Endpaper: Why You May Need a MOLST

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MOLST stands for Medical Orders for Life Sustaining Treatment. It belongs to a group of end-of-life planning tools that are not widely known. Many people are familiar with Advance Directive documents, which include a Living Will and a Health Care Proxy, that provide instructions about the kind of life-sustaining treatments a person would like when death is eminent. Included in these choices is a “Do Not Resuscitate” option.

Having already made a Do Not Resuscitate (DNR) choice with a Living Will, it’s only natural to believe that you’ve done all that’s necessary to ensure that your wishes will be followed. Sadly, that’s not always the case. Most of us have heard stories or had experiences where someone was resuscitated in an emergency, even though they had very specifically stated their DNR choice and documented it in their Living Will.

Why does this happen? Two factors are involved: First, it has to do with the limitations of the Advance Directive Living Will. This document ONLY covers a person’s care decisions in a hospital or certified nursing facility. When someone has a medical emergency where they stop breathing or their heart stops while they are in transit, in a public setting, in a private home, or at a clinic, the information in their Living Will does not apply.

Second, emergency services provided under the umbrella of various EMT or EMS providers are strictly regulated. They must, by law, provide whatever life-sustaining treatment they deem necessary to save a person’s life during emergency circumstances that happen outside a hospital or nursing facility. And they must do so regardless of what a person’s Living Will says.

Due to the implications of such contradictory outcomes surrounding DNR orders, several documents were developed to avoid the use of unwanted life-sustaining treatment measures outside of a hospital. In New York, as early as 1999, a Nonhospital Order Not to Resuscitate or Out of Hospital DNR form became available. Even today this simple, one-page form is free and downloadable from the New York State Department of Heath website.

This Nonhospital Order Not to Resuscitate (DOH-3474) is legally recognized statewide for DNR orders outside an Article 28 licensed care facility. What this means for the person in cardiac or respiratory arrest is NO chest compressions, ventilation, defibrillation, endotracheal intubation, or medications. To ensure that it is followed, it must be signed by a medical provider and presented if an emergency situation happens anywhere outside of a hospital.

In 2008, the MOLST document for DNR and medical orders for life-sustaining treatment became a more widely used alternative for avoiding the possibility of unwanted resuscitation in the event of cardiac or respiratory arrest outside of a medical care facility. The MOLST form does not replace the Nonhospital Order Not to Resuscitate but rather provides an alternative. It also expands the scope of instructions beyond just the DNR provision.

The four-page MOLST form (DOH-5003) is also free and downloadable from the New York State Department of Health. It is similar to the Living Will in that it allows people to make choices about a variety of end of life treatments such as cardio-pulmonary resuscitation, artificial fluids and nutrition, antibiotic use, or comfort measures only and hospital transfer. The form states, “MOLST is generally for patients with serious health conditions.” It goes on to say that the use of the form should be considered in the following circumstances: if the patient wants to avoid or receive any or all life-sustaining treatment; if the patient resides in a long-term care facility or requires long-term care services; if the patient might die within the next year.

It is especially advisable to consider the benefits of having a MOLST for anyone with a potentially terminal illness being cared for in a private home or receiving palliative or hospice care services. This offers a layer of protection for a person in a home setting where treatment choices made in a Living Will are NOT applicable.

The traditional New York MOLST form is described as being bright pink. This was done to make it more clearly identifiable in the case of an emergency. People using a MOLST are advised to either attach it to the refrigerator or place it on the bedside table where EMTs are trained to look for it. MOLST forms obtained online will print in black and white unless you are able to substitute a pink colored paper for the printout. However, any color MOLST form will be honored.

Most importantly, since MOLST is a document containing medical orders, it must be signed by a physician who is familiar with the patient and agrees with their wishes about treatment decisions. When a patient is transported outside a home setting, the form needs to travel with them. In the event that someone doesn’t already have a paper MOLST, they can contact their physician and have an eMOLST created for them.

Not every state has a MOLST policy. New York and nearby Massachusetts do. However, New Jersey has a POLST or Physicians Orders for Life-Sustaining Treatment as their document. Many other states use that abbreviation, but others use the terms MOST or POST for the documents that outline the type of medical treatment options a person in that state wishes to receive when they are outside of a hospital setting. To see a state-by-state guide of end-of-life planning documents like these, you can go to the website Everplans.com.

Keeping informed and up to date about the different types of documents that help an individual make informed decisions about the medical treatments they would or would not want at the end of life is an important first step in ensuring that those wishes will be honored. The next step is to start talking about those wishes with loved ones and health care providers. Having end-of-life tools in place and shared will help create a more positive death experience.

Written by Carolyn Van Ness, a retired Women’s Health Nurse Practitioner with experience as a medical journalist and author. Currently her priority is end-of-life education through her efforts as a Death Doula, Death Cafe member, and Hospice volunteer.