Frequently Asked Questions (FAQs)
What is Medical Orders for Life-Sustaining Treatment (MOLST)?
The Medical Orders for Life-Sustaining Treatment (MOLST) is a program designed to improve the quality of care people receive at the end of life by translating patient/resident goals and preferences into medical orders.
MOLST is based on communication between the patient/resident, Health Care Agent or other designated decision-maker and health care professionals that ensures informed medical decision-making.
What is the MOLST form?
The MOLST form is a bright pink medical order form signed by a New York State Licensed physician that communicates patient wishes regarding life-sustaining treatment to health care providers. The form includes medical orders and patient preferences regarding:
- CPR (cardiopulmonary resuscitation)
- Intubation and mechanical ventilation
- Artificial hydration and nutrition
- Future hospitalization and transfer
- Antibiotics
What is the MOLST Pilot Project?
Governor Pataki signed the MOLST bill (A.8892, S.5785) establishing a pilot of the MOLST program in Monroe and Onondaga Counties on October 11, 2005. This bill allows for the use of the MOLST form in lieu of the New York State Nonhospital Do Not Resuscitate (DNR) form. The Pilot was officially launched on May 1, 2006.
A Chapter Amendment (A.9479, S.6365), signed by Governor Pataki on July 26, 2006, permits EMS to honor Do Not Intubate (DNI) instructions prior to full cardiopulmonary arrest only in Monroe and Onondaga Counties during the MOLST Pilot and provides a carve out for persons with mental retardation and developmental disabilities without capacity. Individuals with mental retardation and developmental disabilities with capacity can complete a MOLST form.
How long will the MOLST Pilot Project last?
The MOLST Pilot legislation is set to expire on June 30, 2008.
What are the goals of the MOLST program?
MOLST aims to improve the communication of personal wishes about life-sustaining treatments resulting in higher quality medical care.
The MOLST Program was designed to:
- Document a person's treatment preferences regarding:
- Cardiopulmonary resuscitation (CPR)
- Intubation and mechanical ventilation
- Other life-sustaining treatments
- Coordinate physician orders with the individual's wishes.
- Communicate an individual's wishes regarding care across health care settings.
- Improve Emergency Medical Services (EMS) personnel's ability to treat according to the individual's wishes.
- Reduce repetitive documentation while complying with New York State law and the federal Patient Self-Determination Act.
Does the MOLST form replace traditional Advance Directives?
No. Although the MOLST form summarizes Advance Directives, it is not intended to replace traditional Advance Directives like the Health Care Proxy and Living Will.
What is the difference between a Health Care Proxy or Living Will and the MOLST form?
A Health Care Proxy and a Living Will are traditional Advance Directives for all adults 18 years of age and older. These documents are completed ahead of time and only apply when decision-making capacity is lost.
To complement the use of traditional Advance Directives and facilitate the communication of medical orders impacting end-of-life care for patients with advanced chronic or serious illness, the Medical Orders for Life-Sustaining Treatment (MOLST) program was created. In contrast to a Health Care Proxy, the MOLST applies right now and is not conditional on losing decision-making capacity. The MOLST program is based on the belief that individuals have the right to make their own health care decisions, including decisions about life-sustaining treatments, to describe these wishes to health care providers and to receive comfort care while wishes are being honored.
Who should have a MOLST form?
Health care professionals should discuss MOLST with their patients who have advanced progressive chronic illness, are terminally ill or are interested in further defining their care wishes if the patients/residents:
- Want all appropriate treatments including cardiopulmonary resuscitation (CPR).
- Want to avoid all life-sustaining treatments.
- Choose to limit life-sustaining treatments.
- Want to avoid cardiopulmonary resuscitation (CPR) by requesting a "Do Not Resuscitate Order" (DNR order).
- Might die within the next year.
- Reside in a long-term care facility.
- Reside in the community and are eligible for long-term care.
Can the MOLST be used for any persons with mental retardation or developmental disabilities or persons with mental illness?
In the inpatient setting, the MOLST form may be completed by persons with mental retardation or developmental disabilities or persons with mental illness with capacity (capable of making their own decisions). The MOLST may be completed for persons with mental retardation or developmental disabilities or persons with mental illness who lack capacity in accordance with Surrogate's Court Procedure Act §1750-B; however, legal counsel should be consulted.
