New York's MOLST holds a seriously ill patient's medical orders on CPR, intubation and other life-sustaining treatment, and every health care professional, EMS included, must follow it as the patient moves between settings. It is the only authorized New York form for both a nonhospital DNR and a nonhospital DNI order. Clinicians complete it after goals-of-care conversations with patients who want to avoid or receive such treatment, need long-term care, or might die within a year.
A physician, NP or PA confers with the patient or health care agent or surrogate and signs Sections E and H, while the decision-maker consents in Sections D and G in front of two adult witnesses. For a patient with an intellectual or developmental disability who lacks capacity and has no health care proxy, only a physician may sign, after the OPWDD checklist is completed and attached.
Enter the patient's name, date of birth, address and preferred phone number. The eMOLST number is filled in automatically when the form is created in eMOLST and can be left blank on paper. Check every advance directive known to be completed: health care proxy, living will, organ donation or documentation of an oral advance directive, which is checked only when the patient or agent cannot sign and has stated their wishes verbally.
Check one: CPR Order (attempt cardiopulmonary resuscitation) or DNR Order (do not attempt resuscitation, allow natural death). The choice follows a discussion of the risks and benefits of both. The instructions define CPR as possibly including intubation, chest compressions and defibrillation, and DNR as not starting any of these when the heart or breathing stops.
Check one respiratory support option: intubation and long-term mechanical ventilation, which may include tracheostomy; a trial period of intubation and/or mechanical ventilation; DNI with non-invasive ventilation only; or DNI with no non-invasive or mechanical ventilation. A trial period is set by the patient or decision-maker and the practitioner. The last option should not be checked if Section B orders CPR.
The patient signs if they have decision-making capacity; otherwise the health care agent or surrogate signs, and the signature must match the printed name. Check who is deciding: patient, health care agent, FHCDA surrogate for an adult or a minor, or SCPA 1750-b surrogate. For verbal consent, leave the signature line blank. Two witnesses over 18 must personally observe the consent and print their names.
The practitioner signs and prints their name, license number and the date and time. A physician licensed in a border state adds that state's abbreviation to the license number. Verbal orders are acceptable if followed by the signature of a New York licensed physician, NP or PA. If a 1750-b surrogate consented for a patient with I/DD, only a physician may sign, after the OPWDD checklist is attached.
Check one treatment guideline (no limitation, limited interventions, or comfort measures only), one future hospitalization option, one choice each for feeding tube and IV fluids, and one each for antibiotics and dialysis. If limited interventions is checked, describe the limits under Other Medical Orders and Instructions, and write NONE there if nothing else was discussed. Choices should agree with the treatment guideline chosen.
Section G repeats the consent step for the Section F orders: the decision-maker signs or gives verbal consent, their role is checked, and two adult witnesses print their names; for a patient with I/DD under 1750-b, one witness must be the treating physician. Section H is the practitioner's signature, license number and date and time for Section F, with the same physician-only rule for 1750-b decisions.
Each review records the date and time, the reviewer's printed name and signature, the location and the outcome: no change, form voided with a new form completed, or form voided with no new form. To void, write VOID in large letters on pages 1 and 2 and keep the voided form in the record. A voided MOLST with no replacement means full treatment and resuscitation unless another decision is made.
Download the current version from the source each time; forms change without notice.
Medical Orders for Life-Sustaining Treatment (MOLST)
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Sources for this guide
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A licensed physician, nurse practitioner or physician assistant signs the orders in Sections E and H after conferring with the patient or decision-maker. A physician licensed in a border state adds the state abbreviation with the license number. For a patient with an intellectual or developmental disability who lacks capacity and has no health care proxy, only a physician may sign.
No. The Department of Health says the MOLST can be printed on any color paper. It still encourages Pulsar Pink when restocking, because EMS personnel are trained to look for a pink form and may miss a white one. White forms, photocopies, faxes and electronic versions of the signed original are legal and valid.
A physician, NP or PA must review it at least every 90 days, and also when the patient moves to another care setting, has a major change in health, or the decision-maker changes their mind. Each review is recorded in Section I. If a review is missed, the last completed MOLST stays valid and must be followed.
Yes, along with Arabic, Bengali, Burmese, French, Haitian Creole, Hindi, Italian, Korean, Nepali, Polish, Russian, Simplified Chinese, Urdu and Yiddish. The Department of Health labels these translations as being for educational purposes only, so they help patients and families follow the choices while the orders themselves are written on the English form.