Compassion and Support

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Medical Orders for Life-Sustaining Treatment - Professionals

How to Complete a MOLST Form

A qualified and trained health care professional must complete or change the MOLST form based on the patient's current medical condition, values, wishes, and these MOLST instructions.  Review the entire MOLST form with the patient and the patient's decision-maker, if any.  The patient or other health care decision maker must consent to the MOLST orders, with the exception of patients covered by checklist #4 (Adult hospital or nursing home patients without medical decision-making capacity who do not have a health care proxy or a Public Health Law Surrogate).  A licensed physician always must sign the orders.  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.

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.

Verbal orders are acceptable with follow-up signature by a NYS licensed physician or a border state physician in accordance with facility / community policy.  Verbal orders must be authenticated within 48 hours under Medicare and Medicaid hospital conditions of participation.

If a patient in the community has a Non-Hospital Do-Not Resuscitate Order form, the physician may transcribe that order onto the MOLST form upon review of the form with the patient and the patient's decision-maker, if any.  Once the physician has signed the MOLST, the separate non-hospital form should stay as part of the patient's medical record in the physician's office, but does not need to remain as part of the MOLST.

If a patient in a facility has a legal and valid DNR order and / or other orders regarding life-sustaining treatment previously written in his / her medical record, these orders may be transcribed directly onto the MOLST.  The original orders should remain as part of the patient's medical record.  Only the MOLST need follow the patient from setting to setting.  Document the conversation and that legal requirements were met in the medical record.

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

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