NEW YORK ATTORNEY GENERAL - ADVANCE DIRECTIVE

(MEDICAL POA, LIVING WILL, MOLST)

(1) 1,_____________________________________________________________________

hereby appoint

______________________________________________________________________

(name, home address and telephone number)

______________________________________________________________________

______________________________________________________________________

as my health care agent to make any and all health care decisions for me, except to the
extent that I state otherwise. This proxy shall take effect only when and if I become
unable to make my own health care decisions.

(2) Optional: Alternate Agent

If the person I appoint is unable, unwilling or unavailable to act as my health care agent, I
hereby appoint

______________________________________________________________________

(name, home address and telephone number)

______________________________________________________________________

______________________________________________________________________

as my health care agent to make any and all health care decisions for me, except to the
extent that I state otherwise.

(3) Unless I revoke it or state an expiration date or circumstances under which it will expire,
this proxy shall remain in effect indefinitely. (Optional: If you want this proxy to expire,
state the date or conditions here.) This proxy shall expire (specify date or conditions):

______________________________________________________________________

______________________________________________________________________

19
(4) Optional: I direct my health care agent to make health care decisions according to my
wishes and limitations, as he or she knows or as stated below. (If you want to limit your
agent’s authority to make health care decisions for you or to give specific instructions,
you may state your wishes or limitations here.) I direct my health care agent to make
health care decisions in accordance with the following limitations and/or instructions
(attach additional pages as necessary):
______________________________________________________________________

______________________________________________________________________

In order for your agent to make health care decisions for you about artificial nutrition and
hydration (nourishment and water provided by feeding tube and intravenous line), your
agent must reasonably know your wishes. You can either tell your agent what your
wishes are or include them in this section. See instructions for sample language that you
could use if you choose to include your wishes on this form, including your wishes about
artificial nutrition and hydration.

(5) Your Identification (please print)

Your Name_____________________________________________________________

Your Signature ____________________________________ Date _________________

Your Address___________________________________________________________

(6) Optional: Organ and/or Tissue Donation

I hereby make an anatomical gift, to be effective upon my death, of: (check any that
apply)

Any needed organs and/or tissues

The following organs and/or tissues__________________________________________

______________________________________________________________________

Limitations______________________________________________________________

If you do not state your wishes or instructions about organ and/or tissue donation on this
form, it will not be taken to mean that you do not wish to make a donation or prevent a
person, who is otherwise authorized by law, to consent to a donation on your behalf.

Your Signature___________________________ Date_________________________

20
(7) Statement by Witnesses (Witnesses must be 18 years of age or older and cannot be the
health care agent or alternate.)

I declare that the person who signed this document is personally known to me and
appears to be of sound mind and acting of his or her own free will. He or she signed (or
asked another to sign for him or her) this document in my presence.

Date Date
_____________________________ ___________________________________

Name of Witness 1 Name of Witness 2

(print) ____________________________ (print)______________________________

Signature _________________________ Signature ___________________________

Address __________________________ Address ____________________________

_________________________________ ___________________________________

21
 NEW YORK
LIVING WILL – PAGE 1 OF 4
______________________________________

PART II This Living Will has been prepared to conform to the law in the State of
New York, and is intended to be “clear and convincing” evidence of my
wishes regarding the health care decisions I have indicated below.

PRINT YOUR NAME I, _______________________________________________, being of

sound mind, make this statement as a directive to be followed if I become
unable to participate in decisions regarding my medical care. These
instructions reflect my firm and settled commitment to regarding health
care under the circumstances indicated below:

LIFE-SUSTAINING TREATMENTS

I direct that my health care providers and others involved in my care

provide, withhold, or withdraw treatment in accordance with the choice I
have marked below: (Initial only one box)

INITIAL ONLY ONE [ ] (a) Choice NOT To Prolong Life

CHOICE: (a) OR (b)

IF YOU DO NOT AGREE I do not want my life to be prolonged if I should be in an incurable or

WITH EITHER CHOICE, irreversible mental or physical condition with no reasonable expectation of
YOU MAY WRITE YOUR recovery, including but not limited to: (a) a terminal condition; (b) a
OWN DIRECTIONS ON permanently unconscious condition; or (c) a minimally conscious condition
THE NEXT PAGE
in which I am permanently unable to make decisions or express my
wishes. While I understand that I am not legally required to be specific
about future treatments if I am in the condition(s) described above I feel
especially strongly about the following forms of treatment:
IF YOU INITIAL BOX (a),
YOU MAY INITIAL
SPECIFIC TREATMENTS
I do not want cardiac resuscitation.
YOU WOULD LIKE I do not want mechanical respiration.
WITHHELD I do not want artificial nutrition and hydration.
I do not want antibiotics.