In the community, the MOLST form may be completed by persons with mental retardation or developmental disabilities or persons with mental illness with capacity (capable of making their own decisions). The Chapter Amendment provides for a carve-out, such that authorization does not extend the use of the MOLST form to persons with mental retardation or developmental disabilities or persons with mental illness who lack capacity.
Does the MOLST take the place of current DNR forms in health care facilities?
In October 2005, New York State Department of Health (NYS DOH) approved the physician order form, the Medical Orders for Life Sustaining Treatment (MOLST), as the legal equivalent of an inpatient Do Not Resuscitate (DNR) form.
On January 11, 2006, NYSDOH sent a letter introducing the MOLST to all health care facilities throughout the New York State.
Will the MOLST form be honored in the community?
Governor Pataki signed the MOLST bill (A.8892, S.5785) establishing a pilot of the MOLST program in only Monroe and Onondaga Counties on October 11, 2005. This bill allows for the use of the MOLST form in lieu of the New York State Nonhospital Do Not Resuscitate (DNR) form. The Pilot was officially launched on May 1, 2006.
A Chapter Amendment (A.9479, S.6365), signed by Governor Pataki on July 26, 2006, permits EMS to honor Do Not Intubate (DNI) instructions prior to full cardiopulmonary arrest in only Monroe and Onondaga Counties during the MOLST Pilot and provides a carve out for persons with mental retardation and developmental disabilities without capacity. Individuals with mental retardation and developmental disabilities with capacity can complete a MOLST form.
Does the MOLST take the place of the current New York State Order Not to Resuscitate (also called the New York State Nonhospital DNR form) in the community?
Governor Pataki signed legislation on October 11, 2005 that allows for the use of alternative forms like the MOLST form in lieu of the NYS Nonhospital Do Not Resuscitate (DNR) form (A8892, S.5785).
This legislation permits a demonstration pilot of use of the MOLST in lieu of the NYS Nonhospital Do Not Resuscitate (DNR) form in Monroe and Onondaga counties.
In all counties other than Monroe and Onondaga, the NYS Nonhospital DNR form is required to indicate DNR orders in nonhospital settings and should be attached to the MOLST form.
Does the existence of a MOLST form mean that the patient has made a decision to forego cardiopulmonary resuscitation (CPR) and has a Do Not Resuscitate (DNR) order?
No. The MOLST form is based on ensuring goal-based discussions that integrate patient preferences and informed medical decision-making. It is not based on limiting medical interventions.
The existence of a MOLST form signifies the occurrence of a thoughtful prior conversation and not the presence of a DNR order.
Does the MOLST form indicate treatment preferences other than DNR?
The DNR order applies in situations when the patient has a complete cardiopulmonary arrest and has no pulse and/or respirations.
In addition to the DNR order, the MOLST contains orders for other life-sustaining treatment when the patient still has pulse and/or is breathing. These include orders for intubation and mechanical ventilation, artificial hydration and nutrition, antibiotics, and hospital transfer.
As a result of the NYSDOH approval, the form may be used in health care settings, including hospitals and nursing homes, to convert the patient's end-of-life treatment preferences beyond DNR into medical orders contained on a single form. The MOLST can be used to transfer these orders from one site of care to another.
Can Do Not Intubate Orders be followed in the community?
The Chapter Amendment to the MOLST Pilot legislation permits EMS to follow a Do Not Intubate (DNI) order only in Monroe and Onondaga Counties.
Do Not Intubate (DNI) is not covered in Nonhospital DNR Law (PHL § 2977). As per current New York State Department of Health policy, Do Not Intubate (DNI) orders can not be honored in the pre-hospital settings and thus is not currently in the scope of practice for EMS.
In counties other than Monroe and Onondaga, EMS cannot directly follow a DNI order. However, as always, EMS can contact Medical Control as is currently within the scope of practice.
How much of the form should be completed?
Completion of the entire form is strongly recommended. Any section not completed implies full treatment for that section.
Review of the entire form serves to educate the patient regarding additional choices for life-sustaining treatment.
