Medical Directive - DNR / MOLST

NEW YORK NONHOSPITAL DNR / MOLST PREPARATION WORKSHEET

Not a Medical Order

CRITICAL NOTICE: Signing this worksheet does not create a New York DNR or DNI order and does not instruct EMS to withhold treatment. Public Health Law § 2994-dd requires a nonhospital DNR order to be issued on the Commissioner's standard form or an authorized alternative form. Use current DOH-3474 for a DNR-only nonhospital order or current DOH-5003 MOLST when the broader MOLST process is appropriate.

Use this worksheet to prepare for a goals-of-care discussion, identify the proper decision-maker and legal pathway, and collect information for the clinician who will complete the official form.

1. PATIENT INFORMATION

2. PATIENT REQUEST AND GOALS

I request a discussion with my treating clinician about resuscitation and other life-sustaining treatment.

My current preferences for discussion are:

☐ If I have no pulse and/or am not breathing, I do not want CPR attempted if a valid medical order is issued.

☐ I want CPR attempted.

☐ I want do-not-intubate and other respiratory-support choices discussed.

☐ I want comfort-focused treatment and symptom management discussed.

☐ I want other life-sustaining-treatment choices discussed.

Questions, values, religious considerations, or other goals:

[____________________________________________________________]

[____________________________________________________________]

Patient signature (documents this request only): [____________________________]

Date: [__/__/____]

3. DECISION-MAKER AND LEGAL-PATHWAY SCREEN

Complete this section before selecting a form. Public Health Law § 2994-cc permits an adult with decision-making capacity, a health care agent, or a surrogate to consent to a nonhospital DNR order orally to the attending practitioner or in writing, subject to the governing rules for that decision-maker.

3.1 Decision-maker

☐ Adult patient with decision-making capacity

☐ Health care agent under a valid health care proxy

☐ Family Health Care Decisions Act surrogate

☐ Parent or other authorized decision-maker for a minor

☐ Court-appointed guardian

☐ Decision-maker under SCPA § 1750-b for a patient with an intellectual or developmental disability

☐ Other asserted authority: [________________________________]

Decision-maker name: [________________________________]

Relationship / authority: [________________________________]

Telephone: [________________________________]

Supporting document reviewed: [________________________________]

A signature on this worksheet does not establish authority. The clinician must verify capacity, consent authority, clinical criteria, setting-specific requirements, and any required concurrence, witnesses, or committee review under the current law and applicable checklist.

3.2 Special circumstances

Check every item that may require a specialized pathway:

☐ Patient is a minor

☐ Patient has an intellectual or developmental disability

☐ Patient is receiving services in a mental-health setting

☐ Patient is in a correctional facility

☐ Patient is in hospice or receiving home care

☐ Patient lacks capacity and has no known health care agent

☐ None identified

Notes:

[____________________________________________________________]

4. CLINICAL DISCUSSION

Clinician name: [________________________________]

Profession: ☐ Physician ☐ Nurse practitioner ☐ Physician assistant

New York license number: [________________________________]

Discussion date: [__/__/____]

☐ Diagnosis, prognosis, goals for care, treatment options, and the consequences of each proposed order were discussed.

☐ The patient's current medical condition, values, and wishes were reviewed.

☐ The proper decision-maker and consent pathway were confirmed.

☐ The current Department of Health legal-requirements checklist or an equivalent compliance method was used.

☐ Any required second determination, concurrence, witnesses, ethics review, or specialized checklist was completed.

Clinical notes:

[____________________________________________________________]

[____________________________________________________________]

5. SELECT THE OFFICIAL FORM

5.1 DOH-3474 — Nonhospital DNR order

Use the current one-page DOH-3474 when a DNR-only nonhospital order is appropriate. It applies when the named person is in cardiac or respiratory arrest; it does not by itself create orders concerning intubation or other life-sustaining treatments.