OR

[ ] (b) Choice To Prolong Life

I want my life to be prolonged as long as possible within the limits
of generally accepted health care standards.

© 2005 National Hospice

and Palliative Care
Organization.
2019 Revised.
 NEW YORK
LIVING WILL – PAGE 2 OF 4
______________________________________

RELIEF FROM PAIN:

Except as I state in the following space, I direct that treatment for

alleviation of pain or discomfort should be provided at all times even if it
hastens my death:

ADD ADDITIONAL __________________________________________________________

INSTRUCTIONS HERE __________________________________________________________
ONLY IF YOU WANT TO
LIMIT PAIN RELIEF
__________________________________________________________
__________________________________________________________

OTHER WISHES:

(If you do not agree with any of the optional choices above and wish to
write your own, or if you wish to add to the instructions you have given
above, you may do so here.) I direct that:
ADD OTHER
INSTRUCTIONS, IF ANY, __________________________________________________________
REGARDING YOUR __________________________________________________________
ADVANCE CARE PLANS __________________________________________________________
__________________________________________________________
THESE INSTRUCTIONS __________________________________________________________
CAN FURTHER ADDRESS
YOUR HEALTH CARE __________________________________________________________
PLANS, SUCH AS YOUR __________________________________________________________
WISHES REGARDING __________________________________________________________
HOSPICE TREATMENT, __________________________________________________________
BUT CAN ALSO ADDRESS __________________________________________________________
OTHER ADVANCE
PLANNING ISSUES, SUCH __________________________________________________________
AS YOUR BURIAL WISHES __________________________________________________________
__________________________________________________________
ATTACH ADDITIONAL __________________________________________________________
PAGES IF NEEDED

These directions express my legal right to refuse treatment, under the law
of New York. I intend my instructions to be carried out unless I have
rescinded them in a new writing or by clearly indicating that I have
changed my mind.

My agent, if I have appointed one in Part I or elsewhere, has full authority

to resolve any question regarding my health care decisions, as recorded in
this document or otherwise, and what my choices may be.
© 2005 National Hospice
and Palliative Care
Organization.
2019 Revised.
ORGAN NEW YORK
DONATION LIVING WILL – PAGE 3 of 4
(OPTIONAL)
______________________________________

OPTIONAL ORGAN DONATION:

INITIAL THE BOX THAT Upon my death: (initial only one applicable box)
AGREES WITH YOUR
WISHES ABOUT ORGAN
DONATION [ ] (a) I do not give any of my organs, tissues, or parts and do
not want my agent, guardian, or family to make a
INITIAL ONLY ONE donation on my behalf;

[ ] (b) I give any needed organs, tissues, or parts;

OR

[ ] (c) I give the following organs, tissues, or parts only:

STRIKE THROUGH ANY ______
USES YOU DO NOT AGREE ______
TO
______

My gift, if I have made one, is for the following

purposes: (initial any of the following you do not want)

[ ] - Transplant
[ ] - Therapy
[ ] - Research
[ ] - Education

© 2005 National Hospice

and Palliative Care
Organization.
2019 Revised.
 NEW YORK
LIVING WILL – PAGE 4 of 4
______________________________________

PART III Part III. Execution

Signed ________________________________________Date_________
SIGN AND DATE
THE DOCUMENT
AND PRINT YOUR NAME Print Name
AND
ADDRESS Address ____________________________________________________

____________________________________________________

I declare that the person who signed this document appeared to execute
the living will willingly and free from duress. He or she signed (or asked
another to sign for him or her) this document in my presence.

