Medical Directive - DNR - Preparation Worksheet

CONNECTICUT MOLST / DNR REQUEST AND CLINICAL WORKSHEET

Not a MOLST, DNR Order, or DNR Transfer Form

CRITICAL NOTICE: Signing this worksheet does not create a Connecticut medical order. The current MOLST requires the signature of the patient or legally authorized representative and a trained physician, advanced practice registered nurse, or physician assistant. A standalone DNR order is also a clinician's medical order, not a private contract.

Use this worksheet to prepare for a MOLST discussion or to organize transfer of an existing DNR order.

1. PATIENT INFORMATION

2. IS MOLST APPROPRIATE?

Connecticut DPH states that MOLST is intended for a person diagnosed with an end stage of a serious life-limiting illness or advanced chronic progressive frailty. Completion is voluntary.

Diagnosis or condition:

☐ End-stage serious life-limiting illness: [________________________________]

☐ Advanced chronic progressive frailty: [________________________________]

☐ Neither established; further evaluation is required before MOLST completion

The patient requests discussion of:

☐ CPR when there is no pulse and no breathing

☐ Respiratory support when there is a pulse but breathing is inadequate

☐ Medical hydration and nutrition

☐ Dialysis

☐ Antibiotics or antivirals, blood products, and vasopressors

☐ Hospital transfer and overall goals of care

Questions, values, or treatment preferences:

[____________________________________________________________]

[____________________________________________________________]

3. PATIENT OR LEGALLY AUTHORIZED REPRESENTATIVE

Signer: ☐ Patient ☐ Legally authorized representative (LAR)

The current MOLST identifies LAR categories including a parent of a minor, guardian, health care representative, and conservator, as applicable under Connecticut law.

LAR name: [________________________________]

Relationship or authority: [________________________________]

Supporting document and date: [________________________________]

Medical-record location: [________________________________]

☐ Patient capacity assessed

☐ LAR authority confirmed, if applicable

☐ Patient's known wishes reviewed; if unknown, best interests addressed

☐ Completion is voluntary

4. ELIGIBLE PROVIDER REVIEW

Provider name: [________________________________]

Profession: ☐ M.D. ☐ D.O. ☐ APRN ☐ PA-C

Connecticut license number: [________________________________]

Provider telephone: [________________________________]

Review date: [__/__/____]

☐ I completed the mandated MOLST provider training.

☐ I discussed diagnosis, prognosis, treatment choices, benefits, burdens, and the patient's goals with the patient or LAR.

☐ MOLST completed separately. Both required signatures and dates were entered on the current DPH form.

☐ Standalone DNR order exists. The order is in the medical record and any required transfer documentation will be completed.

☐ No order completed. Further evaluation, discussion, authority, or documentation is required.

Reason or follow-up plan:

[____________________________________________________________]

Provider signature on this worksheet: [________________________________] Date: [__/__/____]

The signature above documents review of this worksheet. Only the separately executed MOLST or DNR order is operative.

5. CURRENT MOLST ORDER CHECKLIST

Complete selections only on the current DPH form.

Overall goals of care

☐ Full Treatment

☐ Selective Treatments

☐ Comfort-Focused Treatments

All selections include symptom management for comfort.

Section A — patient has no pulse and is not breathing

☐ Do attempt CPR; Full Treatment must also be selected

☐ Do NOT attempt CPR; no compressions and no intubation

Sections B-E

☐ Respiratory-support choices completed

☐ Medical-hydration and nutrition choices completed

☐ Dialysis choices completed

☐ Other treatment preferences completed

☐ Additional preferences written clearly

Required signatures

☐ Patient or LAR signed and dated

☐ Trained MD/DO, APRN, or PA-C signed and dated

6. USING, COPYING, AND REVIEWING MOLST

The May 2026 DPH form states that:

• orders are effective immediately upon signature;
• the patient may keep the paper form, if any;
• photocopy, fax, and electronic copies are valid;
• the patient should bring the form to medical appointments and admissions;
• a substantive change requires the old form to be voided and a new form completed; and
• review is appropriate with disease progression, transfer to a different care setting or level, or a change in preferences.

Checklist:

☐ Current signed form placed in the medical record

☐ Printed version placed where EMS can readily see it at home, if applicable

☐ Copy travels with the patient between settings

☐ Caregivers and receiving providers know where the order is kept

☐ Superseded paper forms marked “VOID” across both pages

Validity of a MOLST copy does not mean that a private contract or unsigned draft is a valid order.

7. DNR BRACELETS

Connecticut DPH states that the orange plastic DNR bracelet and the metal DNR bracelet from the Connecticut College of Emergency Physicians remain valid ways to communicate a DNR instruction.

Bracelet type: ☐ Orange plastic ☐ Approved metal bracelet ☐ None

Date and source: [________________________________]

☐ Bracelet corresponds to a current DNR order or MOLST selection of “Do NOT attempt CPR”

Do not describe a necklace or ordinary wallet card as Connecticut DNR recognition material without current official authority.

8. TRANSFER OF AN EXISTING DNR ORDER

The current DPH Transfer of Do Not Resuscitate Order form is used when a patient with an existing DNR order moves from one health-care institution to another.

☐ Existing DNR order is in the transferring institution's medical record

☐ Original order date recorded

☐ Original order identified as entered by physician or APRN

☐ Transfer form signed by the physician or APRN who wrote the order, or by an RN attesting that the valid order is in the record

☐ Transfer form or legible copy sent with the patient

The DNR transfer form transmits an existing order. It does not create a DNR order through a patient signature, witnesses, notarization, or a private directive.

9. REVOCATION OR REQUEST FOR TREATMENT

The May 2026 MOLST states that the patient or the LAR who signed the form may revoke it at any time or request previously refused medically indicated treatments.

Do not use this worksheet as the revocation itself. Immediately notify the treating provider and caregivers, document the request, void superseded forms, update the medical record and electronic copies, and address any DNR bracelet.

Date change requested: [__/__/____]

Person notified: [________________________________]

Action taken and record location:

[____________________________________________________________]

10. OFFICIAL SOURCES

• Connecticut DPH, MOLST Consumer FAQ — https://portal.ct.gov/dph/knowledge-base/articles/molst/consumer-faq
• Connecticut MOLST, May 2026 — https://portal.ct.gov/dph/-/media/dph/dph-2025/molst/molst-digital-form-fillable.pdf?rev=59b3f878850c4d5eb01698a2f87f5449
• Connecticut DPH, Transfer of DNR Order, revised December 2023 — https://portal.ct.gov/dph/-/media/departments-and-agencies/dph/dph/facility_licensing_and_investigations/forms/dnr-transfer-form-december-2023-revised.pdf?rev=002df7351d784d1fa77df0462c6844ef&hash=BE54AF3792F661B705B97FA644B3ADAE
• Connecticut DNR regulations, §§ 19a-580d-1 to -9 — https://portal.ct.gov/-/media/sots/regulations/Title_19a/580dpdf.pdf?la=en
• Connecticut DPH, EMS regulations and statutes — https://portal.ct.gov/dph/emergency-medical-services/ems/oems-regulations-and-statutes

Verify the current statute, DPH forms, provider training, bracelet program, and EMS or facility protocol before relying on any DNR or MOLST order.