Is there any reason to complete the MOLST form if the patient chooses full cardiopulmonary resuscitation?
Reviewing the entire MOLST form with a patient serves to educate the patient regarding additional choices for life-sustaining treatment.
Inconsistencies in goals and preferences may emerge through the discussion that needs to be reconciled. For example, a patient may indicate a desire to never undergo intubation and mechanical ventilation under any circumstance. The patient may not realize that intubation and mechanical ventilation will be required if CPR is successful.
Who can complete a MOLST form with the patient or Health Care Agent?
MOLST must be completed by a health care professional, based on patient preferences and medical indications. Health care professionals should be trained, competent and comfortable with having the conversation in accordance with the MOLST 8-Step Protocol.
MOLST must be signed by a NYS licensed physician to be valid.
Conversations between the health care professional and patient should be shared with the Health Care Agent and family to ensure the Health Care Agent and family are aware of the patient's wishes and to avoid future conflict.
Conflict often arises when the wrong person is chosen as the Health Care Agent or if there is no antecedent conversation.
Can midlevel providers (NP, PA) complete the MOLST form and issue DNR and other orders for life sustaining treatments?
While New York State Law allows only a doctor to complete a DNR order, practicality demands that there is a mechanism for conveying this order when the doctor is not on site. The midlevel provider NP/PA may complete MOLST after a discussion with the attending or covering physician and the physician issues a verbal order. The midlevel notes this in the medical record and the MOLST form and the physician signs the order later.
Verbal orders are acceptable, in accordance with facility or community policy. The orders should be cosigned by an attending physician within a specified brief period of time; for example, within 24 hours in a hospital, and within 1-7 days in a nursing home.
Are verbal orders for DNR given to nurses, nursing supervisors, residents, NP, or PA's acceptable?
Yes. Verbal orders are acceptable, in accordance with facility or community policy. The orders should be cosigned by an attending physician within a specified brief period of time; for example, within 24 hours in a hospital, and within 1-7 days in a nursing home.
Can a physician who has never seen a patient (e.g. a new admission to a skilled nursing facility assigned to a new physician) give a verbal order for DNR to nurses, nursing supervisors, residents, NP, or PA's?
Yes. Verbal orders are acceptable, in accordance with facility or community policy.
Verbal orders are acceptable when followed by a signature of a doctor, in accordance with facility or community policy. The orders should be cosigned by an attending physician within a specified brief period of time; for example, within 24 hours in a hospital, and within 1-7 days in a nursing home.
Can residents (physicians in training) sign a MOLST form that serves as an in-patient DNR?
Yes. The MOLST is approved for use in all health care facilities in NYS by NYSDOH. The resident (physician in training) may complete MOLST after a discussion with the attending physician or covering physician and the physician issues a verbal order. The resident notes this in the medical record and the MOLST form and the physician signs the order later.
Can residents (physicians in training) sign a MOLST form that will also serve as a Nonhospital DNR in Monroe or Onondaga counties during the MOLST pilot program?
No. The New York State Nonhospital DNR must be signed by a New York State licensed MD. Thus, DNR orders signed by a resident (physicians in training) in the inpatient setting, consistent with facility policy, must be co-signed a New York State licensed MD, at the time of discharge.
Who provides consent for a Do Not Resuscitate (DNR) order?
Consent for DNR must be obtained and documented in Section B of Page 1.
Consent can be provided by the patient, resident, a duly appointed Health Care Agent or a surrogate decision-maker, in accordance with NYS Public Health law (PHL § 2977):
- An individual with capacity (the ability to make health care decisions) can provide their own consent.
- If the individual lacks capacity and has a designated health care agent or proxy, then the health care agent or proxy can provide consent for the individual.
- If the individual lacks capacity and does not have a designated health care agent or proxy, then the surrogate must be selected from the following list [in order of priority with "a" as the highest priority and "h" as the lowest priority]:
- Designated health care agent
- Court-appointed committee or guardian
- Spouse
- Son or daughter, age 18 or older
- Parent
- Brother or sister, age 18 or older
- Close friend of the person, age 18 or older (affidavit of close friend required)
- No appropriate surrogate decision-maker is available
May a parent provide verbal consent to a DNR order for a minor child?