Witness 1
WITNESSING
PROCEDURE Signed ________________________________________Date_________

Print Name

Address ____________________________________________________
YOUR
WITNESSES ____________________________________________________
MUST SIGN AND DATE
AND
PRINT THEIR NAMES AND
ADDRESSES HERE
Witness 2

Signed ________________________________________Date_________

Print Name

Address ____________________________________________________

____________________________________________________

© 2005 National Hospice

and Palliative Care
Made Fillable by eForms
Organization.
2019 Revised.
NEW YORK STATE DEPARTMENT OF HEALTH Medical Orders for Life­Sustaining Treatment (MOLST)

THE PATIENT KEEPS THE ORIGINAL MOLST FORM DURING TRAVEL TO DIFFERENT CARE SETTINGS. THE PHYSICIAN KEEPS A COPY.

LAST NAME/FIRST NAME/MIDDLE INITIAL OF PATIENT

ADDRESS

CITY/STATE/ZIP

Male Female
DATE OF BIRTH (MM/DD/YYYY) eMOLST NUMBER (THIS IS NOT AN eMOLST FORM)

Do­Not­Resuscitate (DNR) and Other Life­Sustaining Treatment (LST)

This is a medical order form that tells others the patient’s wishes for life­sustaining treatment. A health care professional must complete or change the MOLST
form, based on the patient’s current medical condition, values, wishes 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. A physician 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 physician examines the patient, reviews the orders and changes them.
MOLST is generally for patients with serious health conditions. The patient or other decision­maker should work with the physician and consider asking
the physician to fill out a MOLST form if the patient:
• Wants to avoid or receive any or all life­sustaining treatment.
• Resides in a long­term care facility or requires long­term care services.
• Might die within the next year.
If the patient has a developmental disability and does not have ability to decide, the doctor must follow special procedures and attach the appropriate
legal requirements checklist.

SECTION A Resuscitation Instructions When the Patient Has No Pulse and/or Is Not Breathing
Check one:
CPR Order: Attempt Cardio­Pulmonary Resuscitation
CPR involves artificial breathing and forceful pressure on the chest to try to restart the heart. It usually involves electric shock (defibrillation) and a
plastic tube down the throat into the windpipe to assist breathing (intubation). It means that all medical treatments will be done to prolong life when
the heart stops or breathing stops, including being placed on a breathing machine and being transferred to the hospital.
DNR Order: Do Not Attempt Resuscitation (Allow Natural Death)
This means do not begin CPR, as defined above, to make the heart or breathing start again if either stops.

SECTION B Consent for Resuscitation Instructions (Section A)

The patient can make a decision about resuscitation if he or she has the ability to decide about resuscitation. If the patient does NOT have the ability to
decide about resuscitation and has a health care proxy, the health care agent makes this decision. If there is no health care proxy, another person will
decide, chosen from a list based on NYS law.

Check if verbal consent (Leave signature line blank)

SIGNATURE DATE/TIME

PRINT NAME OF DECISION­MAKER

PRINT FIRST WITNESS NAME PRINT SECOND WITNESS NAME

Who made the decision? Patient Health Care Agent Public Health Law Surrogate Minor’s Parent/Guardian §1750­b Surrogate

SECTION C Physician Signature for Sections A and B

PHYSICIAN SIGNATURE PRINT PHYSICIAN NAME DATE/TIME

PHYSICIAN LICENSE NUMBER PHYSICIAN PHONE/PAGER NUMBER

SECTION D Advance Directives

Check all advance directives known to have been completed:
Health Care Proxy Living Will Organ Donation Documentation of Oral Advance Directive
DOH­5003 (6/10) Page 1 of 4 HIPAA permits disclosure of MOLST to other health care professionals & electronic registry as necessary for treatment.
 THE PATIENT KEEPS THE ORIGINAL MOLST FORM DURING TRAVEL TO DIFFERENT CARE SETTINGS. THE PHYSICIAN KEEPS A COPY.

LAST NAME/FIRST NAME/MIDDLE INITIAL OF PATIENT DATE OF BIRTH (MM/DD/YYYY)

Orders For Other Life­Sustaining Treatment and Future Hospitalization

SECTION E When the Patient has a Pulse and the Patient is Breathing
Life­sustaining treatment may be ordered for a trial period to determine if there is benefit to the patient. If a life­sustaining treatment is started, but turns
out not to be helpful, the treatment can be stopped.
Treatment Guidelines No matter what else is chosen, the patient will be treated with dignity and respect, and health care providers will offer
comfort measures. Check one:
Comfort measures only Comfort measures are medical care and treatment provided with the primary goal of relieving pain and other symptoms and
reducing suffering. Reasonable measures will be made to offer food and fluids by mouth. Medication, turning in bed, wound care and other measures
will be used to relieve pain and suffering. Oxygen, suctioning and manual treatment of airway obstruction will be used as needed for comfort.
Limited medical interventions The patient will receive medication by mouth or through a vein, heart monitoring and all other necessary treatment,
based on MOLST orders.
No limitations on medical interventions The patient will receive all needed treatments.

