On June 2, 2025, the New York State Department of Health (DOH) issued a “Dear CEOs and Administrators” letter (DAL)   to announce issuance of a revised Medical Orders for Life Sustaining Treatment (MOLST) form, along with updated guidance. The June DAL updates preliminary revisions announced in the May 1, 2025, DAL and reflects feedback DOH received in response to the preliminary revisions. These are the first revisions to the MOLST forms and guidance since 2022. Notably, the DALs reveal that, for the first time, the Office for People with Developmental Disabilities (OPWDD) and the Office of Mental Health (OMH) joined with DOH in issuing the new form and guidance, marking welcome coordination among the three agencies with respect to sensitive end-of-life decisions.

Along with changes aimed at more consistent use of defined terms, the most substantive updates include:

• Clarifying that a patient’s health care agent or surrogate decisionmaker cannot change a decision, previously made by a patient with capacity, regarding withholding or withdrawing treatment, even after such patient has lost capacity;

• Clarifying that a health care agent or surrogate who has consented to the directions in the MOLST may continue to make decisions about life-sustaining treatment based on the patient’s current health care status – in other words, the agent or decisionmaker can change their mind as circumstances change;

• Moving the orders to be followed in an emergency situation (i.e. the patient has no pulse or is not breathing) to a more prominent location on the first page of the MOLST, addressing the administration of cardiopulmonary resuscitation (CPR) or, alternatively, the issuance of a do not resuscitate (DNR) order;

• Expanding of orders related to intubation and mechanical ventilation, to explicitly include possible tracheostomy and the employment of trial periods for intubation and mechanical ventilation;

• Highlighting those circumstances when additional procedures, found later in the MOLST, must be followed for treatment decisions involving patients with intellectual or developmental disabilities;

• Adding an option, in certain portions of the MOLST, to allow the clinician to defer issuing a specific aspect of the order while the patient or other decisionmaker further considers the question (i.e., in non-emergency situations, giving the decisionmaker time to digest all the information provided by the care team before consenting to the applicable care directive);

• Moving directives about transporting a patient to a hospital to its own section, and offering the option to transport whenever medically necessary or to preclude transport unless the patient’s pain or other severe symptoms cannot be otherwise controlled outside of a hospital setting;

• Facilitating regular review and renewal of the MOLST and providing a space for explicit voiding of previous MOLSTs, as needed, but also explicitly acknowledging that, even if a MOLST has not been reviewed and renewed within 90 days, the last completed MOLST remains valid and must be followed; and

• Moving “General Instructions” to page four of the MOLST and adding clear and specific guidance regarding patients with an intellectual or developmental disability

The DALs also note that updated checklists – to assist in implementing the process to finalize a MOLST to ensure that all the legal requirements are satisfied – have been added to the MOLST website  and encourage facility leadership to educate clinicians and other facility personnel about the availability and use of these supportive tools. The website also contains other educational resources, including updated “Frequently Asked Questions”, to help clinicians and personnel navigate this sensitive topic with patients, families and other decisionmakers.

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