Emergency Medical Services

Recommended Best Practices

Become a HeartSafe Community

Medical Orders for Life Sustaining Treatment (MOLST)

Medical Orders for Life Sustaining Treatment (MOLST) are instructions to follow a terminally ill patient’s wishes regarding resuscitation, feeding tubes and other life-sustaining medical treatments. The MOLST form can be used to refuse or request treatments and are completely voluntary on the part of patients. These orders can supplement Do Not Resuscitate (DNR) instructions or a COMFORT ONE bracelet. more

A physician, registered nurse practitioner, advanced practice registered nurse or physician assistant who is authorized by the patient is authorized to sign Medical Orders for Life Sustaining Treatment.

  • Treat a patient in accordance with the patient's MOLST form, even if the healthcare provider who signed the MOLST order is not on staff at a facility.
  • Ensure a patient's Medical Orders for Life Sustaining Treatment are transferred with the patient if he/she is transferred to another healthcare provider.
  • If a new terminally ill patient comes under your care, you should ask about the existence of a MOLST form from the patient and/or the facility that is transferring the patient.
  • Review the Medical Orders for Life Sustaining Treatment on admission and ensure that the orders reflect the patient’s current wishes.
  • If the terminally ill patient does not have Medical Orders for Life Sustaining Treatment, you should offer them the opportunity to complete a form on admission to a nursing home, assisted living facility, home health agency, hospice program, kidney dialysis center, or hospital.
  • Document if a terminally ill patient does not file Medical Orders for Life Sustaining Treatment and explain the consequences of making no decision to the patient or their recognized healthcare decision maker. If there are no limitations on care, except as otherwise provided by law, cardiopulmonary resuscitation will be attempted and other treatments will be given. If a choice regarding cardiopulmonary resuscitation (CPR) is not made, cardiopulmonary resuscitation will be attempted using all available treatment options.
  • Void the Medical Orders for Life Sustaining Treatment if requested by your patient. To do this draw a diagonal line through the sheet, write “VOID” in large letters across the page, and sign and date below the line. Keep the voided MOLST form in the patient’s active or archived medical record, as appropriate.
  • Follow the most recent version of the Medical Orders for Life Sustaining Treatment if more than one form is found in the medical records.

Naloxone

Screen all patients and caregivers.

  • Check a patient’s electronic health record (EHR) and ask the patient about previous naloxone use.
  • Check Rhode Island’s Prescription Drug Monitoring Program (PDMP) for clinical alerts and evidence of high-dose opioids (i.e., more than 50 oral Morphine Milligram Equivalents (MMEs) per day), long-acting opioid use, or opioid use for longer than 90 days.
  • Screen all patients for a history or diagnosis of Substance Use Disorder (SUD), Alcohol Use Disorder (AUD), mental health conditions, respiratory or neurologic conditions that affect breathing, harmful use or misuse of opioids, and/or opioid overdose.
  • Screen patients for use of Medication Assisted Treatment (MAT) to treat OUD.
  • Screen all patients to identify use of opioids in combination with benzodiazepines, alcohol, anti-depressants, and/or sedatives.

Educate yourself, patients, and staff.

  • Ask caregivers if they feel comfortable administering naloxone during an overdose in case a friend or loved one is experiencing a bad reaction to an opioid.
  • Tell patients who are taking opioids about the potential for bad reactions that make breathing slow down or stop, leading to an overdose.
  • Emphasize to patients that naloxone is an antidote and can save a life, just like a seatbelt or fire extinguisher.
  • Tell patients and caregivers about what to expect after giving someone naloxone.
  • Include a conversation about the importance of having naloxone on-hand as a standard part of opioid safety messages.
  • Ensure all office staff know where to locate and how to use naloxone in case of an overdose.
  • Review the signs and symptoms of opioid overdose and the legal protections under Rhode Island’s Good Samaritan Law.
  • Sign and display these pledges on opioid safety.
  • Print, hang, and distribute educational materials about naloxone.

Promote increased access to naloxone.

  • Join the US Surgeon General and be a role model. Purchase and carry naloxone. Incorporate naloxone co-prescribing in EHRs, office protocols, and electronic prescribing systems.
  • Co-prescribe naloxone to patients who are currently being prescribed syringes and needles.
  • Stock naloxone in the office for emergency use and for direct dispensing to patients.
  • Remind patients and staff that pharmacists can dispense naloxone and bill insurance companies without a prescription from a healthcare provider.
  • If cost is a barrier for patients, help them enroll in a health insurance plan.