DNR and Medical Orders for Life- Sustaining Treatment (MOLST)

Bureau of EMS Policy Statement
Policy Statement # 11-02
Date March 1, 2011
Subject Re: DNR and Medical Orders for Life- Sustaining Treatment (MOLST)
Supercedes/Updates 99-10, 08-07, 10-05

Purpose

This policy updates all EMS providers and agencies of changes in the laws regarding Do Not Resuscitate (DNR) orders and Medical Orders for Life-Sustaining Treatment (MOLST). The Department now has an approved MOLST form, DOH-5003 Medical Orders for Life-Sustaining Treatment. This form does not replace the Nonhos-pital Order Not to Resuscitate in either the English or the Spanish version (DOH-3474, DOH-3474es), but rather provides an alternative. Nonhospital DNR orders are now governed by Public Health Law Article 29 CCC.

Additionally, this policy will provide an introduction to the Family Health Care Decisions Act (FHCDA). FHCDA allows family members or certain other individuals to make health care decisions, including decisions about the withholding or withdrawing of life-sustaining treatment, on behalf of patients who lose their ability to make such decisions and have not prepared advance directives regarding their wishes. FHCDA went into effect on June 1, 2010.

Nonhospital Order Not to Resuscitate

The New York State Department of Health has an approved standard Out of Hospital DNR form (DOH-3474) that is legally recognized statewide for DNR requests occurring outside of Article 28 licensed facilities. This form is intended for patients not originating from a hospital or nursing home.

For patients with a valid Nonhospital DNR or MOLST form with a DNR order, the Public Health Law allows a standard metal bracelet to be worn by the patient, which includes a caduceus and the words "DO NOT Resusci-tate." EMS providers should assume that there is a valid DNR in place when a DNR bracelet is identified on a patient.

Medical Orders for Life-Sustaining Treatment (MOLST)

MOLST is an alternative form for patients to document their end-of-life care preferences and to assure that those preferences are made known to health care providers across the health care delivery system. Unlike the Nonhospital Order Not to Resuscitate, the MOLST form documents DNI orders and orders regarding other life-sustaining treatment, in addition to DNR orders. MOLST should be honored by EMS agencies, hospitals, nurs-ing homes, adult homes, hospices and other health care facilities and their health care provider staff. MOLST has been approved by the Office of Mental Health and the Office for People With Developmental Disabilities for use as a nonhospital DNR/DNI form for persons with developmental disabilities, or persons with mental illness, who are incapable of making their own health care decisions or who have a guardian of the person appointed pursuant to Article 81 of the Mental Hygiene Law or Article 17-A of the Surrogate's Court Procedure Act.

Chapter 197 of the Laws of 2008 authorized the MOLST form to be used statewide as an alternative form for nonhospital DNR and/or DNI and allowed EMS providers to honor this form in all counties in New York State.

Both the Nonhospital Order Not to Resuscitate form (DOH-3474) and the MOLST form (DOH-5003) are New York State Department of Health forms. The MOLST form was updated in June 2010 to make it more user-friendly and to align the form with the recently enacted Family Health Care Decisions Act. The MOLST form is currently utilized by many health care systems. If a patient has a prior version of the MOLST in place and signed by a physician, the form is still considered VALID, and the patient care orders should be hon-ored, unless it is known that the patient's form has been revoked.

What are the DNR/DNI rules that affect EMS agencies and providers now?

  1. Effective July 7, 2008, the MOLST form is approved for use statewide without the need for a standard one-page Nonhospital Order Not to Resuscitate form.
  2. EMS agencies must still honor the standard one-page nonhospital DNR form or bracelet.
  3. When a patient wears a DNR bracelet, it refers ONLY to the do not resuscitate rules that apply to the nonhospital DNR order. At present there are no nonhospital DNI bracelets.
  4. The MOLST form also provides the patient and his/her physician with the ability to give a Do Not Intubate (DNI) order to health care providers including EMS. Refer to Section E on the MOLST form to review DNI information.
  5. Occasionally EMS providers may encounter a patient who has a newly completed MOLST that does not have the authorizing physician's signature. While the unsigned MOLST form may provide the EMS pro-vider with information about the patient's treatment preferences, it is not a valid DNR or other order. In the case of an unsigned MOLST form EMS providers should:
    1. Initiate rescusitation following applicable state and/or regional protocols;
    2. Obtain clinical information on status of the patient;
    3. Confirm the MOLST form is specific to the patient;
    4. Consult with local medical control and relay the above information; and
    5. Follow the direction of the medical control physician.

