Medical Orders for Life-Sustaining Treatment (MOLST) - Do-Not-Resuscitate (DNR) and Do-Not-Intubate (DNI) Medical Orders

Sep 19, 2026

Medical Orders for Life-Sustaining Treatment (MOLST) form for documenting life-sustaining treatment choices and advance directives for patients with serious health conditions. The document instructs healthcare professionals to complete sections based on the patient’s current condition, values, and wishes, including when the patient cannot decide. It defines resuscitation and intubation orders (CPR, DNR, DNI options), consent and decision-maker roles, and physician signing requirements with specific procedures for I/DD patients.

LanguageEnglish

CategoryForms

FormatPDF

Pages4

Reading Time2 min

AccessFree to download

SECTION A Patient Information

SECTION B Resuscitation Orders

SECTION C Intubation Orders

SECTION D Consent for Sections B and C

SECTION E Physician Signature for Sections B and C

SECTION F Additional Orders for Life-Sustaining Treatment

SECTION G Consent for Section F

SECTION H Physician Signature for Section F

NEW YORK STATE DEPARTMENT OF HEALTH Medical Orders for Life-Sustaining Treatment (MOLST) | This is a medical order form for life-sustaining treatment. A health care professional must complete the MOLST form based on the patient’s current medical condition, values, and wishes. If the patient is unable to make medical decisions, the orders should re ect patient wishes, as best understood by the health care agent or surrogate. The health care practitioner issuing the medical orders must sign the MOLST form. All health care professionals must follow these medical orders as the patient moves from one location to another, unless a health care practitioner examines the patient, reviews the orders, and voids this form. General Instructions for completing the MOLST are found on page 4 of this document.
MOLST is generally for patients with serious health conditions. The patient or other decision-maker should work with the physician, nurse practitioner, or physician assistant who will issue the orders and consider asking them to 􀀞ll out a MOLST form if the patient:
• Wants to avoid or receive any or all life-sustaining treatment.
• Resides in a long-term care facility or requires long-term care services.
• Might die within the next year.
If the patient has an intellectual or developmental disability (I/DD) and lacks the capacity to decide, a physician (not a nurse practitioner or physician assistant) must issue the orders. The physician must follow special procedures and attach the completed O􀀝ce for People with Developmental Disabilities (OPWDD) legal requirements checklist before signing the MOLST. An asterisk (*) on this form means:
*If this decision relates to an adult or minor patient with an intellectual or developmental disability (I/DD), refer to the instructions on page 4 before proceeding.
DO-NOT-RESUSCITATE (DNR) AND DO-NOT-INTUBATE (DNI) MEDICAL ORDERS | | --- | |
SECTION A Patient Information | | | | LAST NAME/FIRST NAME/MIDDLE INITIAL OF PATIENT | | ADDRESS/CITY/STATE/ZIP | PREFERRED PHONE NUMBER DATE OF BIRTH (MM/DD/YYYY) eMOLST NUMBER, if applicable (THIS IS NOT AN eMOLST FORM) Check All Advance Directives Known to be Completed Health Care Proxy Living Will Organ Donation Documentation of an Oral Advance Directive SECTION B Resuscitation Orders When the Patient Has No Pulse and/or Is Not Breathing Check one: CPR Order: Attempt Cardio-Pulmonary Resuscitation DNR Order: Do Not Attempt Resuscitation (Allow Natural Death) SECTION C Intubation Orders for Life-Sustaining Treatment When the Patient Has a Pulse and Is Breathing Respiratory Support: Non-invasive Ventilation and/or Intubation and Mechanical Ventilation Check one: Intubation and long-term mechanical ventilation, may include tracheostomy A trial period of intubation and/or mechanical ventilation* Do Not Intubate (DNI): Use of non-invasive ventilation only Do Not Intubate (DNI) and Do Not Use Non-invasive Ventilation or Mechanical Ventilation SECTION D Consent for Sections B and C SIGNATURE OF INDIVIDUAL MAKING DECISIONS For verbal consent only, leave signature line blank Written consent, sign above Who is the individual making decisions: Patient Health Care Agent FHCDA Surrogate for adult PRINTED NAME OF INDIVIDUAL MAKING DECISIONS DATE/TIME OF CONSENT FHCDA Surrogate for minor §1750-b Surrogate for adult or minor with I/DD PRINTED NAME OF FIRST WITNESS* PRINTED NAME OF SECOND WITNESS SECTION E Physician, Nurse Practitioner, Physician Assistant Signature for Sections B and C If consent inSection D was provided by a §1750-b Surrogate for an individual with an intellectual or developmental disability (I/DD), only a physician may sign this section and only a􀀜er the OPWDD MOLST Legal Requirements Checklist for Individuals with I/DD has been completed and attached. SIGNATURE PRINT NAME LICENSE NUMBER DATE/TIME *If this decision relates to an adult or minor patient with an inte

FAQs

Who is responsible for completing and signing the MOLST form?

A health care professional must complete the MOLST based on the patient’s condition, values, and wishes. The issuing healthcare practitioner must sign the MOLST, and other professionals follow the orders unless a practitioner examines and voids the form.

What options are available for resuscitation when the patient has no pulse and/or is not breathing?

Section B requires selecting either a CPR order to attempt cardio-pulmonary resuscitation or a DNR order to do not attempt resuscitation (allow natural death).

What extra requirements apply if the patient has an intellectual or developmental disability (I/DD)?

If the patient lacks decision-making capacity, a physician must issue the orders. The physician must follow special procedures and attach the OPWDD legal requirements checklist before signing, and an asterisk indicates referral to page 4 instructions.

Sep 19, 2026

Upload by Aria Callaghan