The MOLST form is a set of medical orders that defines life-sustaining treatment the patient wants to receive or avoid now. A physician or nurse practitioner must complete or change the MOLST based on the patient’s current medical condition, prognosis, values, goals, preferences, and MOLST Instructions. If the patient is unable to make medical decisions, the orders should reflect patient wishes, as best understood by the health care agent or surrogate and based on the patient’s values, beliefs and goals.
MOLST became a New York State Department of Health (NYSDOH) form, at the same time Family Health Care Decisions Act (FHCDA) became effective on June 1, 2010. NYSDOH made a decision to have the DOH-5003 (6/10) MOLST written in plain language to ensure the physicians, nurse practitioners, patients, health care agents, surrogates and all who are involved in the process of completing the MOLST understand what MOLST represents. In addition, using plain language allows for appropriate translation into other languages for educational purposes only and to prepare the medical decision maker for the MOLST discussion. A Spanish translation of the MOLST is available for educational purposes only. The Spanish MOLST may not be completed or signed by the physician or nurse practitioner, but it can be used to educate Spanish-speaking patients and families about the MOLST process and form.
The MOLST form was revised to comply with changes in NYS Public Health Law that changes the authority of nurse practitioners with respect to completing and signing the MOLST form. Please Note: The changes in NYSPHL do not amend the Surrogate Court Procedures Act (SCPA) 1750-b, which relates to individuals with developmental disabilities who lack the capacity to make their own health care decisions and do not have a health care proxy.
The revised MOLST form was posted on the DOH web page on December 31, 2018. eMOLST has been updated; when eMOLST is queried for the most recent eMOLST form and copy of the MOLST discussion, all eMOLST forms created after January 1, 2019 will reflect the revised MOLST form.
The revised MOLST form does not include suggested clinical edits recommended to improve quality and reduce harm, based on recommendations received from physicians, nurse practitioners, EMS and others who work with patients, families and medical decision makers on a daily basis. Per NYSDOH, “We are working on the comments that we got from the (Advance Care Planning) RFI and are open to additional changes if all can agree.” Additional changes will result in another revised MOLST form estimated to be released in late 2019.
Given our limited budget and human resources, we will not be printing MOLST forms at this time. In the meantime, I encourage you and your organizations to implement eMOLST in your setting and encourage use in the communities you serve. While you’re working on eMOLST implementation, you can print the MOLST form on pulsar pink paper using the link from the NYSDOH website.
The proposed language revisions that are not directly a result of the new and proposed change in public health law are based on clinical feedback focused on ensuring MOLST is completed correctly to ensure patient preferences for resuscitation and life-sustaining treatment are honored. Through use of the MOLST form, consensus has been achieved on suggestions to clarify language to improve quality and reduce patient harm, including adding MOLST instructions to the form and clarifying MOLST is not for everyone and that MOLST is a set of medical orders to be followed now and not an advance directive created for future use when future health status and prognosis is unknown.
The proposed revisions are based on feedback received from multiple sources since June 1, 2010, as well as objective data and comments from working with health systems and physicians on the paper to eMOLST conversion since 2011. Feedback was also gathered through outreach to key palliative care physicians, NPs and others across the state via personal phone conversations, emails, NY MOLST Update, and at educational presentations. The suggested revisions were reviewed through several iterations by members of the MOLST Statewide Implementation Team & the EMS MOLST work group, key palliative care physicians, nurse practitioners and other clinicians who use MOLST &/or eMOLST extensively and a survey conducted in the summer of 2018. Additionally, the NYSDOH conducted an RFI on Advance Care Planning soliciting comments on the MOLST form.
The MOLST program began as a community initiative in Rochester to improve end‑of-life care in 2001. After working from 2001 to 2003 on the creation of the MOLST form and the MOLST Supplemental Documentation Forms for Adults and Minors, the MOLST program was launched in the Greater Rochester Region in 2004, followed quickly by adoption in Syracuse and the areas surrounding both communities.
Collaboration with the NYSDOH began in 2004. NYSDOH reviewed, suggested needed revisions and then approved use of MOLST in all health care facilities in 2005, prompting use in all counties. Simultaneously, the MOLST Supplemental Documentation Forms for Adults and Minors were also reviewed, revised and approved for use. Each four-page MOLST Supplemental Documentation Forms outlined the necessary requirements for issuing a Do Not Resuscitate (DNR) order in Adults and/or Minor patients in New York, per the 1987 DNR law. At that time, New York did not have surrogacy laws; a health care proxy and/or “clear and convincing evidence” was needed to make decisions regarding life-sustaining treatment.
An annual review of the MOLST form and program is conducted in August following each legislative session. The review includes the need to revise the MOLST based on statutory changes and feedback from physicians, clinicians, health systems and EMS who use MOLST.
In order to permit EMS to use a MOLST to follow DNR and Do Not Intubate (DNI) orders in the community, legislation was required and obtained in 2005 to modify NYSPHL. Legislation permitted testing community use of MOLST in Monroe and Onondaga counties to ensure EMS could read, interpret and follow both DNR and DNI orders. After a successful legislated community pilot (2005-2008), the MOLST form became the only NYSDOH approved form that EMS can follow for both DNR and DNI orders. NYSDOH directs all health care providers to follow MOLST orders in all settings, including the community. At the same time, NYSDOH approved statewide use of MOLST in all settings.
MOLST became a New York State Department of Health (NYSDOH) form in 2010 when F. MOLST became a New York State Department of Health (NYSDOH) form, at the same time FHCDA became effective on June 1, 2010. NYSDOH made a decision to have the DOH-5003 (6/10) MOLST form written in plain language to ensure the physicians, nurse practitioners, patients, health care agents, surrogates and all who are involved in the process of completing the MOLST understand what MOLST represents. In addition, using plain language allows for appropriate translation into other languages for educational purposes only and to prepare the medical decision maker for the MOLST discussion.
When FHCDA became effective, the MOLST Supplemental Forms for Adult and Minor Patients were no longer legally accurate, nor sufficient to document the ethical-legal requirements to make resuscitation and life-sustaining treatment decisions in accordance with changes put into effect as a result of the MOLST, Health Care Proxy law, FHCDA and Surrogate Court Procedures Act (SPCA) 1750-b. The NYSDOH created five MOLST Checklists for Adults and one MOLST Checklist for Minors to ensure compliance with public health law.
SPCA 1750-b outlines special procedures and requirements for making end-of-life decisions regarding resuscitation and life-sustaining treatment for persons with developmental/intellectual disabilities. The Office for People with Developmental Disabilities (OPWDD) created the MOLST Legal Requirements Checklist for Individuals with Developmental Disabilities. If the patient has a developmental disability, is appropriate for the MOLST and does not have ability to decide, only a physician (not a nurse practitioner) must follow special procedures as outlined by SCPA 1750-b and attach the completed OPWDD legal requirements checklist before signing the MOLST. If the patient has a developmental disability, is appropriate for the MOLST, and has the ability to decide, the patient makes their own decisions. If the patient has a developmental disability, is appropriate for the MOLST, does not have ability to decide, but has a properly completed health care proxy, the health care agent is able to make MOLST decisions.
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