MOLST

NEW YORK STATE DEPARTMENT OF HEALTH

Medical Orders for Life-Sustaining Treatment (MOLST)

THE PATIENT KEEPS THE ORIGINAL MOLST FORM DURING TRAVEL TO DIFFERENT CARE SETTINGS.THE PHYSICIAN/NURSE PRACTITIONER/PHYSICIAN ASSISTANT KEEPS A COPY.

LAST NAME/FIRST NAME/MIDDLE INITIAL OF PATIENT

ADDRESS

CITY/STATE/ZIP

DATE OF BIRTH (MM/DD/YYYY)

Date

eMOLST NUMBER (THIS IS NOT AN eMOLST FORM)

Do-Not-Resuscitate (DNR) and Other Life-Sustaining Treatment (LST)

This is a medical order form that tells others the patient's wishes for life-sustaining treatment. A health care proffessional must complete or change the MOLST form based on the patient's current medical condition, values, wishes, and MOLST instrusctions. If the patient is unable to make medical decisions, the orders should reflect the patients wishes, as best understood by the health care agent or surrogate. A physician/nurse practicioner/ physician assistant must sign the MOLST form. All health care proffessionals must follow these medical orders as the patient moves from one location to another, unless a physician/nurse practitioner/physician assistant examines the patient, reviews the orders and changes them.

MOLST is generally for patients with serious health conditions. The patient or other decision-maker should work with the physician/nurse practitioner/physician assistant and consider asking the physician/nurse practitioner/physician assistant to fill out a MOLST form if the patient:

Wants to avoid or recieve any or all life sustaining treatment
Resides in a long-term care facility or requires long-term care services
Might die within the next year

If the patient has an itellectual or developmental disability (I/DD) and lacks the capacity to decide, the physician (not a nurse practitioner or physician assistant) must follow special procedures and attach the completed Office for People with Developmental Disabilities (OPWDD) legal requirements checklist before signing the MOLST. See page 4.

SECTION A: Resuscitation Instructions When the Patient Has No Pulse and/or Is Not Breathing. Check one:

CPR Order: Attempt Cardio-Pulmonary Resuscitation CPR involves artificial breathing and forceful pressure on the chest to try to restart the heart. It usually involves electric shock defibrillation and a plastictube down the throat into the windpipe to assist breathing intubation It means that all medical treatments will be done to prolong life when the heart stops or breathing stops, including being placed on a breathing machine and being transferred to the hospital.

Consent for Resuscitation Instructions (Section A)

The patient can make a decision about resuscitation if he or she has the ability to decide about resuscitation. If the patient does NOT have the ability to decide about resuscitation and has a health care proxy, the health care agent makes this decision. If there is no health care proxy, another person will decide, chosen from a list based on NYS law. Individuals with I/DD who do not have capacity and do not have a health care proxy must follow SCPA 1750-b.

SIGNATURE

DATE/TIME

Date

DATE/TIME

PRINT NAME OF DECISION MAKER

PRINT FIRST WITNESS NAME

PRINT SECOND WITNESS NAME

Who made the decisions?

SECTION C: Physician/Nurse Practitioner/Physician Assistant Signature for Sections A and B

PHYSICIAN/NURSE PRACTITIONER/PHYSICIAN ASSISTANT SIGNATURE

PHYSICIAN/NURSE PRACTITIONER/PHYSICIAN ASSISTANT NAME

DATE/TIME

Date

PHYSICIAN/NURSE PRACTITIONER/PHYSICIAN ASSISTANT LICENSE NUMBER

PHYSICIAN/NURSE PRACTITIONER/PHYSICIAN ASSISTANT PHONE/PAGER NUMBER

Format: (000) 000-0000.

SECTION D: Advanced Directives Check all advance directives known to have been completed:

*If this decision is being made by a 1750-b surrogate, a physician must sign the MOLST.

THE PATIENT KEEPS THE ORIGINAL MOLST FORM DURING TRAVEL TO DIFFERENT CARE SETTINGS. THE PHYSICIAN/NURSE PRACTITIONER/PHYSICIAN ASSISTANT KEEPS A COPY.

LAST NAME/FIRST NAME/MIDDLE INITIAL OF PATIENT

Date

SECTION E: Orders For Other Life-Sustaining Treatment and Future Hospitalization When the Patient has a Pulse and the Patient is Breathing

Life-sustaining treatment may be ordered for a trial period to determine if there is benefit to the patient. If a life-sustaining treatment is started,but turns out not to be helpful, the treatment can be stopped. Before stopping treatment, additional procedures may be needed as indicated on page 4.

Treatment Guidelines No matter what else is chosen, the patient will be treated with dignity and respect, and health care providers will offer comfort measures. Check one:

Comfort measures only Comfort measures are medical care and treatment provided with the primary goal of relieving pain and other symptoms and reducing suffering. Reasonable measures will be made to offer food and fluids by mouth. Medication, turning in bed, wound care and other measures will be used to relieve pain and suffering. Oxygen, suctioning and manual treatment of airway obstruction will be used as needed for comfort.

Instructions for Intubation and Mechanical Ventilation. Check One:

Future Hospitalization/Transfer Check one

Artificially Administered Fluids and Nutrition When a patient can no longer eat or drink, liquid food or fluids can be given by a tube inserted in thestomach or fluids can be given by a small plastic tube (catheter) inserted directly into the vein. If a patient chooses not to have either a feeding tube or IV fluids, food and fluids are offered as tolerated using careful hand feeding. Additional procedures may be needed as indicated on page4. Check one each for feeding tube and IV fluids

Antibiotics Check one

Other Instructions about starting or stopping treatments discussed with the physician/nurse practitioner/physician assistant or about other treatments not listed above (dialysis, transfusions, etc

Consent for Life-Sustaining Treatment Orders (Section E) (Same as Section B, which is the consent for Section A)

SIGNATURE

Check if verbal consent (Leave signature line blank)

DATE/TIME

Date

PRINT NAME OF DECISION MAKER

PRINT FIRST WITNESS NAME

PRINT SECOND WITNESS NAME

Who made the decisions?

Physician/Nurse Practitioner/Physiciar Assistant Signature for Section E

PHYSICIAN/NURSE PRACTITIONER/PHYSICIAN ASSISTANT SIGNATURE

PRINT PHYSICIAN/NURSE PRACTITIONER/PHYSICIAN ASSISTANT NAME

DATE/TIME

Date

*If this decision is being made by a 1750-b surrogate, a physician must sign the MOLST.

This MOLST form has been approved by the NYSDOH for use in all settings.