7.3 MOLST/DNR Review

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:
    1. 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:

      1. the patient’s name, and all other patient identifiers requested on the form;
      2. date of issuance;
      3. the signature and telephone number of an attending physician, nurse practitioner, or
        authorized physician assistant;
      4. the signature and printed name of the patient, guardian or health care agent signing the form, and:
      5. 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.
    2. MOLST: Alternatively, to assure a patient with a desire to document decisions regarding
      DNR and/or other life-sustaining treatments (LST, 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:

      1. patient name and appropriate identifiers as requested on the form,
      2. 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. A MOLST order that has an
        expiration date or revocation date that is in the past is not valid.
    3. 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
  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:
    1. If the patient is in full respiratory or cardiac arrest, the EMS personnel shall not
      resuscitate, which means:

      1. do not initiate CPR,
      2. do not insert an oropharyngeal airway (OPA),
      3. do not provide ventilatory assistance,
      4. do not artificially ventilate the patient (e.g. mouth-to-mouth, bag valve mask,
      5. do not administer chest compressions,
      6. do not initiate advanced airway measures,
      7. do not administer cardiac resuscitation drugs, and
      8. do not defibrillate.
    2. 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:

      1. additional interventions a patient has indicated be given on the MOLST form, including intubation with ventilation or non-invasive ventilation such as CPAP.
      2. emotional support;
      3. suction airway;
      4. administer oxygen;
      5. application of cardiac monitor;
      6. control bleeding;
      7. splint;
      8. position for comfort;
      9. initiate IV line; and,
      10. contact Medical Control, if appropriate for further orders, including necessary medications.
    3. 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 goodfaith 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 trip record. For a MOLST form, EMS personnel must specifically
    document on the trip record 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 trip record 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.
    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 trip record.