Checklist for Minor Patients

MOLST Instructions and Legal Requirements Checklist for Minor Patients

The New York State Department of Health developed Medical Orders for Life-Sustaining Treatment (MOLST) instructions to aid physicians and health care professionals in using the MOLST form for minor patients.  The MOLST Instructions include a checklist outlining the legal requirements for issuing orders to withhold or withdraw life-sustaining treatment using the MOLST.  

For more information about the MOLST Program, view the Department of Health's Website and the Compassion and Support Website MOLST Training Center found on www.CompassionAndSupport.org.  

NYSDOH MOLST Legal Requirements Checklist for Minor Patients

•  MOLST Legal Requirements Checklist for Minor Patients and Glossary

MOLST Chart Documentation Form for Minor Patients (align with NYSDOH Checklist)

•  MOLST Chart Documentation Form for Minor Patients

NYS MOLST Form

•  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 MOLST for Professionals and NYSDOH and MOLST.