Medical Orders for Scope of Medical Orders for Scope of Treatment (MOST)Treatment (MOST)

Preparation and ImplementationPreparation and Implementation

What is a MOST form?What is a MOST form? A physician order – Medical Orders for A physician order – Medical Orders for

Scope of Treatment (MOST) regarding Scope of Treatment (MOST) regarding treatment optionstreatment options– MOST form allows patients to specify end of life MOST form allows patients to specify end of life

care wishes from a range of options, including care wishes from a range of options, including cardiopulmonary resuscitation, medical cardiopulmonary resuscitation, medical interventions, antibiotics and medically interventions, antibiotics and medically administered fluids and nutritionadministered fluids and nutrition

– Contains a signature of the physician and the Contains a signature of the physician and the patient or authorized representativepatient or authorized representative

– Has an effective date and is renewable annuallyHas an effective date and is renewable annually

What does a MOST form Address?What does a MOST form Address? Top portion of the MOST (Section A) directs the Top portion of the MOST (Section A) directs the

provider regarding CPR choice – UNC HCS provider regarding CPR choice – UNC HCS accepts accepts this section onlythis section only as a valid portable DNR as a valid portable DNR order (if a DNR Order is entered) until order (if a DNR Order is entered) until reassessmentreassessment

Other sections of MOST address patient treatment Other sections of MOST address patient treatment preferences – these portions are not accepted at preferences – these portions are not accepted at UNC HCS as orders, but these choices should be UNC HCS as orders, but these choices should be discussed with the patient and added to the discussed with the patient and added to the electronic advance care planning noteelectronic advance care planning note

A copy of the MOST should be retained in the A copy of the MOST should be retained in the patient’s medical record to provide information patient’s medical record to provide information regarding patient treatment choicesregarding patient treatment choices

How is MOST Implemented?How is MOST Implemented? Portable DNR portion of MOST (Section A) Portable DNR portion of MOST (Section A)

is accepted as a valid DNR order (if a DNR is accepted as a valid DNR order (if a DNR Order is entered) until the order is Order is entered) until the order is reassessed per existing policiesreassessed per existing policies– See UNC HCS Policy D-17, Portable Do Not See UNC HCS Policy D-17, Portable Do Not

Resuscitate Orders, for information on Resuscitate Orders, for information on reassessment of DNR ordersreassessment of DNR orders

How is MOST Implemented?How is MOST Implemented? Treatment choices on a MOST other than DNR Treatment choices on a MOST other than DNR

are used as evidence of the patient’s wishes, but are used as evidence of the patient’s wishes, but are not accepted as a valid order at UNC HCSare not accepted as a valid order at UNC HCS

Physician should determine whether the issuance Physician should determine whether the issuance of a DNR Order is appropriate under UNC HCS of a DNR Order is appropriate under UNC HCS policies and if implementation of patient’s wishes policies and if implementation of patient’s wishes is medically appropriate under the circumstances. is medically appropriate under the circumstances. This information should be documented in the This information should be documented in the electronic advance care planning noteelectronic advance care planning note

When choices in MOST conflict with patient’s When choices in MOST conflict with patient’s advance directives, if the MOST form was signed advance directives, if the MOST form was signed later, the MOST form choices may suspend (but later, the MOST form choices may suspend (but not revoke) the conflicting provisions in the not revoke) the conflicting provisions in the advance directivesadvance directives

How is MOST Implemented?How is MOST Implemented? MOST only valid for one year from date signedMOST only valid for one year from date signed MOST must be reviewed and re-signed by the MOST must be reviewed and re-signed by the

physician and the patient or patient’s physician and the patient or patient’s representative at least annually or earlier if: representative at least annually or earlier if: – (1) the patient is admitted to and/or discharged from a (1) the patient is admitted to and/or discharged from a

health care facility; health care facility; – (2) there is a substantial non-emergency change in the (2) there is a substantial non-emergency change in the

patient’s health status; or patient’s health status; or – (3) the patient’s treatment preferences change. (3) the patient’s treatment preferences change.

In emergency situations, a DNR Order in Section In emergency situations, a DNR Order in Section A of the MOST should be followed without any A of the MOST should be followed without any prior assessmentprior assessment

How is MOST Completed?How is MOST Completed?

ONLY the original pink MOST form issued ONLY the original pink MOST form issued by the Department of Health and Human by the Department of Health and Human Services may be used – no photocopies or Services may be used – no photocopies or print-outsprint-outs

Original pink MOST form should be given to Original pink MOST form should be given to patientpatient

Central Distribution has these pink formsCentral Distribution has these pink forms

How is MOST Completed?How is MOST Completed?

Patients may request that a physician complete Patients may request that a physician complete and sign a MOSTand sign a MOST

UNC HCS physicians are not obligated to UNC HCS physicians are not obligated to complete a MOST form for a patient, however, complete a MOST form for a patient, however, completion of a MOST form for a patient may help completion of a MOST form for a patient may help achieve goals which are medically appropriate for achieve goals which are medically appropriate for the patient the patient

MOST forms enable the patient to make their MOST forms enable the patient to make their treatment choices known outside our facilities, and treatment choices known outside our facilities, and are considered a service to our patients, but are considered a service to our patients, but completion by physicians is optional completion by physicians is optional

How is MOST Completed?How is MOST Completed?

Physician should review the MOST with the Physician should review the MOST with the patient and document the patient’s choicespatient and document the patient’s choices

Basis for MOST must be documented in the Basis for MOST must be documented in the progress notes of patient’s medical recordprogress notes of patient’s medical record

Physician who completes the MOST must Physician who completes the MOST must sign it as an ordersign it as an order

Signatures for MOSTSignatures for MOST If the patient is decisionally capable, the patient should If the patient is decisionally capable, the patient should

always consent to and sign the MOST. always consent to and sign the MOST. Authorized representatives for a patient who is not Authorized representatives for a patient who is not

decisionally capable must be taken in this order:decisionally capable must be taken in this order: Court-appointed guardian (except to the extent a Health Care Court-appointed guardian (except to the extent a Health Care

Power of Attorney is granted authority) Power of Attorney is granted authority) Health Care Power of AttorneyHealth Care Power of Attorney General Power of AttorneyGeneral Power of Attorney SpouseSpouse A majority of reasonably available parents and adult childrenA majority of reasonably available parents and adult children A majority of reasonably available adult siblingsA majority of reasonably available adult siblings Other individual with an established relationship with patientOther individual with an established relationship with patient

MOST form MOST form MUSTMUST be signed by either the patient or be signed by either the patient or authorized representativeauthorized representative

Double Click Below to Open MOST FileDouble Click Below to Open MOST File(FYI ONLY – DO NOT USE THIS PDF File)(FYI ONLY – DO NOT USE THIS PDF File)

For QuestionsFor Questions

Review UNC HCS Policy D-17, Portable Do Review UNC HCS Policy D-17, Portable Do Not Resuscitate Orders, and UNC HCS Not Resuscitate Orders, and UNC HCS Policy E-5, End-of-Life – ProceduresPolicy E-5, End-of-Life – Procedures

Contact Legal Department or Ethics Contact Legal Department or Ethics CommitteeCommittee