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Medical Orders for Life-Sustaining Treatment (MOLST)

NEW YORK STATE DEPARTMENT OF HEALTH

THE PATIENT KEEPS THE ORIGINAL MOLST FORM DURING TRAVEL TO DIFFERENT CARE SETTINGS. THE PHYSICIAN KEEPS A COPY.

LAST NAME/FIRST NAME/MIDDLE INITIAL OF PATIENT

ADDRESS

CITY/STATE/ZIP

Male

Female

DATE OF BIRTH (MM/DD/YYYY)

eMOLST NUMBER (THIS IS NOT AN eMOLST FORM)

Do-Not-Resuscitate (DNR) and Other Life-Sustaining Treatment (LST)

This is a medical order form that tells others the patient’s wishes for life-sustaining treatment. A health care professional must complete or change the MOLST

form, based on the patient’s current medical condition, values, wishes and MOLST Instructions. If the patient is unable to make medical decisions, the orders

should reflect patient wishes, as best understood by the health care agent or surrogate. A physician must sign the MOLST form. All health care professionals must

follow these medical orders as the patient moves from one location to another, unless a physician examines the patient, reviews the orders and changes them.

MOLST is generally for patients with serious health conditions. The patient or other decision-maker should work with the physician and consider asking

the physician to fill out a MOLST form if the patient:

• Wants to avoid or receive any or all life-sustaining treatment.

• Resides in a long-term care facility or requires long-term care services.

• Might die within the next year.

If the patient has a developmental disability and does not have ability to decide, the doctor must follow special procedures and attach the appropriate

legal requirements checklist.

SECTION A

Resuscitation Instructions When the Patient Has No Pulse and/or Is Not Breathing

Check one:

CPR Order: Attempt Cardio-Pulmonary Resuscitation

CPR involves artificial breathing and forceful pressure on the chest to try to restart the heart. It usually involves electric shock (defibrillation) and a

plastic tube down the throat into the windpipe to assist breathing (intubation). It means that all medical treatments will be done to prolong life when

the heart stops or breathing stops, including being placed on a breathing machine and being transferred to the hospital.

DNR Order: Do Not Attempt Resuscitation (Allow Natural Death)

This means do not begin CPR, as defined above, to make the heart or breathing start again if either stops.

SECTION B

Consent for Resuscitation Instructions (Section A)

The patient can make a decision about resuscitation if he or she has the ability to decide about resuscitation. If the patient does NOT have the ability to

decide about resuscitation and has a health care proxy, the health care agent makes this decision. If there is no health care proxy, another person will

decide, chosen from a list based on NYS law.

Check if verbal consent (Leave signature line blank)

SIGNATURE

DATE/TIME

PRINT NAME OF DECISION-MAKER

PRINT FIRST WITNESS NAME

PRINT SECOND WITNESS NAME

Who made the decision?

Patient

Health Care Agent

Public Health Law Surrogate

Minor’s Parent/Guardian