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Medical Orders for Life Sustaining Treatment (MOLST) Form and eMOLST Revisions

The Situation Report | May 5, 2025

The New York State Department of Health has revised the Medical Orders for Life-Sustaining Treatment (MOLST) Form, (DOH-5003). The comprehensive revision was completed with collaboration and consensus among the Department, New York State Office for People with Developmental Disabilities (OPWDD), and the New York State Office of Mental Health (OMH), with input from the Statewide MOLST Implementation Committee, which has been principally and inspirationally led by Dr. Pat Bomba, and on which HCANYS has been a participant and strong supporter.

“HCANYS applauds the entire committee, the Department of Health and state agency colleagues, and especially Dr. Bomba , who has devoted herself to this critical human, societal and medical cause to unparalleled levels.  She has not only been New York’s clinical leader in this effort, but Dr. Bomba has been a clinical treasure to the state, the health care system, and ultimately to the patients and families served.”

Additionally, the electronic MOLST (eMOLST) has been updated to match the newly released paper form. Healthcare providers with an existing eMOLST agreement with Excellus BlueCross and BlueShield will be able to continue using the registry.  Earlier versions of the MOLST paper and electronic forms are still valid if patients present with an older version of the MOLST.

All information regarding the MOLST, including the form, supporting checklists, glossary, and instructions are available on the NYSDOH Center for Hospice & Palliative Care's Medical Orders for Life-Sustaining Treatment (MOLST) page.

No changes have been made to the one-page Nonhospital Order Not to Resuscitate (DOH-3474).The changes to the MOLST form are being incorporated into the electronic MOLST application (eMOLST).

It is strongly recommended that staff involved with MOLST read the instructions and legal requirements checklists that are on the Department’s website here. 

Changes to the MOLST form include the following:

“Do-Not-Resuscitate” (DNR) and “Do-Not-Intubate” (DNI) Medical Orders, which emergency medical services (EMS) and health care professionals look for in an emergency, have been moved to the first page.

The first page includes:

  • Section A, which outlines patient information and advanced
  • Section B, “Resuscitation Orders When the Patient Has No Pulse and/or Is Not ”
  • Section C, “Intubation Orders for Life-Sustaining Treatment When the Patient Has a Pulse and is Breathing,” provide clarity as to available choices, which now include:
    • Intubation and long-term mechanical ventilation, includes tracheostomy;
    • Intubation and long-term mechanical ventilation, includes tracheostomy, following use of non-invasive ventilation;
    • Do Not Intubate (DNI) Use of Non-Invasive Ventilation Only; and
    • Do Not Intubate (DNI) and Do Not Use Non-Invasive Ventilation or Mechanical
  • Section D, “Consent for Sections B and C,” updated check boxes under “Who is the individual making decisions” to change the checkbox “FHCDA Surrogate” to “FHCDA Surrogate for Adult,” and to change the checkbox “Minor’s Parent/Guardian” to “FHCDA Surrogate for Minor.”
  • Section E, “Physician, Nurse Practitioner, or Physician Assistant Signature for Sections B and C.”

On the second page:

  • Section F, “Additional Orders for Life-Sustaining Treatment,” are to be reviewed with the patient and reflect the patient’s personal An urgent in-depth discussion may be required based on the patient’s diagnosis, prognosis, and disease trajectory. For other patients, these conversations may be deferred, in which case those treatments will then be provided in full to the patient as necessary. Under Section F of the form, if a decision has not been made, the physician, nurse practitioner, or physician assistant may choose the option “Determine use or limitation if need arises.” If the patient or decision-maker reaches a decision concerning the treatment option at a later time, a new form must be completed and signed by a physician, nurse practitioner, or physician assistant.
  • Future Hospitalization/Transfer has a new option: “Do not send to the hospital unless pain or severe symptoms cannot be otherwise controlled.” When the patient, Health Care Agent, or Surrogate chooses “Do not send to the hospital unless pain or severe symptoms cannot be otherwise controlled,” additional assessment, care planning, and education is required to review the scope of care that can be provided by community- based services as compared with those available within a
  • Section G, “Consent for Section F,” was updated in the same manner as Section D, “Consent for Sections B and C,” as noted above.
  • Section H, “Physician, Nurse Practitioner, or Physician Assistant Signature for Section ”
  • Section I is on the third page. This section allows regular review and renewal of the form, and in the event that a new MOLST form is completed, this section provides a place to document that the old form was voided.
  • The MOLST General Instructions section begins on the fourth page and includes a listing and description of the MOLST checklists. The checklist used when working with minor patients was renamed to “DOH Checklist #6 for Minor Patients.” This checklist should be used for minor patients for whom decisions are being made under the FHCDA. The instructions for instances in which the medical orders are for an adult or minor patient with an intellectual or developmental disability (I/DD), were expanded to provide additional clarity.