about a person’s
preferences.
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A Comparison of Forms
MOLST
HEALTH CARE PROXY
Form type
Medical document
Legal document
Form users
Patients of any age with
advanced illness
All adults (ages 18 and older)
healthy or sick
Form
contains
Current medical orders about
life-sustaining treatments
Name of the person’s appointed
health care agent(s) for future
shared decision-making
Form
signer(s)
The patient* and clinician
The person and two witnesses of
their own choice
* Or health care agent (only if the patient lacks capacity)
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Who signs the MOLST form?
The patient or patient’s health care agent (only if the patient
has been declared to lack capacity). If there is no agent, a guardian or
the parent/guardian of a minor can sign to the extent permitted by
Massachusetts law. Seek legal counsel about a guardian’s authority.
and
The clinician – a physician, nurse practitioner or physician
assistant, after goals of care discussions with the patient and his or her
surrogates.
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Which patients are suitable for MOLST?
Patients of any age with an advanced illness including,
but not limited to:
• Life-threatening diseases
• Chronic progressive diseases
• Life-threatening injuries
• Medical frailty
• Any patient suitable for considering DNR orders
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When a patient has a MOLST form
• Honor the MOLST form as you would honor other
medical orders, until a physician, nurse practitioner or
physician assistant can assess the clinical situation.
• Alert a clinician about the existence and contents of the
MOLST form.
• Contact the clinician who signed the patient’s MOLST for
more information if needed.
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When a patient wants a MOLST form
1) Alert a clinician when:
• Any patient/health care agent asks about MOLST
• Any patient/health care agent expresses preferences
about life-sustaining treatments
• Any patient may be suitable for MOLST
2) Assist patients and families to get information they need
for advance care planning – especially the importance of
completing a health care proxy form
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Contents of the MOLST form
Page 1 contains:
• Section A – CPR: for a patient in cardiac or respiratory arrest
• Section B – Ventilation: for a patient in respiratory distress
• Section C – Transfer to Hospital
• Section D – Patient signature, printed name, phone , date*
• Section E – Clinician signature, printed name, phone , date*
• Optional expiration date and other optional contact information
* Required for a valid page 1
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Page 2 contains
• Section F – Preferences about treatments that may be
appropriately offered in the future – including:
Non-invasive ventilatory support; Dialysis; Artificial Nutrition;
Artificial Hydration; and other treatment preferences.
Includes Treatment Options: Give treatment; No treatment;
Short-term only; Undecided; Did not discuss
REQUIRED FOR A VALID PAGE 2

Section G – Patient signature, print name, contact info, date

Section H – Clinician signature, print name, contact info, date
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After the MOLST is signed
• The original MOLST form stays with the patient.
• The MOLST form should be placed where it can be easily
located (e.g. on the refrigerator, at the bedside).
• The form should go with the patient to all care settings and
during any trips/appointments outside the home.
• Family and caregivers should be informed about the MOLST
form, its contents, and where to find it.
• Copies of the MOLST are valid; make copies for all the
patient’s health care providers and to put in the EHR.
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Updating MOLST forms



MOLST forms should be re-discussed with patients any time
there is a significant change in the patient’s health status;
location or level of care; goals of care; or treatment wishes.
Patients can ask to change or void their MOLST at any time
(or request and receive previously refused medicallyindicated treatment).
Any change to the MOLST form requires the form to be
voided and a new form created (and documented in the EHR)
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Voiding the MOLST forms
• Write “VOID” across Page 1 and Page 2 of the form.
• Instruct the patient that all copies of the outdated form must
be destroyed.
• Document updates to MOLST instructions in the EHR system.
• Create a new MOLST form if the patient desires it.
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If you have further questions about MOLST in
Massachusetts, please review the MOLST website,
especially the FAQs and other information for Health
Professionals at www.molst-ma.org.
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