What are the differences and similarities between the standard one-page nonhospital DNR order and the MOLST form?

  1. The MOLST form (DOH-5003) is a bright pink multi-page form; however, a photocopy or facsimile of the original form is acceptable and legal. A Nonhospital Order Not to Resuscitate form (DOH-3474) is a sin-gle-page form on white paper with black ink.
  2. The MOLST form is meant to be utilized by health care providers across the health care system. It is not limited to EMS agencies; it travels with the patient to different care settings. The Nonhospital Order Not to Resuscitate form is not intended for use in facilities.
  3. MOLST provides for end-of-life orders concerning resuscitation and intubation for Advanced EMTs when the patient is in full cardio-pulmonary arrest or has progressive or impending pulmonary failure without acute cardiopulmonary arrest. The Nonhospital Order Not to Resuscitate form (DOH-3474) only applies to patients in full cardio or pulmonary arrest.
  4. Both forms, the MOLST form and the Nonhospital Order Not to Resuscitate form (DOH-3474) must be authorized by a physician.
  5. Unlike the Nonhospital Order Not to Resuscitate form, there are multiple patient orders contained on the MOLST form that are intended for other health care providers to follow in other health care settings such as the hospital or nursing home.
  6. The MOLST form gives prehospital care providers and agencies direction regarding the patient's end-of-life treatment orders in Section A (page 1) and Section E (page 2). See below.

Orientation to the MOLST Form, DOH-5003 (June 2010)

Section A - Resuscitation Instructions When Patient has No Pulse and/or is Not Breathing

Section A is titled Resuscitation Instructions When a Patient Has No Pulse and/or Is Not Breathing. It provides two boxes, only one of which will be checked. The first box, "CPR Order: Attempt Cardio-Pulmonary Resus-citation," indicates that the patient wants all resuscitation efforts to be made, including defibrillation and intuba-tion, if they are found in cardiac and/or respiratory arrest.

The second box, "DNR Order: Do Not Attempt Resuscitation (Allow Natural Death)," indicates the patient does not want any resuscitation efforts made, and the patient wishes to be allowed a natural death. This does not prevent treatment up to the point of resuscitation.

Section B - Consent for Resuscitation Instructions

This section MUST be filled out in accordance with New York State law. A box should always be checked to in-dicate who consented to the decision, and the name of the decision-maker should be printed. If the signature line is left blank, the box for verbal consent should be checked. If the box for verbal consent is checked, the at-tending physician who signed the order should have witnessed the consent or two other adult witnesses should be indicated.

Section C - Physician Signature for Sections A and B and for section E

A licensed physician must always sign the orders. If the physician is licensed in a border state, the physician must insert the abbreviation for the state in which he/she is licensed, along with the license number.

As with the Nonhospital Order Not to Resuscitate form (DOH 3474), the MOLST form is required to be reviewed by the physician periodically. However, both forms should be considered valid unless it is known that the medi-cal order has been revoked.

Section D - Advance Directives

This section contains multiple check boxes listing advanced directives for the patient.

Section E - Orders for Other Life-Sustaining Treatment and Future Hospitalization When the Patient has a Pulse and the Patient is Still Breathing

This section contains several parts containing treatment options that must be reviewed by prehospital care pro-viders and includes:

Treatment Guidelines

  • Comfort measures only
  • Limited medical interventions
  • No limitations

Instructions for Intubation and Mechanical Ventilation

  • Do Not Intubate (DNI)
  • A trial period
    • Intubation and mechanical ventilation
    • Non-invasive ventilation (e.g. BIPAP)
  • Intubation and long-term mechanical ventilation

Future Hospitalization/Transfer

  • Do not send to hospital unless pain or severe symptoms cannot otherwise be controlled
  • Send to hospital if necessary, based on MOLST orders.