Yes. As per Public Health Law §2967(4)(b), a parent may give a verbal consent in the presence of 2 witnesses one of whom must be a MD affiliated with the hospital in which the patient is being treated. The decision must be noted in the patient's medical chart.
How does a designated health care agent or proxy named in a legal Health Care Proxy make DNR decisions?
The Health Care Agent makes DNR decisions based on known patient wishes and is not limited to specific situations. Thus, Step 3 outlined in the "Supplemental" Documentation Form for Adults does not apply and does not need to be completed.
Under what circumstances does a surrogate chosen from a hierarchy list make decisions for DNR?
The physician must determine the lack of utility of cardiopulmonary resuscitation to a reasonable degree of medical certainty. The physician must indicate all pertinent circumstances that apply in Step 3 of the "Supplemental" Documentation Form for Adults:
- The patient/resident has a terminal condition.
- The patient/resident is permanently unconscious.
- Resuscitation would be medically futile.
- Resuscitation would impose an extraordinary burden on the patient/resident in light of the patient/resident's medical condition and the expected outcome of resuscitation.
Can a Health Care Agent serve as a witness of the signature for a DNR order for the patient?
For the patient with capacity, the Health Care Agent can serve as a witness for a DNR order.
For the patient without capacity, the Health Care Agent is providing consent and someone else needs to witness the signature.
Are DNR orders completed when a patient has capacity still valid when the patient loses capacity?
Yes. The patient's preference and expressed wishes for DNR are not lost due to loss of capacity (the ability to make health care decisions). Attach the previously completed DNR form when the patient had capacity and attach to the MOLST. Check the box 'Prior form attached'. Proceed to complete the rest of the MOLST form with the appropriate consent as outlined in 'Who provides consent for 'Orders for Life-Sustaining Treatment and Future Hospitalization'? Use the process outlined in the 8-Step Protocol.
Does a DNR order imply that a patient does not want treatment?
No. Do Not Resuscitate (DNR) does not mean Do Not Treat (DNT).
A well-informed patient may recognize the futility of CPR in the presence of advanced or serious illness and may request a DNR order. However, based on their goals for care, the patient may wish to receive further treatment.
Can a patient choose to have a CPR order and also choose to have an order for DNI?
No. These preferences are inconsistent and reflect a lack of understanding of cardiopulmonary resuscitation (CPR). Choosing CPR implies accepting the entire array of treatments in an emergency situation without limitations.
Since intubation is required after successful cardiopulmonary resuscitation (CPR), the presumption in the case of full cardiopulmonary arrest is that the patient agrees to intubation and mechanical ventilation.
Thus, all patients who prefer DNI should also have a DNR order.
Should all patients who choose DNR also be DNI?
No. DNR applies to patient who experience acute cardiopulmonary arrest, where as DNI applies only to intubation for patients who experience impending pulmonary failure.
Patients may not want CPR and have a DNR order, but may benefit from ventilator support and therefore may not wish to have a DNI order.
What is 'a trial period of intubation and ventilation'?
A time-limited trial of intubation and mechanical ventilation provides the patient a choice of a trial of therapy where the underlying acute impending pulmonary failure is potentially reversible and the patient does not wish long term mechanical ventilation.
The potential need for tracheostomy, preferences for alternate treatments such as BIPAP and CPAP and the provision of symptomatic treatment for dyspnea (oxygen, morphine) should be reviewed.
The patient's goals for care, response and wishes should be documented in the patient's chart and clarified on the MOLST form in "Other Instructions".
Does a 'trial period' of intubation raise ethical issues?
Time-limited trials are ethically and legally appropriate. There is no ethical or legal distinction between withholding and withdrawing life-sustaining treatment.
Who provides consent for a Do Not Intubate (DNI) order?
Do Not Intubate (DNI) is not addressed in DNR PH law.
- An individual with capacity (the ability to make health care decision) can provide their own consent for DNI in the absence of full arrest.
- If the individual lacks capacity and has a designated health care agent or proxy, then the health care agent or proxy can provide consent for DNI in the absence of full arrest. The Agent can make all decisions just as the patient can, including DNI.
- If the individual lacks capacity and does not have a designated health care agent or proxy, then a decision for DNI in the absence of full arrest can only be made with "clear and convincing" evidence.
