MOLST: Honoring Patient’s Life-Sustaining Treatment Preferences
by Matthew Solomon, Esq.
In 2012, Massachusetts introduced a new medical form called the Medical Order for Life Saving Treatment (MOLST) form. The driving force behind MOLST, and the broader National Physicians Order for Life Sustaining Treatment (POLST), came from a need for end-of-life planning based on conversations between patients, their loved ones, and medical providers.
The concept was to improve the quality of patient care and reduce medical errors by creating a system that identifies seriously ill patients’ wishes regarding medical treatment, and communicates and respects these wishes through portable medical orders. See National POLST website, http://www.polst.org
The MOLST form stays with the patient, so the form would be available at the location of the patient if he or she is picked up by emergency medical transportation or receive emergency care in his home or elsewhere, if the form is on his or her person.
In, Massachusetts, MOLST consists of a standardized process and form. The stated goals of the MA MOLST Program are to:
(1) Encourage discussions between clinicians and their patients nearing the end of life about treatment options and patients’ preferences for care; and
(2) Provide clinicians and their patients with a mechanism for translating patients’ preferences into portable signed medical orders (the MOLST form) which travel with the patient and can be honored across health care settings.
An important aspect of MOLST is that enables doctors, nurse practitioners and/or physician assistants to collaborate with the patient, the patient’s health care agent and (to the extent permitted by law), the patients’ guardian, to complete the MOLST form. The MOLST form, once completed and signed by the patient, is an actionable medical order.
The MOLST form consists of two pages, which are designed to be valid independently. Both pages require signatures from both the patient (or the patients’ Health Care Agent/Guardian/Parent or Guardian of a minor) and the Physician, Nurse Practitioner, or Physician Assistant for it be valid. Each page pertains to medical orders for specific medical treatments:
(1) Page 1 contains three treatment options:
(i) Cardiopulmonary Resuscitation: in the case of cardiac or pulmonary arrest (either “Do Not Resuscitate” or “Attempt Resuscitation”;
(ii) Ventilation: for a patient in respiratory distress (either “Do Not Intubate and Ventilate” or “Intubate and Ventilate” and either “Do Not Use Non-Invasive Ventilation (e.g. CPAP) or “Use Non-Invasive Ventilation (e.g. CPAP)), and
(iii) Transfer to Hospital: (either “Do Not Transfer to Hospital (unless needed for comfort) or “Transfer to Hospital”).
(2) Page 2 identifies five additional medically-indicated treatments that may be offered in a clinical setting and also documents whether the treatment has either been discussed or that the patient is undecided:
(i) Intubation and Ventilation: refers back to Page 1 and includes an option to choose short term;
(ii) Non-Invasive Ventilation: Includes the same options as for Intubation and Ventilation;
(iii) Dialysis: choices include “No Dialysis”, “Use dialysis”, and “Use dialysis, but short term only”;
(iv) Artificial Nutrition: Same options as for Dialysis; and
(v) Artificial Hydration: Same options as for Dialysis.
Page 2 is designed to assist further discussion between if and when new clinicians become involved in the patients’ care.
It should be noted the MOLST form is very different than a Health Care Proxy. The two most important distinctions between the two documents are that (1) the Health Care Proxy is a legal document while the MOLST form is a medical document, and (2) the Health Care Proxy becomes effective only if the person is declared to lack the capacity to make his/her own medical decision while the MOLST form goes into effect immediately upon signing. Thus, it is still recommended that people have both forms executed in order to hopefully cover every situation or setting.
Several important questions remain with regard to MOLST forms:
1. Will the form be honored in other states?
According to molst-ma.org, the MOLST form may or may not be honored in other states. Thus, there is no certainty that the form will be honored outside of Massachusetts, so it shouldn’t be solely relied on as a definitive and fool-proof medical order.
2. What happens if a person has a Comfort Care/Do Not Resuscitate Form (“CC/DNR”) as well as a MOLST form?
The Massachusetts CC/DNR form continues to be valid. The CC/DNR form can still be used to show that a valid DNR order exists, and should be honored by EMTs. MOLST forms can also be used in place of a CC/DNR form. If a patient has both forms, the most recent of the two orders should be honored.
3. Can a spouse or relative sign the MOLST form if the patient has lost capacity?
The only person that can sign the MOLST form for a patient who is over the age of 18 and has lost capacity is the patient’s designated health care agent.
4. Will EMTs or Emergency Room medical personnel really abide by them and let someone die?
That’s the big question that remains unanswered. EMTs do have the obligation to honor MOLST forms. The Massachusetts Department of Public Health’s Office of Emergency Medical Services (“OEMS”) has jurisdiction over emergency medical services and instructs that MOLST forms must be honored by EMS personnel. EMS personnel are told to call Medical Control (which acts as a link between EMS providers and physicians) if they are in the field and have a question about a MOLST form or the form’s instructions. EMS personnel are also instructed that a patient may, at any time, ask for treatment that has been previously refused on the MOLST form.