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Checklist for Patients with Developmental Disabilities

MOLST Instructions and Legal Requirement Checklist for Individuals with Developmental Disabilities who Lack Medical Decision-Making Capacity

Effective January 21, 2011, the New York State Office For People With Developmental Disabilities (OPWDD)* has approved use of the revised New York State DOH-5003 Medical Orders for Life-Sustaining Treatment (MOLST) form** for the individuals served in the OPWDD system.  However, the MOLST form must be accompanied by the MOLST Legal Requirements Checklist for Individuals with Developmental Disabilities

Use of this checklist is required for individuals with developmental disabilities (DD) who lack the capacity to make their own health care decisions and do not have a health care proxy.  Medical decisions which involve the withholding or withdrawing of life-sustaining treatment (LST) for individuals with DD who lack capacity and do not have a health care proxy must comply with the process set forth in the Health Care Decisions Act for persons with MR (HCDA)
[SCPA § 1750-b(4)].  Effective June 1, 2010, this includes the issuance of DNR orders.

This means that the MOLST form may only be completed after the Health Care Decision Act (HCDA) process has been completed for an individual.  Use of the Checklist ensures that the appropriate statutory standards have been met prior to use of the MOLST process.  Please note that use of the MOLST form is optional.

The most significant change resulting from approval of the MOLST form is with respect to non-hospital Do Not Resuscitate (DNR) orders.  Previously, such DNR orders were required to be on the NYSDOH DNR form (DOH-3474).  Now a non-hospital DNR order can be written on either the MOLST form (DOH-5003) or the DOH form 3474.  The advantage of the MOLST form is that it is transferable to other (non-hospital) settings.  Accordingly, a DNR issued on a MOLST form is effective in hospitals, nursing homes and community settings.  The MOLST includes medical orders and instructions for intubation and mechanical ventilation, future hospitalization/transfer, etc.

Visit the OPWDD website for more information on use of MOLST with individuals serviced by the OPWDD system.

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.

* OPWDD was previously known as the Office of Mental Retardation and Developmentally Disabled (OMRDD).

** The DOH-5003 MOLST form should be printed on bright pulsar pink, heavy stock paper.  Astrobrights Pulsar
     Pink 24lb paper is available through Office Depot, Staples, Office Max, and other paper suppliers.

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