Effective: 05-28-21
Supersedes: 04-03-20 [Emergency procedure change during COVID19 State of Emergency suspended requirement of written signature on MOLST form]
Introduction
EMS personnel at all levels are required to provide emergency care and transport patients to appropriate health care facilities. EMS personnel are further required to provide treatment to the fullest extent possible, subject to their level of certification and the level of licensure of the ambulance service for which they are working. However, more and more patients, where it is medically appropriate, are opting for limitations on life-sustaining treatments, such as cardiopulmonary resuscitation (CPR), in the event of cardiac arrest. Thus, EMS personnel may encounter a patient who has chosen such options and has either a Massachusetts Medical Orders for Life Sustaining Treatments (MOLST) or the Comfort Care/DNR Order Verification Form or bracelet (CC/DNR). These documents provide for a statewide, standardized form, approved by the Massachusetts Department of Public Health (DPH), Office of Emergency Medical Services (OEMS), that EMS personnel can instantly recognize as an actionable order (MOLST) or verification of such an order (CC/DNR) regarding the use of life sustaining treatments. This protocol governs EMS personnel response to a patient with a MOLST or CC/DNR form.
Implementation Procedures
1. Confirm the identity of the individual with the MOLST or CC/DNR Order Verification Form or bracelet;
2. Check validity:
a. CC/DNR: To assure that a DNR order is recognized in any out-of-hospital setting, an attending physician, nurse practitioner, or authorized physician assistant, who is licensed in Massachusetts, must provide a patient who has a current DNR order, with a fully executed CC/DNR Order Verification form to verify the existence of a DNR order. To be valid, the CC/DNR Order Verification Form shall contain:
i. the patient’s name, and all other patient identifiers requested on the form;
ii. date of issuance;
iii. the signature and telephone number of an attending physician, nurse practitioner, or authorized physician assistant;
iv. the signature and printed name of the patient, guardian or health care agent signing the form, with the following exception; and:
v. a date of expiration, if any, of the underlying DNR order. If there is a date of expiration, and that date has passed, the CC/DNR is not valid.
b. MOLST: Alternatively, to assure a patient with a desire to document decisions regarding DNR and/or other life-sustaining treatments (which includes CPR, intubation with ventilation, and non-invasive ventilation, such as continuous positive airway pressure, or CPAP) has those preferences honored, a Massachusetts-licensed attending physician, nurse practitioner or authorized physician assistant can provide a patient with a MOLST form. The MOLST form represents actual medical orders to EMS personnel related to a patient’s preferences for resuscitation, ventilation and hospitalization. To be valid, the MOLST form must contain:
i. patient name and appropriate identifiers as requested on the form;
ii. box D and E of the MOLST form must be fully completed for page 1 to be considered valid – which is all that is relevant for EMS personnel. The form must be signed by a patient, patient’s guardian, or activated health care agent. For a patient in a licensed health care facility only, this requirement is met if the guardian or agent cannot sign the form, and the licensed health care facility provides an alternate signature indicating that the required conversation with the guardian or agent has occurred and the form reflects the patient’s wishes and goals of care as expressed to the clinician who signed Section E on the agent’s behalf. If a MOLST form is presented by the licensed health care facility with such signatures in box D, EMS can assume the form is valid;
iii. A MOLST order that has an expiration date or revocation date that is in the past is not valid.
c. Revocation: A MOLST order for DNR or CC/DNR form may state it has been revoked. If that is the case, the order or form is not valid.
d. Health Care Agent with Documentation on Scene: If the patient’s activated health care agent is on scene with his/her health care proxy document in hand, the health care agent may change or revoke the patient’s MOLST form directions. EMS is not responsible to check the validity of the health care proxy document. If presented by a health care agent, they can assume it is valid.
3. Action of EMS if no valid CC/DNR or no valid MOLST that includes a DNR order: In accordance with standard EMS Statewide Treatment Protocols, EMS personnel will resuscitate patients without a valid CC/DNR Order Verification Form or without a MOLST that has documented a DNR order, as well as a patient who has a MOLST form indicating a preference FOR resuscitation. Remember, if there is any doubt about the current validity of a MOLST or CC/DNR Order Verification form, EMS personnel are to resuscitate and provide care in accordance with the Statewide Treatment Protocols.
4. Patient Care for confirmed valid CC/DNR or MOLST with orders for DNR:
a. If the patient is in full respiratory or cardiac arrest, the EMS personnel shall not resuscitate, which means:
i. do not initiate CPR,
ii. do not insert an oropharyngeal airway (OPA),
iii. do not provide ventilatory assistance,
iv. do not artificially ventilate the patient (e.g. mouth-to-mouth, bag valve mask),
v. do not administer chest compressions,
vi. do not initiate advanced airway measures,
vii. do not administer cardiac resuscitation drugs, and
viii. do not defibrillate.
b. If the patient is not in full respiratory or cardiac arrest, but the patient’s heartbeat or breathing is inadequate, EMS personnel shall not resuscitate but shall provide, within the scope of their training and level of certification, full palliative care and transport, as appropriate, including:
i. additional interventions a patient has indicated be given on the MOLST form, including intubation with ventilation or non-invasive ventilation such as CPAP.
ii. emotional support;
iii. suction airway;
iv. administer oxygen;
v. application of cardiac monitor;
vi. control bleeding;
vii. splint;
viii. position for comfort;
ix. initiate IV line; and,
x. contact Medical Control, if appropriate for further orders, including necessary medications.
c. If the patient is not in respiratory or cardiac arrest, and the patient’s heart beat and breathing are adequate, but there is some other emergency illness or injury, the EMS personnel shall provide full treatment and transport, as appropriate, within the scope of their training and level of certification.
5. Questions about the MOLST or CC/DNR: If EMS personnel have any questions regarding the applicability of the MOLST or CC/DNR form with regard to any specific individual, or a good-faith basis to doubt the continued validity of the MOLST or CC/DNR form, EMS personnel shall verify with the patient if the patient is able to respond. If the patient cannot respond, EMS personnel shall provide full treatment and transport, or contact Medical Control for further orders. In all cases, EMS personnel shall document the circumstances on the trip record.
6. Previously-initiated CPR: In the event of respiratory or cardiac arrest and resuscitative efforts are initiated prior to EMS confirmation of the valid DNR order on the MOLST form or a valid CC/DNR Order Verification form, EMS shall discontinue the following measures: a) CPR; b) cardiac medications, and c) advanced airway measures.
7. Documentation: EMS personnel must document the existence and validity of the MOLST order or CC/DNR form on their patient care report (PCR). For a MOLST form, EMS personnel must specifically document on the PCR all clinical information on the MOLST form regarding the patient’s preferences for care. For both MOLST and CC/DNR Order Verification Form, EMS personnel must also document on the PCR all care they provided to the patient, including palliative measures.
8. Revocation on scene: The MOLST order with DNR or CC/DNR may be revoked by the patient at any time, regardless of mental or physical condition, by the destruction or affirmative revocation of the MOLST or CC/DNR Order Verification, or by the patient’s direction that the MOLST or CC/DNR Order Verification not be followed by EMS personnel or be destroyed. It may also be revoked by the patient’s activated health care agent who is on scene with his/her health care proxy document in hand. EMS personnel, upon witnessing or verifying a revocation, shall communicate that revocation in writing to the hospital to ensure its inclusion in the patient's medical record. EMS personnel shall also document the revocation on their PCR.