"Clear and convincing" evidence is defined by a living will or repeated oral expression of wishes instead of application of a literal interpretation of an isolated, out-of-context, patient statement made earlier in life.
Who provides consent for 'Orders for Life-Sustaining Treatment and Future Hospitalization'?
Consent for 'Orders for Life-Sustaining Treatment and Future Hospitalization' should be obtained and documented in Section E of Page 2.
- An individual with capacity (the ability to make health care decisions) can provide their own consent.
- If the individual lacks capacity and has a designated health care agent or proxy, then the agent or proxy can provide consent for the individual.
- If the individual lacks capacity and does not have a designated health care agent or proxy, then "clear and convincing evidence" of the individual's preferences is required in the form of a Living Will or repeated oral expression. Confirmation of the person's treatment preferences must be obtained and consent documented in Section E.
Does the supplemental form for adults always need to be completed?
No. The MOLST supplemental form for adults must be completed only when the adult patient lacks capacity to consent for himself or herself.
What is capacity?
Capacity is the ability to take in information, understand its meaning and make an informed decision using the information. Intact capacity permits functional independence. Capacity requires a cluster of mental skills people use in everyday life and includes memory, logic, the ability to calculate and "flexibility" to turn attention from one task to another.
How does one access capacity?
Medical determination of capacity is often difficult. There is no standard "tool." Capacity assessment is a complex process and is not simply determined by the Mini-Mental Status Exam (MMSE). Capacity assessment should involve a detailed history from the patient, collateral history from family, focused physical examination, including cognitive, function and mood screens and appropriate testing to exclude reversible conditions.
How does capacity vary?
Capacity requirements vary by task.
For example, the capacity to choose a trusted individual as an appropriate Health Care Agent differs from the capacity to make health care decisions such as agreeing to a medical procedure or treatment.
Who determines capacity?
The physician determines capacity. This determination must be affirmed by a concurring physician.
Who determines capacity in the case of "mild dementia" in a new resident in a long term care facility who requests a DNR order?
The physician determines capacity. This determination must be affirmed by a concurring physician.
Remember that capacity requirements vary by task.
The patient with dementia may retain the capacity to choose a trusted individual as an appropriate Health Care Agent but not the capacity to make health care decisions such as agreeing to a medical procedure or treatment.
In this situation, a Health Care Proxy may be completed and the designated Health Care Agent can then make the health care decisions.
Do I need a psychiatric consultation in all cases to determine decision-making capacity?
No. The physician can determine capacity and should seek consultation if there is a question regarding capacity determination.
When do I need a psychiatric consultation?
If the individual lacks capacity because of a mental illness, the concurring physician must be board certified in psychiatry.
Mental illness is defined by conditions such as schizophrenia or acute psychotic episode and does not refer to dementia.
Who determines capacity for individuals with developmental disabilities?
If the individual lacks capacity because of a developmental disability, the concurring opinion must be provided by a physician or psychologist with special experience or training in the field of developmental disabilities.
Is documentation in the medical record important and part of the process?
Yes. The health care professional should document:
- Conversations with the patient, Health Care Agent or 'family', as defined by the patient.
- Patient capacity assessments.
- Evidence of 'clear and convincing' evidence.
What is 'clear and convincing' evidence?
'Clear and convincing evidence' can be in the form of a living will or repeated oral expression, established In the Matter of Westchester County Medical Center, on behalf of Mary O'Connor, p. 8.
"The ideal situation is one in which the patient's wishes were expressed in some form of a writing, perhaps a 'living will,' while he or she was still competent. The existence of the writing suggests the seriousness of purpose and ensures that the court is not being asked to make a life-or-death decision based upon casual remarks".
The decision went on to state,
"Of course, a requirement of a written expression in every case would be unrealistic. Further, it would unfairly penalize those who lack the skill to place their feelings in writing. For that reason, we must always remain open to applications such as this, which are based upon the repeated oral expressions of the patient".
What does a physician do if there is disagreement about the 'clear and convincing evidence'?
If there is disagreement among family members, there are often reasons for conflict unrelated to the underlying medical condition. Attention must be focused on identifying the source of conflict and then proceeding with a plan for conflict resolution. An Ethics or Palliative Care Consult may help.