☐ Current DOH-3474 obtained from the New York State Department of Health

☐ Person's name and date of birth entered

☐ DNR order reviewed with the proper decision-maker

☐ Physician, nurse practitioner, or physician assistant signed and dated the official form and entered the required license information

☐ If the patient has an intellectual or developmental disability, the form's physician-only and SCPA § 1750-b instructions were followed

☐ Issuance recorded in the medical record

5.2 DOH-5003 (06/25) — MOLST

The current MOLST is a medical-order form for patients with serious health conditions. It includes resuscitation, intubation, and other life-sustaining-treatment orders. The current Department of Health form is DOH-5003 (06/25).

☐ Current DOH-5003 obtained from the New York State Department of Health

☐ Patient information and known advance directives entered

☐ Resuscitation order completed

☐ Intubation / respiratory-support order completed

☐ Consent section completed for the proper decision-maker

☐ Physician, nurse practitioner, or physician assistant signed and dated the applicable medical orders

☐ Remaining treatment-order sections completed as clinically appropriate

☐ If the patient has an intellectual or developmental disability, the form instructions and required OPWDD process were followed

☐ Official form and supporting documentation placed in the medical record

5.3 Clinician disposition

☐ DOH-3474 completed separately

☐ DOH-5003 MOLST completed separately

☐ No order completed; additional evaluation or documentation is required

☐ Request declined because statutory or clinical requirements were not met

Reason / follow-up plan:

[____________________________________________________________]

Clinician signature (documents worksheet review only): [________________________]

Date: [__/__/____]

The clinician's signature on this worksheet is not the operative order. The current official form must be completed and signed separately.

6. REVIEW, TRANSFER, AND ACCESS

Public Health Law § 2994-dd requires the attending practitioner to review whether a nonhospital DNR remains appropriate whenever the patient is examined, but at least every 90 days; the statute also states that failure to complete that review does not make the order ineffective.

☐ Review due date recorded: [__/__/____]

☐ Review reminder placed in the clinical record

☐ Order location communicated to patient, decision-maker, caregivers, and facility staff

☐ Official form will accompany the patient during transfers

☐ Receiving practitioner will be informed of the order

☐ Standard DNR bracelet or other authorized article discussed, if desired

A bracelet or other article is optional. Public Health Law § 2994-dd prohibits requiring one as a condition of honoring the order or providing health care.

7. REVOCATION OR CHANGE

Under Public Health Law § 2994-dd, a person who consented to a nonhospital DNR may revoke consent at any time by an act showing a specific intent to revoke. A health professional informed of revocation must notify the attending practitioner; the attending practitioner must record the revocation, cancel the order, and make diligent efforts to retrieve the order form and bracelet, if any.

Do not use this worksheet itself to revoke or replace an order. Immediately notify the treating team and follow the instructions on the operative DOH-3474 or MOLST and in the medical record.

Change / revocation notes:

[____________________________________________________________]

[____________________________________________________________]

8. FINAL RECORDS CHECKLIST

☐ Operative DOH-3474 or DOH-5003 is complete and legible

☐ Required signatures, dates, license information, and supporting documentation are present

☐ Copy or original retained in the medical record as directed

☐ Patient or caregiver knows where the EMS-facing form is kept

☐ Transfer packet and facility records are consistent

☐ Conflicting or superseded orders were addressed through the proper clinical process

☐ Next review date is tracked

9. CURRENT OFFICIAL SOURCES

• New York Public Health Law § 2994-cc — https://www.nysenate.gov/legislation/laws/PBH/2994-CC
• New York Public Health Law § 2994-dd — https://www.nysenate.gov/legislation/laws/PBH/2994-DD
• New York Public Health Law § 2994-ee — https://www.nysenate.gov/legislation/laws/PBH/2994-EE
• New York State Department of Health, Nonhospital DNR Order, DOH-3474 (8/20) — https://www.health.ny.gov/forms/doh-3474.pdf
• New York State Department of Health, MOLST, DOH-5003 (06/25) — https://www.health.ny.gov/forms/doh-5003.pdf
• New York State Department of Health, MOLST instructions and legal-requirements checklists — https://www.health.ny.gov/professionals/patients/patient_rights/molst/

This worksheet is for preparation and clinical intake only. Verify the current statute, Department of Health forms, legal-requirements checklists, and applicable facility or EMS procedures before completing or relying on an order.