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 New York State Department of Health (DOH) began in 2004. DOH reviewed, recommended 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 the 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 DOH approved form that EMS can follow for both DNR and DNI orders. DOH directs all health care providers to follow MOLST orders in all settings, including the community. At the same time, DOH approved statewide use of MOLST in all settings.

MOLST became a DOH form in 2010 when Family Health Care Decisions Act (FHCDA) became effective on June 1, 2010. DOH decided to have the DOH-5003 (6/10) MOLST form written in plain language to ensure the physicians, nurse practitioners, physician assistants, other clinicians, 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 DOH 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 or physician assistant) 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.

The revised MOLST form was posted on the DOH web page on December 31, 2018. eMOLST was 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 reflect the revised DOH-5003 12/18 MOLST form.

Effective June 17, 2020, PAs have the authority and accountability to complete a MOLST form. Given the COVID-19 pandemic, it is unlikely that a revised MOLST form will be available.

Future Changes

In 2018, DOH released a Request for Information (RFI) to gather input on necessary changes to the Medical Orders for Life-Sustaining Treatment (MOLST) form. In response to the comments and recommendations, DOH put forth a condensed and simplified draft MOLST and MOLST instructions. The goal of the DOH proposed drafts is to ultimately finalize more streamlined forms.

DOH also presented for review and comment a MOLST to be used exclusively for the Intellectual and Developmentally Disabled (I/DD) population.  A statewide coalition vehemently opposed a separate MOLST form for the I/DD population. The Coalition view a separate MOLST form as discriminatory, unethical, difficult to honor in an emergency, problematic to not include in eMOLST, and most importantly, negatively impacts the progress made in improving end-of-life care for these vulnerable individuals.  New York should never again witness another case of suffering as endured by Sheila Pouliot and her family.

Members of the MOLST Statewide Implementation Team (MOLST Team) Executive Committee extensively reviewed the draft MOLST form and MOLST Instructions and created alternative draft recommended MOLST and recommended MOLST instructions. The goal was to improve quality and reduce harm. The MOLST Team approved the recommended alternative MOLST and instructions and opposed creation of a separate MOLST for individuals with I/DD who lack capacity to make MOLST decisions.

Comments and/or recommendations were due no later than March 16, 2020.  Given the COVID-19 crisis in New York, this process is on hold.

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The MOLST Update is a Newsletter dedicated to providing up-to-date information on advance care planning, MOLST and eMOLST.