Instructions for Intubation and Mechanical Ventilation Check one:

Do not intubate (DNI) Do not place a tube down the patient’s throat or connect to a breathing machine that pumps air into and out of lungs. Treatments
are available for symptoms of shortness of breath, such as oxygen and morphine. (This box should not be checked if full CPR is checked in Section A.)
A trial period Check one or both:
Intubation and mechanical ventilation
Noninvasive ventilation (e.g. BIPAP), if the health care professional agrees that it is appropriate
Intubation and long­term mechanical ventilation, if needed Place a tube down the patient’s throat and connect to a breathing machine as long as
it is medically needed.

Future Hospitalization/Transfer Check one:

Do not send to the hospital unless pain or severe symptoms cannot be otherwise controlled.
Send to the hospital, if necessary, based on MOLST orders.

Artificially Administered Fluids and Nutrition When a patient can no longer eat or drink, liquid food or fluids can be given by a tube inserted in the
stomach or fluids can be given by a small plastic tube (catheter) inserted directly into the vein. If a patient chooses not to have either a feeding tube or IV
fluids, food and fluids are offered as tolerated using careful hand feeding. Check one each for feeding tube and IV fluids:
No feeding tube No IV fluids
A trial period of feeding tube A trial period of IV fluids
Long­term feeding tube, if needed

Antibiotics Check one:

Do not use antibiotics. Use other comfort measures to relieve symptoms.
Determine use or limitation of antibiotics when infection occurs.
Use antibiotics to treat infections, if medically indicated.

Other Instructions about starting or stopping treatments discussed with the doctor or about other treatments not listed above (dialysis, transfusions, etc.).

Consent for Life­Sustaining Treatment Orders (Section E) (Same as Section B, which is the consent for Section A)
Check if verbal consent (Leave signature line blank)
SIGNATURE DATE/TIME

PRINT NAME OF DECISION­MAKER

PRINT FIRST WITNESS NAME PRINT SECOND WITNESS NAME

Who made the decision? Patient Health Care Agent Based on clear and convincing evidence of patient’s wishes
Public Health Law Surrogate Minor’s Parent/Guardian §1750­b Surrogate

Physician Signature for Section E

PHYSICIAN SIGNATURE PRINT PHYSICIAN NAME DATE/TIME

DOH­5003 (6/10) Page 2 of 4 This MOLST form has been approved by the NYSDOH for use in all settings.
 THE PATIENT KEEPS THE ORIGINAL MOLST FORM DURING TRAVEL TO DIFFERENT CARE SETTINGS. THE PHYSICIAN KEEPS A COPY.

LAST NAME/FIRST NAME/MIDDLE INITIAL OF PATIENT DATE OF BIRTH (MM/DD/YYYY)

SECTION F Review and Renewal of MOLST Orders on This MOLST Form

The physician must review the form from time to time as the law requires, and also:
• If the patient moves from one location to another to receive care; or
• If the patient has a major change in health status (for better or worse); or
• If the patient or other decision­maker changes his or her mind about treatment.
Reviewer’s Name Location of Review
Date/Time and Signature (e.g., Hospital, NH, Physician’s Office) Outcome of Review

No change
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DOH­5003 (6/10) Page 3 of 4

 THE PATIENT KEEPS THE ORIGINAL MOLST FORM DURING TRAVEL TO DIFFERENT CARE SETTINGS. THE PHYSICIAN KEEPS A COPY.

LAST NAME/FIRST NAME/MIDDLE INITIAL OF PATIENT DATE OF BIRTH (MM/DD/YYYY)

SECTION F Review and Renewal of MOLST Orders on This MOLST Form Continued from Page 3

Reviewer’s Name Location of Review

Date/Time and Signature (e.g., Hospital, NH, Physician’s Office) Outcome of Review

No change
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Form voided, no new form

No change
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DOH­5003 (6/10) Page 4 of 4

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