Medical Orders for Life Sustaining Treatment - Patients & Families

MOLST: Supplemental Documentation Form for Adults

 

The MOLST: Supplemental Documentation Form for Adults must be completed only when an adult patient lacks capacity (the ability to make health care decisions) to consent for him or herself or under any of the following situations:

• Therapeutic Exception – when an individual with capacity would be harmed by a discussion of Do Not Resuscitate or Do Not Intubate.
  
• Medical Futility – when CPR would be ineffective given the individual’s condition and the individual has no appointed surrogate (the Health Care Agent or proxy).
  
• When the individual is a resident of a care setting administered by the Office of Mental Health or Office of Mental Retardation and Developmental Disabilities facilities.
  
• When the individual resides in a correctional facility.
  

The MOLST: Supplemental Documentation Form for Adults is a supplement to the MOLST form and should be kept with it.

NOTE: Adult patients with capacity who do not meet the above criteria do not need a MOLST: Supplemental Documentation Form for Adults.

Download a printable sample of the MOLST Supplemental Documentation Form for Adults

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