Artificially Administered Fluids and Nutrition

  • No feeding tube
  • A trial period of feeding tube
  • Long-term feeding tube
  • No IV fluids
  • A trial period of IV fluids

Antibiotics

  • Do not use antibiotics
  • Limited use of antibiotics
  • Use antibiotics

Other Instructions (e.g. dialysis, transfusions)

If any part of Section E is completed, additional consent and a physician signature, similar to Section B, must be documented at the end of this section. Sometimes two boxes will be checked in Section E. If the form was completed in the community (as opposed to a hospital or nursing home), a Public Health Law Surrogate may consent to a nonhospital DNR and/or DNI order, but may not consent to withholding other life-sustaining treat-ment unless the consent is based on clear and convincing evidence of the patient's wishes. For that reason, the box for "based on clear and convincing evidence of the patient's wishes" may be checked in addition to the box for "Public Health Law Surrogate."

Liability Protection

PHL § 2994-gg provides: "No person shall be subjected to criminal prosecution or civil liability, or be deemed to have engaged in unprofessional conduct, for honoring reasonably and in good faith pursuant to this section a nonhospital order not to resuscitate, for disregarding a nonhospital order pursuant to section twenty-nine hun-dred ninety-four-ee of this article, or for other actions taken reasonably and in good faith pursuant to this sec-tion."

Frequently Asked Questions

What should I do if I am uncertain how to proceed?

Contact Medical Control.

What do I do if the patient has both a nonhospital DNR order and a MOLST form? Which do I honor?

If the forms have different orders, you should follow the form that has the most recently dated authorization. In all instances you should follow the DNI instructions on the MOLST form if the form is signed by a physician, as the nonhospital DNR order does not provide this advice.

What if the old MOLST form was signed prior to June 1, 2010, the date the Family Health Care Decisions Act became effective?

You may honor the previous versions of the form as if it were authorized after the statutory effective date.

Does the MOLST law allow EMS to honor other advance directives?

The law does not expand the ability of EMS personnel to honor advance directives such as a Health Care Proxy or Living Will.

What procedures are, and are not, performed if the patient presents a DNR?

Do not resuscitate (DNR) means, for the patient in cardiac or respiratory arrest (i.e., when the patient has no pulse and/or is not breathing), NO chest compressions, ventilation, defibrillation, endotracheal intubation, or medications. If the patient is NOT in cardiac or respiratory arrest, full treatment for all injuries, pain, difficult or insufficient breathing, hemorrhage and/or other medical conditions must be provided, unless Section E of the MOLST form provides different instructions. Relief of choking caused by a foreign body is usually appropriate, although if breathing has stopped, ventilation should not be assisted.

CPR must be initiated if no Out of Hospital or facility DNR is presented. If a DNR order is presented after CPR has been started, stop CPR.

What documentation is required for a patient with a DNR order?

Prehospital care providers should attach a copy of the Out of Hospital DNR form, MOLST form, hospital DNR order and/or copy of the patient's chart to the patient care report, along with all other usual documentation. It should be noted on the patient care report that a written DNR order was present including the name of the phy-sician, date signed and other appropriate information.

If the cardiac/respiratory arrest occurred during transport, the DNR form should accompany the patient so that it may be incorporated into the medical record at the receiving facility.

Patients who are identified as dead at the scene need not be transported by ambulance; however, local EMS agencies should consider transportation for DNR patients who collapse in public locations. In these cases it may be necessary to transport the individual to a hospital without resuscitative measures in order to move the body to a location that provides privacy. Local policies need to be coordinated with the Medical Examiner/Coroner and law enforcement.

MOLST Training

EMS providers and agencies who are interested in more specific training regarding the MOLST form and proc-ess may go to http://www.compassionandsupport.org. This site has a specific training program for EMS provid-ers. The site contains frequently asked questions and a training video that would be useful to better understand the MOLST form and process.

If you have other questions about this policy guidance please contact your DOH Regional EMS office or you may call 518-402-0996.

Resources

New York State Department of Health MOLST Information:

MOLST Forms

Compassion and Support Website:

MOLST Training Center:

MOLST EMS Training Page:

Issued and authorized by Lee Burns, Acting Director of the Bureau of EMS