Compassion and Support


Patients & Families

Checklist for Minor Patients

Resources for Completing MOLST in Minor Patients

The New York State Department of Health (NYSDOH) approved the DOH-5003 MOLST for use with minor patients in 2010.  MOLST can be used statewide by health practitioners and facilities in all levels of care, including the community. 

To help physicians and health care professionsl to use the MOLST for minor patients, NYSDOH developed MOLST instructions and a checklist outlining the legal requirements for issuing orders to withhold or withdraw life-sustaining treatment in minor patients.  These requirements must be followed with or without using the MOLST form. 

NYSDOH MOLST Instructions and Legal Requirements Checklist for Minor Patients

Clinical Resources for MOLST discussions with Minor Patients and Families

To help providers recognize when children and families are appropriate for thoughtful goals for care and MOLST discussions, the MOLST for Minor Patients Workgroup developed additional resources.


  •  DOH-5003 MOLST form 
  • Printing the MOLST form on bright "pulsar" pink, heavy stock paper is strongly encouraged.
  • Astrobrights Pulsar Pink 24lb paper is available through Office Depot, Staples, Office Max, and other paper suppliers. 
  • When EMS personnel respond to an emergency call in the community, they are trained to check whether the patient has a pink MOLST form before initiating
    life-sustaining treatment.  They might not notice a MOLST form on plain white paper.
  • However, white MOLST forms and photocopies, faxes, or electronic representations of the original, signed MOLST are legal and valid.
  •   Spanish version of the DOH-5003 MOLST form is for educational purposes ONLY.

For more information on MOLST, view the NYSDOH MOLST web pageMOLST for Professionals and the MOLST Training Center on