1. Medical Orders for Scope of Treatment (MOST) Preparation and Implementation

2. What is a MOST form?  A physician order – Medical Orders for Scope of Treatment (MOST) regarding treatment options –MOST form allows patients to specify end of life care wishes from a range of options, including cardiopulmonary resuscitation, medical interventions, antibiotics and medically administered fluids and nutrition –Contains a signature of the physician and the patient or authorized representative –Has an effective date and is renewable annually

3. What does a MOST form Address?  Top portion of the MOST (Section A) directs the provider regarding CPR choice – UNC HCS accepts this section only as a valid portable DNR order (if a DNR Order is entered) until reassessment  Other sections of MOST address patient treatment preferences – these portions are not accepted at UNC HCS as orders, but these choices should be discussed with the patient and added to the electronic advance care planning note  A copy of the MOST should be retained in the patient’s medical record to provide information regarding patient treatment choices

4. How is MOST Implemented?  Portable DNR portion of MOST (Section A) is accepted as a valid DNR order (if a DNR Order is entered) until the order is reassessed per existing policies –See UNC HCS Policy D-17, Portable Do Not Resuscitate Orders, for information on reassessment of DNR orders

5. How is MOST Implemented?  Treatment choices on a MOST other than DNR are used as evidence of the patient’s wishes, but are not accepted as a valid order at UNC HCS  Physician should determine whether the issuance of a DNR Order is appropriate under UNC HCS policies and if implementation of patient’s wishes is medically appropriate under the circumstances. This information should be documented in the electronic advance care planning note  When choices in MOST conflict with patient’s advance directives, if the MOST form was signed later, the MOST form choices may suspend (but not revoke) the conflicting provisions in the advance directives

6. How is MOST Implemented?  MOST only valid for one year from date signed  MOST must be reviewed and re-signed by the physician and the patient or patient’s representative at least annually or earlier if: –(1) the patient is admitted to and/or discharged from a health care facility; –(2) there is a substantial non-emergency change in the patient’s health status; or –(3) the patient’s treatment preferences change.  In emergency situations, a DNR Order in Section A of the MOST should be followed without any prior assessment

7. How is MOST Completed?  ONLY the original pink MOST form issued by the Department of Health and Human Services may be used – no photocopies or print-outs  Original pink MOST form should be given to patient  Central Distribution has these pink forms

8. How is MOST Completed?  Patients may request that a physician complete and sign a MOST  UNC HCS physicians are not obligated to complete a MOST form for a patient, however, completion of a MOST form for a patient may help achieve goals which are medically appropriate for the patient  MOST forms enable the patient to make their treatment choices known outside our facilities, and are considered a service to our patients, but completion by physicians is optional

9. How is MOST Completed?  Physician should review the MOST with the patient and document the patient’s choices  Basis for MOST must be documented in the progress notes of patient’s medical record  Physician who completes the MOST must sign it as an order

10. Signatures for MOST  If the patient is decisionally capable, the patient should always consent to and sign the MOST.  Authorized representatives for a patient who is not decisionally capable must be taken in this order:  Court-appointed guardian (except to the extent a Health Care Power of Attorney is granted authority)  Health Care Power of Attorney  General Power of Attorney  Spouse  A majority of reasonably available parents and adult children  A majority of reasonably available adult siblings  Other individual with an established relationship with patient  MOST form MUST be signed by either the patient or authorized representative

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

12. For Questions  Review UNC HCS Policy D-17, Portable Do Not Resuscitate Orders, and UNC HCS Policy E-5, End-of-Life – Procedures  Contact Legal Department or Ethics Committee