Compassion and Support


Patients & Families

Medical Orders for Life-Sustaining Treatment - Professionals

MOLST Discussion

The MOLST form must be completed based on the patient's current medical condition, values, and wishes.  Completion of the MOLST begins with a conversation or a series of conversations between the patients, the health care agent or the surrogate, and a qualified, trained health care professionals that defines the patient's goals for care, reviews possible treatment options on the entire MOLST form, and ensures shared, informed medical decision-making.  The conversation should be documented in the medical record.

Discuss values, beliefs and goals for care with the person who will make the decision

Review what the patient/family knows and wants to know about the patient's condition/prognosis.  Provide new information about the patient's condition/prognosis.  Explore common understanding and differences.  Determine next steps needed to resolve any differences.

You can identify core patient values and beliefs by asking the patient

  • "What makes life worth living?"
  • "What really matters to the person?"

Examples of responses include

  • Participation in meaningful relationships
  • Not to be a burden to loved ones
  • Avoidance of severe discomfort
  • Relief of suffering
  • Improvement or maintenance of quality of life
  • Maintenance of personhood
  • Achieve a good death
  • Support for families and loved ones
  • Other personal values and beliefs

The degree to which the patient is meeting their core values generally determines their goals for care that in turn guides the patient's choice of treatments.  Broad categories of goals for care include:

  • Longevity:  "Do what is necessary to keep me alive."
  • Functional preservation:  “Being independent is most important to me. I want to do as much as I can for myself for as long as I can.”
  • Comfort Care:  "I am currently not meeting my core values and have a poor quality of life.  Focus solely on my comfort.  Longevity at this point may increase my suffering."

Document the conversation

Briefly summarize pertinent content of the discussion and document core patient values and/or goals for care.  Documentation of the clinical process and legal requirements under FHCDA must be included in the medical record. MOLST Chart Documentation forms align with the NYSDOH Legal Requirements Checklists for Adult Patients. Completion of the appropriate form serves as documentation of the conversation and legal requirements and a copy should remain in the medical record.

Use of these forms is optional but documentation is mandatory. Compliance with documentation requirements will ensure providers in facilities, especially nursing homes, meet legal requirements and prevent deficiencies with the NYSDOH survey.

MOLST Chart Documentation Forms (Align with NYSDOH Checklists)

Adult Patients

  1.  MOLST Chart Documentation Form adult with capacity any setting (Checklist 1)
  2.  MOLST Chart Documentation Form adult health care proxy any setting (Checklist 2)
  3.  MOLST Chart Documentation Form adult FHCDA surrogate (Checklist 3)
  4.  MOLST Chart Documentation Form adult FHCDA no surrogate (Checklist 4)
  5.  MOLST Chart Documentation Form adult without capacity in the community (Checklist 5)

Minor Patients

  1.  MOLST Chart Documentation Form minor any setting

Although the conversation(s) about goals and treatment options may be initiated by any qualified and trained health care professional, a licensed physician must always, at a minimum:

  • Confer with the patient and/or the patient's health care agent or surrogate about the patient's diagnosis, prognosis, goals for care, treatment preferences, and consent by the appropriate decision-maker
  • Sign the orders derived from that discussion.

If the physician is licensed in a border state, the physician must insert the abbreviation for the state in which he/she is licensed, along with the license number.


  •  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 MOLST form for educational purposes ONLY.

 Key Resources

For more information on MOLST, view MOLST for Professionals and NYSDOH and MOLST.

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