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
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.
Resuscitation Instructions When the Patient Has No Pulse and/or Is Not Breathing
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.
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)
PRINT NAME OF DECISION-MAKER
PRINT FIRST WITNESS NAME
PRINT SECOND WITNESS NAME
Who made the decision?
Health Care Agent
Public Health Law Surrogate
Physician Signature for Sections A and B
PRINT PHYSICIAN NAME
PHYSICIAN LICENSE NUMBER
PHYSICIAN PHONE/PAGER NUMBER
Check all advance directives known to have been completed:
Health Care Proxy
Documentation of Oral Advance Directive
HIPAA permits disclosure of MOLST to other health care professionals & electronic registry as necessary for treatment.
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