How to Fill Out the Massachusetts MOLST Form: Sections A–H

To fill out the Massachusetts MOLST form, you and your physician, nurse practitioner, or physician assistant work through two pages of treatment choices together, then both of you sign. The form has eight sections labeled A through H. Page one (Sections A through E) covers what emergency responders should do if your heart stops, you cannot breathe, or you need transfer to a hospital. Page two (Sections F through H) covers longer-term treatments like dialysis, feeding tubes, and IV hydration. Each page is only enforceable when every line of its signature sections is filled in.¹

Before You Start

The MOLST is designed for people with a serious illness whose clinician would not be surprised if they died within the next year, including patients in long-term care, hospice, or palliative care.² A healthy adult planning ahead should use a health care proxy or advance directive instead.³

Signing one is voluntary. No hospital or nursing home can require it as a condition of admission or treatment.² If you have the capacity to understand the decisions, you sign for yourself. Otherwise your health care agent, guardian, or (for a minor) parent signs on your behalf.

The official form is a free download from the Massachusetts Department of Public Health at mass.gov.⁴ Hospitals, nursing homes, and hospice programs also keep blank copies on hand and will bring one to your care-planning conversation.

Page One: Emergency Orders (Sections A–E)

Page one is what paramedics and emergency department staff look at first. Finish all five sections or page one does not take effect.¹

Section A: CPR

This section applies only if your heart and breathing have both stopped. Choose one option: attempt resuscitation, or do not attempt resuscitation. If you check “do not attempt,” responders will skip chest compressions and defibrillation and focus on keeping you comfortable.¹

Section B: Ventilation

Section B is for the situation where you are struggling to breathe but your heart is still beating. You can combine choices here:

Intubate or ventilate: a breathing tube is placed through the mouth, nose, or a surgical airway opening for mechanical breathing support.
Do not intubate or ventilate: no breathing tube of any kind.
Use non-invasive ventilation (CPAP): a mask delivers pressurized air without a tube, and you can still speak, swallow, and move.
Do not use non-invasive ventilation: no ventilation at all during respiratory distress.

One carve-out matters: if you stop breathing because you are choking on food or an object, responders will clear your airway regardless of what you checked here. Section B governs respiratory distress from your underlying illness, not a blocked airway.⁵

Section C: Transfer to Hospital

You choose whether to be transported to a hospital or to stay in your current setting unless transfer becomes necessary for comfort. “Do not transfer” tells EMS to treat you where you are.¹

Section D: Patient or Representative Signature

If you are signing for yourself, your signature confirms the form reflects your wishes and that you signed freely. If a health care agent, guardian, or parent of a minor signs instead, they confirm the form reflects either the patient’s known wishes or, if those are unknown, the patient’s best interests.¹

Section E: Clinician Signature

A physician, nurse practitioner, or physician assistant signs here, confirming that the orders on page one match the conversation they had with the person who signed Section D.¹ Fill in every line, including the date and the clinician’s printed name and credentials. A missing line can make the page unenforceable.

Page Two: Other Treatment Preferences (Sections F–H)

Page two addresses treatments that typically come up during ongoing care rather than in the first minutes of a crisis. Section F only takes effect when Sections G and H are also complete.¹

Section F: Six Treatment Categories

Check a single circle in each category:

Intubation and ventilation for longer-term respiratory support beyond the emergency setting.
Non-invasive ventilation (CPAP) in the ongoing-care context.
Dialysis if your kidneys fail.
Artificial nutrition through a feeding tube: full use, short-term use only, none, undecided, or did not discuss.
Artificial hydration through IV fluids, with the same range of options.
Other preferences: a free-text space for instructions specific to your condition.

Checking “undecided” or “did not discuss” is a real choice, not a gap. It leaves that question open for a later conversation as your condition changes.¹

Sections G and H: Page-Two Signatures

These mirror Sections D and E. You or your representative sign Section G, and a clinician signs Section H. Every line must be completed for Section F to be enforceable. The clinician on page two does not have to be the same one who signed page one, though it often is.

After You Sign: Where to Keep It and Who Gets Copies

The original stays with the patient. At home, keep it somewhere visible and predictable so EMS can find it fast. The refrigerator door is the standard spot because paramedics are trained to check there. In a facility, the original goes in your medical chart, usually with a copy near the bedside.

Photocopies and faxed copies are legally valid, and the paper color does not matter.⁶ Give copies to your health care agent, your primary care provider, any specialists treating you, and family members likely to be present in a crisis.

Changing or Revoking the Form

You can revoke a MOLST at any time, and so can a health care agent, guardian, or parent of a minor acting for a patient who lacks capacity. You can also ask for and receive any treatment you previously refused on the form.¹

You cannot amend a MOLST by crossing out one box and checking another. To change any order, void the entire form by writing “VOID” in large letters across both sides, then complete and sign a new form with the updated choices. If you void a form without replacing it, nothing is documented and providers will default to full treatment.¹ Revisit the form after any significant health change, hospitalization, or move between care settings.

How the MOLST Fits With Your Other Documents

A MOLST does not replace a health care proxy. The proxy names someone to make decisions the MOLST does not cover, so keep both in place. A living will describes general wishes but does not carry the force of a medical order, and EMS cannot follow one during an emergency.⁷ The MOLST is the piece that paramedics and clinicians act on immediately because it is a signed medical order that travels with you across care settings.

Massachusetts also uses a separate Comfort Care/DNR verification form, which specifically verifies a do-not-resuscitate order rather than covering the broader treatment picture. EMS is trained to recognize and honor either document as long as it is current and properly signed.⁴ You do not need both.

What the POLST Transition Means for You

Massachusetts is moving from MOLST to the national POLST (Portable Orders for Life-Sustaining Treatment) model, with the changeover planned for Spring 2027. Until then, keep using the current MOLST form. A MOLST you sign today will still be honored after the switch to POLST, so there is no reason to wait.²

1
Honoring Choices Massachusetts. Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST)
2
Mass.gov. MOLST Transition to POLST
3
National POLST Paradigm. About the National POLST Paradigm
4
Mass.gov. MOLST and Comfort Care DNR Verification
5
UMass Chan Medical School. Massachusetts Medical Orders for Life Sustaining Treatment (MOLST)
6
Honoring Choices Massachusetts. Medical Orders for Life-Sustaining Treatment and CC/DNR
7
Bassett Healthcare Network. MOLST: Medical Orders for Life-Sustaining Treatment