Thoughtful MOLST Discussions
MOLST orders are completed at the end of a thorough conversation or series of conversations between the patient (or the Health Care Agent or Surrogate if the patient is unable to make complex MOLST decisions) and their physician, nurse practitioner, or physician assistant. Conversations may include other medical team members, within scope of practice but the attending physician, nurse practitioner, or beginning June 17, 2020, physician assistant, is always accountable.
View the full 8-Step MOLST Protocol document
8-Step MOLST Protocol
1. Prepare for Discussion
- Be sure the person is appropriate for MOLST
- Review what is known about the patient’s goals and values
- Understand the medical facts about the patient’s medical condition and prognosis
- Retrieve and review completed advance directives and any prior MOLST or DNR forms
- Review what is known about the patient’s capacity to consent
- Find uninterrupted time for discussion
- Review ethical & legal requirements under NYS Public Health Law. The correct legal pathway is determined by who the patient is, who the decision-maker is and where the decision is being made.
- As the best practice, use eMOLST to ensure the correct process is followed
2. Begin with what the patient and family knows
- Determine what the patient & family know regarding the patient’s condition and prognosis
- Determine what is known about the patient’s values, beliefs & goals
3. Provide any new information about the patient’s medical conditions 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 and in light of patient’s condition and values, beliefs & goals
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 family wishes
- Review key elements with the patient or designated decision maker and family
- Apply shared, informed medical decision making
- Manage conflict resolution
- Use eMOLST to ensure the correct process is followed
7. Complete and sign MOLST
- Obtain verbal or written consent from the patient or designated decision maker
- Follow ethical and legal requirements under relevant NYS Public Health Laws
- Document conversation
8. Review and revise periodically on page 3 & 4 of the MOLST form according to the following items:
- If there is a change in care setting
- If there is a major change in health status (for better or for worse)
- If the patient changes their mind about treatment
- As the law requires and according to facility policies & procedures, maximum 90 days for the general population, maximum 60 days for patients with developmental disabilities who lack capacity to make decisions. (MOLST orders remain legal and valid even if the provider fails to review/renew them on time.)
After MOLST is Complete
After MOLST is completed, a palliative care plan is needed to guarantee the patient’s MOLST orders are honored, pain and symptoms are managed and the caregivers are engaged, educated, empowered and supported.
The palliative care plan must include guidance on what to do and who to call in an emergency 24/7 when a patient does not wish to return to the hospital.
