Compassion and Support

Professionals

Patients & Families

Medical Orders for Life-Sustaining Treatment - Professionals

What to do with a Completed MOLST Form

MOLST forms are designed to travel with the individual between care settings.

Facility
The form should be kept in the front of the individual's medical chart when the individual is in a facility.

Home
When the individual is at home, the MOLST form should be kept on the refrigerator, by the phone in the kitchen or by the individual's bedside.  In case of emergency, EMS personnel are trained to look for the MOLST form in these locations.

Care Transitions
A photocopy of the MOLST form should be made when the individual is transferred from one healthcare setting to another (e.g., being admitted from a nursing home to a hospital).  The photocopy of the form should be kept in the medical chart at the original location at the time of care transition.  The original form should accompany the individual and be placed in the individual's medical chart at the new care setting.

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.

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