8-Step Medical Orders for Life-Sustaining Treatment (MOLST) Protocol

Refer to Public Health Law 2994-b

Honoring patient preferences is a critical element in providing quality end-of-life care. To help physicians and other health care providers discuss and convey a patient's wishes regarding cardiopulmonary resuscitation (CPR) and other life-sustaining treatment, the New York State Department of Health (NYS DOH) has approved a physician order form (DOH-5003), Medical Orders for Life-Sustaining Treatment (MOLST), which can be used statewide by health care practitioners and facilities. MOLST is an approved Physician Orders for Life-Sustaining Treatment (POLST) Paradigm Program and incorporates New York State Public Health Law.

  1. Prepare for Discussion
    • Review what is known about patient goals and values.
    • Understand the medical facts about the patient's medical condition and prognosis.
    • Review what is known about the patient's capacity to consent.
    • Retrieve and review completed Advance Directives and prior Do Not Intubate (DNI)/ Do Not Resuscitate (DNR)/MOLST forms.
    • Determine key family members and/or close friend (if there are any).
    • If the patient lacks medical decision-making capacity, identify the Health Care Agent or Surrogate.
    • Find uninterrupted time for the discussion.
    • Review the legal requirements under New York State Public Health Law, and the Surrogate's Court Procedure Act, to determine who can make the decision and where the decision can be made.
    • Review the patient's medical history to identify whether they:
      • Have a developmental disability, which may trigger additional legal requirements under the Surrogate's Court Procedure Act section1750-b.
      • Are currently in, or have been temporarily transferred from, a psychiatric unit of a general hospital, a stand-alone psychiatric hospital, a State-Operated Psychiatric Center, or a state-operated patient program.
  2. Begin with What the Patient and Family Knows
    • Determine what the patient and family or close friends know regarding condition and prognosis.
    • Determine what is known about the patient's values and beliefs.
  3. Provide Any New Information about Patient's Medical Condition from Medical Team's Perspective
    • Provide information in small amounts, giving time for response.
    • Seek a common understanding; understand areas of agreement and disagreement.
    • Make recommendations based on clinical experience in light of patient's condition/values.
  4. Try to Reconcile Differences in Terms of Prognosis, Goals, Hopes and Expectations
    • Negotiate and try to reconcile differences; seek common ground; be creative.
    • Use conflict resolution when necessary.
  5. Respond Empathetically
    • Acknowledge.
    • Legitimize.
    • Explore (rather than prematurely reassuring).
    • Empathize.
    • Reinforce commitment and non-abandonment.
  6. Use MOLST to Guide Choices and Finalize Patient and/or Family/Close Friend Wishes
    • Review the key elements with the patient and/or family/close friend.
    • Apply shared, informed medical decision-making.
    • Manage conflict resolution.
  7. Complete and Sign MOLST
    • Obtain verbal or written consent from the patient or designated decision-maker.
    • Follow legal requirements under New York State Law, including the Family Health Care Decisions Act (FHCDA) and the Health Care Decisions Act for People with Intellectual or Developmental Disabilities (HCDA/1750-b).
    • If the patient has a developmental disability, lacks medical decision-making capacity, and does not have an applicable health care proxy, complete all steps of the OPWDD MOLST Checklist before finalization and implementation of MOLST.
    • For adult patients without medical decision-making capacity (with a mental illness but no I/DD), who are in a hospital, nursing home or hospice and do not have a health care proxy:
      • See Checklist 3 for those who have selected a surrogate, or
      • Checklist 4 for those who do not have a surrogate.
    • For adult patients, (with a mental illness but no I/DD), who are in the community and do not have a health care proxy, see Checklist 5.
  8. Review and Revise Periodically
    • The MOLST form should be reviewed at least every 90 days.
    • Review the MOLST form if the patient moves from one location to another to receive care.
    • Review the MOLST form if the patient has a major change in health status (for better or worse).
    • Review the MOLST form if the patient or other decision-maker changes his or her mind about treatment.
    • The MOLST remains valid and must be followed, even if it has not been reviewed within the 90-day period.
    • Public Health Law requires documented review of non-hospital DNR orders at least every 90 Days.