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.
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.
To view, download a printable sample of the MOLST: Supplemental Documentation Form for Adults.[pdf]
