8-Step MOLST Protocol

  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 DNR/MOLST forms
    • Determine key family members and 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, based on who will make the decision and where the decision is made
  2. Begin with what the patient and family knows
    • Determine what the patient and family know regarding condition and prognosis
    • Determine what is known about the patient’s values and beliefs
  3. Provide any new information about the patient’s medical condition and values from the 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/family wishes
    • Review the key elements with the patient and/or family
    • 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 Public Health Law, including Family Health Care Decisions Act (FHCDA)
    • Document conversation
  8. Review and revise periodically

* 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 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.