Medical Orders for Life Sustaining Treatment (MOLST)

Bureau of EMS Policy Statement
Policy Statement # 08-07
Date 09/8/2008
Subject Medical Orders for Life Sustaining Treatment (MOLST)
Supercedes/Updates 99-10

Purpose

The purpose of this policy is to advise all EMS providers and agencies of a change in the law regarding Do Not Resuscitate Orders (DNR). On July 7, 2008 Governor David Paterson signed Chapter 197 of the Laws of 2008 allowing the use of an alternative DNR form. This form is the Medical Orders for Life Sus-taining Treatment or MOLST form.

These guidelines are not intended to replace the current out of hospital DNR orders and Policy #99-10 governed by Chapter 370 of the Laws of 1991. They remain in effect. These guidelines are an update to that policy and will discuss only the addition of the MOLST form that can now be used as an alternative DNR form to the traditional non-hospital DNR form currently in use.

Medical Orders for Life Sustaining Treatment (MOLST)

MOLST is an alternative form and process for patients to provide their end of life care preferences to health care providers across the spectrum of the health care delivery system. MOLST may be honored by EMS agencies, hospitals, nursing homes, adult homes, hospices and other health care facilities and their health care provider staff. The MOLST form is a bright pink form that was piloted by the Rochester Health Commission under previous legislation for use by the EMS community in Onondaga and Monroe Coun-ties. The recently enacted legislation mentioned above now allows EMS to honor this form in all counties in New York State. Previous to the enactment of Chapter 197 EMS agencies outside of Onondaga and Monroe Counties still required the use of the non-hospital DNR form.

Unlike the Non Hospital Order Not to Resuscitate form (DOH-3474), the MOLST form is not a New York State Department of Health produced or distributed form. However, it is an approved form that was previ-ously modified with the assistance of the NYS Department of Health, Division of Legal Affairs so that it complies with other health care statutes. The MOLST form is currently utilized by many health care sys-tems.

What are the DNR requirements in NYS law that affect EMS agencies and providers now?

  1. Effective July 7, 2008 the MOLST form may be honored without the need for a non-hospital DNR order.
  2. EMS agencies must still honor the use of the non-hospital DNR form or bracelet.
  3. A patient with a DNR bracelet only refers to the do not resuscitate rules that apply to the non-hospital DNR order. At present there are no MOLST DNR bracelets.
  4. The MOLST form also provides the patient with the ability to give a Do Not Intubate order to health care providers including EMS. See section on DNI.

What are the differences and similarities between the non-hospital DNR order and the MOLST form?

  1. The MOLST form is a bright pink multi-page form; however a photocopy or facsimile of the original form is acceptable and legal. The DNR order remains a single 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. The Non Hospital Order Not to Resuscitate form (DOH-3474) is valid in out of hospital settings only.
  3. MOLST provides end of life orders for resuscitation and intubation orders for Advanced EMTs when the patient has progressive or impending pulmonary failure without acute cardiopulmonary arrest. The Non Hospital Order Not to Resuscitate form (DOH-3474) only apply to patients in full cardiopulmonary arrest.
  4. Both forms, the MOLST form and the Non Hospital Order Not to Resuscitate form (DOH-3474) form, must be authorized by a physician.
  5. Different than the non-hospital DNR form, there are multiple patient orders contained on the MOLST form that is intended for other health care providers to follow in other health care settings such as the hospital or nursing home.
  6. EMS providers and agencies are provided direction regarding the patient end of life treatment orders in Section A (page 1) and Section E (page 2). See below.

Section A of the MOLST Form

Section A is on the first page of the MOLST form. It is titled RESUSCITATION INSTRUCTION (ONLY for Patients in Cardiopulmonary Arrest). It then provides two boxes, one of which will be checked. The first box indicates the patient does not want resuscitation efforts to be made if they are found in full cardiopul-monary arrest. The second box indicates they want full CPR efforts with no limitations.

Note: The current MOLST form in use contains additional written guidance in this section. The last sen-tence states "For patients in the community, also complete NYS DOH Nonhospital DNR Form unless lo-cated in Monroe or Onondaga Counties. Please disregard this. The passage of Chapter 197 makes this form valid in all counties. It is expected that this form will be revised at a later date but. However, MOLST forms with this language may be honored without the need of the non-hospital NYS DNR form.

Section C of the MOLST Form

This section contains the physician authorization. As with the Non Hospital Order Not to Resuscitate form (DOH-3474), the MOLST form is recommended to be reviewed by the patient and his/her physician peri-odically. However, both forms should be considered valid unless it is known that it has been revoked.

Section E (DNI instructions)

This section, on page 2 of the MOLST form contains a box titled "Additional Intubation and Mechanical Ventilation Instructions". This section should be honored by EMS providers when the patient has progres-sive or impending pulmonary failure without acute cardiopulmonary arrest.

What is progressive or impending pulmonary failure?

The recognition of progressive or impending pulmonary failure must be made by the Advanced EMT in charge of patient care at the scene. Advanced EMTs who are not certain if this condition exists should contact medical control for advice.

Some Questions to consider

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

If one form has 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 phy-sician as the non-hospital DNR order does not provide this advice.

What if the MOLST form was signed prior to the date the statute was authorized?

You may honor the form as if it were authorized after the statutory date?

Does the new MOLST law allow EMS to honor other advanced directives?

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

Can EMS honor a DNR form from an Article 28 licensed facility, such as a hospital or nursing home?

All Article 28 licensed facilities are required to issue, review and maintain DNR orders. EMS providers will honor hospital DNR orders for patient transports originating from the facility. The DNR can not be expired. The facility staff must provide a copy of the order and/or patient's chart with the recorded DNR order to the ambulance crew. Facilities, other than hospitals or nursing homes, are encouraged to use the NYS-DOH approved non-hospital DNR Form as supplemental documentation to avoid confusion and poten-tially unwanted resuscitation.

MOLST Training

EMS providers and agencies who are interested in more specific training regarding the MOLST form and process may go to http://www.compassionandsupport.com. This site has a specific training program for EMS providers. 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.

Thank you for your efforts to comply with your patient's end of life wishes.

Resources

Compassion and Support Website:

MOLST Training Center:

MOLST EMS Training Page:

New York State Department of Health MOLST Information:

Issued and authorized by Bureau of EMS Office of the Director