Medical Orders for Life-Sustaining Treatment - Professionals

MOLST: Supplemental Documentation Form for Adults

The MOLST: Supplemental Documentation Form for Adults must be completed by a physician and a concurring physician only when an adult patient lacks capacity (the ability to make health care decisions) to consent for himself or herself or under exceptional circumstances.

These exceptional circumstances include:

• Therapeutic Exception – when an individual with capacity would be harmed by a discussion of Do Not Resuscitate.
  
  
• Medical Futility – when CPR would be ineffective given the individual’s condition and the individual has no appointed surrogate (the health care agent or proxy).
  
  
• When the individual is a resident of a care setting administered by the Office of Mental Health or Office of Mental Retardation and Developmental Disabilities facilities.
  
  
• When the individual resides in a correctional facility. Decision

Download a printable sample of the MOLST Supplemental Documentation Form for Adults (with December 2008 revision) 

*December 2008 Update to the MOLST Supplemental Documentation Form for Adults*
The header on Step 9 of the "Supplemental" Documentation Form for Adults has caused confusion and has been revised.  The December 2008 version is being put into production and will be available in 2009.  In the interim, the current form is legal and valid.
Two physician certification and signature for determination of lack of decision-making capacity and lack of utility of CPR remains a requirement for ALL individuals, not only individuals with developmental disability.

View a printable sample of the MOLST Supplemental Documentation Form for Adults with December 2008 Edits in Red

View Explanations of the Revisions made to the MOLST Supplemental Documentation Form for Adults in August 2008

View a printable sample of the MOLST Supplemental Documentation Form for Adults with August 2008 Edits in Red

The MOLST: Supplemental Documentation Form for Adults satisfies the documentation requirements outlined by the 1988 New York State legislation governing do-not-resuscitate (DNR) orders.

Consent for DNR can be provided by the patient, resident, a duly appointed health care agent or proxy or surrogate decision-maker, in accordance with NYS Public Health law (PHL § 2977).

Note: If the patient/resident lacks capacity, the Health Care Agent makes DNR decisions based on known patient wishes and is not limited to specific situations. Thus, Step 3 outlined in the “Supplemental” Documentation Form for Adults does not apply and does not need to be completed.

If the patient lacks capacity and does not have a designated health care agent or proxy, the surrogate makes DNR decisions under any of the following situations:

• The patient/resident has a terminal condition.
• The patient/resident is permanently unconscious.
• Resuscitation would be medically futile.
• Resuscitation would impose an extraordinary burden on the patient/resident in light of the patient/resident’s medical condition and the expected outcome of resuscitation.

The MOLST: Supplemental Documentation Form for Adults is a supplement to the MOLST form and should be kept with the MOLST at all times.

NOTE: After completing the MOLST: Supplemental Documentation Form for Adults, please check the corresponding box in Section B of the original MOLST form.

Concurring Physician Certification Requirement for DNR Orders for Individuals Lacking Capacity including Mental Illness, Mental Retardation or Developmental Disability:

In cases of individuals who lack capacity including mental illness, mental retardation or developmental disability, the MOLST: Supplemental Documentation Form for Adults requires certification and signature of a concurring physician.

If the individual lacks capacity because of a mental illness, the concurring physician must be board certified in psychiatry.

Note: Mental illness is defined by conditions such as schizophrenia or acute psychotic episode and does not refer to dementia.

If the individual lacks capacity because of a developmental disability, the concurring opinion must be provided by a physician or psychologist with special experience or training in the field of developmental disabilities.

The certification and signature of the concurring physician is documented in Section 1, Step 9 of the MOLST: Supplemental Documentation Form for Adults.

Note: Individuals with mental illness, mental retardation or developmental disability with capacity may complete a MOLST form. No additional documentation on supplemental forms is needed.