Does the presence of MOLST eliminate the need for hospitals to establish clear and convincing evidence of the incapacitated patient's wishes for end of life treatments?
If the MOLST is completed after the person loses capacity, the Adult Supplemental Form must be completed.
For incapacitated patients, 'clear and convincing evidence', as defined by New York State case law, should be established.
Ideally, once established capacity assessment and clear and convincing evidence should be documented in the medical record and should travel with the patient.
In the absence of a Health Care Proxy, is it acceptable for only one family member to state what the patient/resident's wishes were?
The physician must focus on what clearly represents 'clear and convincing evidence' and then achieving family consensus.
Conversation should be focused to provide evidence of previous repeated oral expression of wishes instead of applying a literal interpretation of an isolated, out-of-context, patient statement made earlier in life. If conflict persists, an Ethics or Palliative Care Consult may help.
Is there a difference between a decision to withhold or discontinue life sustaining treatments?
No. Ethical or legal distinctions exist between withholding or withdrawing treatment. If such a distinction existed, the patient would refuse treatment fearing that treatment could not be discontinued.
Can hospitals rely solely on the MOLST form to withhold or discontinue life sustaining treatments?
Yes. Similar to the NYS Nonhospital Do Not Resuscitate (DNR) form, a properly completed MOLST form records actionable medical orders written by a licensed NYS physician. In addition to DNR orders, MOLST contains 'Orders for Life-Sustaining Treatment and Future Hospitalization'.
The presence of a MOLST signifies the occurrence of a thoughtful prior discussion between a patient and health care professional, shared with 'family', as designated by the patient/resident. It is based on informed medical decision-making and patient preferences. Further, a set of medical orders has been signed by a licensed NYS physician.
When the need occurs in an emergency, first follow these orders, and then contact the physician. The form should be reviewed at the time of transfer as indicated in the guidelines for review and renewal of orders.
The entire MOLST form should be reviewed and renewed by a physician periodically, as required by New York State and Federal law or regulations, and/or if:
- The patient/resident is transferred from one facility to another.
- There is a substantial change in the person's health status (improvement or deterioration).
- The patient/resident treatment preferences change.
If the patient now lacks capacity, review orders with the Health Care Agent and affirm the prior conversation.
Can the MOLST form be changed if the patient or doctor does not like the form?
No. The original MOLST forms have undergone an extensive review process with the NYSDOH in 2005. The forms revised in October 2005 are consistent with New York State Law and are approved for use by NYSDOH for all health care facilities in New York State.
However, additional guidelines for starting/stopping treatment not addressed elsewhere on the form can be included in Section E under "Other Instructions," for example, decisions about dialysis, implantable defibrillators, and the duration of time-limited trials.
What do you do with a completed MOLST form?
MOLST forms are designed to travel with the individual between care settings.
The form should be kept in the front of the individual's medical chart when the individual is in a facility.
When the individual is transferred between care settings, a copy of the form should be made and kept in the medical chart at the transferring location. The original form should accompany the individual and be placed in the individual's medical chart at the new care setting.
When the individual is at home, the MOLST form should be kept on the refrigerator, by the phone in the kitchen or by the individual's bedside. In case of emergency, EMS personnel are trained to look for the MOLST form in these locations.
MOLST, supplemental forms, traditional Advance Directives and documentation of any 'clear and convincing evidence' should be kept together and transferred with patient at discharge. Otherwise the form may need to be redone.
Should the MOLST be reviewed? If so, how often?
Yes. The entire MOLST form should be reviewed and renewed by a physician periodically, as required by New York State and Federal law or regulations, and/or if:
- The patient/resident is transferred from one facility to another.
- There is a substantial change in the person's health status (improvement or deterioration).
- The patient/resident treatment preferences change.
The DNR Order on the MOLST form must be reviewed and renewed by a physician as required by New York State law and regulations:
- Hospital: at least every 7 Days.
- Nursing Home/Skilled Nursing Facility: at least every 60 Days.
- Nonhospital/Community Setting: at least every 90 Days.
If a completed MOLST form is present upon admission or transfer to a health care facility and the patient does not remember the conversation, how should the health care professional proceed?
Assess patient capacity at the time of form completion. Was patient deemed to have decisional-capacity at the time of MOLST completion, as evidenced by the fact that the patient completed the form and no supplemental documentation is completed and attached?
Review admission or transfer papers for evidence of documentation of the conversation.
If no documentation is present, verify information through a conversation with the physician who completed the MOLST form. The physician license # and phone/pager # is on the MOLST form.
Reassess patient capacity at the time of transfer as the patient may have had capacity when the MOLST form was completed but lost capacity in the interim.
If capacity is intact, the patient's goals for care may have changed. Initiate a goal-based discussion, per the 8-Step Protocol and complete a new MOLST consistent the patient's current preferences.
If a patient from another county completes a MOLST in a health care facility in Monroe or Onondaga county, can the MOLST be used in the community after discharge?
The Chapter Amendment and the MOLST Pilot legislation apply to the county in which the patient resides, not the county in which MOLST is completed. A New York State Department of Health Nonhospital DNR Order form must be completed in addition to the MOLST.
Is a copy of the MOLST form acceptable and legal?
Yes.
Is a facsimile (fax) of the MOLST form acceptable and legal?
Yes.
Is a stamped signature on the MOLST form acceptable and legal?
No.
Why is the MOLST form bright pink?
The MOLST form is bright pink so Health Care Providers can identify it in case of an emergency.
How can the pinkness of the MOLST form be maintained?
When the individual is transferred between care settings, a copy of the form should be made on Pulsar Pink paper. The original MOLST form should accompany the patient and placed in the chart in the new care setting or placed on the refrigerator at home.
How does MOLST work with electronic health records?
Scan MOLST into the computer at time of admission and discharge. Review MOLST at the time of discharge or transition of care and retain an electronic copy. For example, if a patient is discharged to home, the original MOLST form should go with the patient. A copy should be retained in the electronic medical record, a copy should go to the primary care physician's office and a copy should go to the health care agency if the patient has home care.
How is MOLST implemented for a patient receiving Home Care services?
If the patient is homebound and the physician is making home visits, the physician completes the MOLST form, makes a copy and returns the original MOLST to the patient. If the patient is seen by the physician in the office, the MOLST form is completed, a copy is made and the original MOLST is given to the patient.
How is MOLST implemented for a patient receiving Hospice services?
If the patient is homebound and the physician is making home visits, the physician completes the MOLST form, makes a copy and returns the original MOLST to the patient.
If the patient is seen by the physician in the office, the MOLST form is completed, a copy is made and the original MOLST is given to the patient.
Is honoring a DNR order in the outpatient dialysis unit prohibited by Public Health Law?
Public Health Law does not prohibit a free standing Art 28 renal dialysis site from honoring a DNR rather it does not require that they follow it. Because this setting is not contemplated under the statute it would be a Nonhospital DNR that the center would be considering. If there is a DNR from a hospital or nursing home to the ESRD then the hospital form may or may not be honored.
Should the completion of Advance Directives be a routine part of quality of care measures similar to pain assessment?
Yes. The National Quality Forum Framework and Preferred Practices for Quality Palliative Care & Hospice Care issued in 2006 recommends preferred practices for advance care planning. Adapted for New York State, these include:
- Document the designated agent (surrogate decision maker) in a Health Care Proxy for every patient in primary, acute and long-term care and in palliative and hospice care.
- Document the patient/surrogate preferences for goals of care, treatment options, and setting of care at first assessment and at frequent intervals as condition changes.
- Convert the patient treatment goals into medical orders and ensure that the information is transferable and applicable across care settings, including long-term care, emergency medical services, and hospital, i.e., the Medical Orders for Life-Sustaining Treatments – MOLST, a POLST Paradigm Program.
- Make Advance Directives and surrogacy designations available across care settings.
- Develop and promote healthcare and community collaborations to promote advance care planning and completion of Advance Directives for all individuals.
Where can I get MOLST forms?
MOLST forms are available at participating health care facilities in New York State.
Compassion and Support - End-of-Life and Palliative Care Planning, MOLST of New York State offers the forms free-of-charge to the community at CompassionandSupport.org