- What is MOST?
- Brief review of the process to develop the MOST document
- Exploration of the MOST format
- Guidance for discussing and completing the MOST form
- Examine solutions to Frequently Asked Questions (FAQs) regarding utilization of MOST
What is MOST?
MOST is a medical document that is: Brief, simple, highly visible and portable, with the authority of a physician order.
- Medical Orders for Scope of Treatment (MOST)
- Entirely voluntary Advance Directive (AD) for individuals facing serious, life-limiting illness
- Acts as a portable physician order
- With the goal of achieving concordance of informed patient preferences with treatment received
- Outcome neutral - it may be used either to limit medical interventions or to clarify a request for any or all medically indicated treatments
Definition for KY MOST (2015-SB 77)
- "SB 77 will allow Kentuckians to use a health care directive known as a "medical order for scope of treatment." These orders spell out patients' wishes for end-of-life care. Unlike advance directives, the orders are considered to be physician's orders and are signed by both the patient or patient's legal surrogate, and the patient's physician."
- A "Medical Orders for Scope of Treatment" form or "MOST" form is a standardized, uniquely identifiable form, designed to complement an Advance Directive and available for completion on a voluntary basis in consultation with a health care professional. MOST is designed to be utilized by patients who have an advanced, progressive, serious or terminal illness, or their surrogate, and who desire to define their preferences for health care, such as those set forth in an Advance Directive and convert those preferences into a set of portable medical orders that shall be complied with by all health professionals across care settings.
The POLST Paradigm
"The Physician Orders for Life-Sustaining Treatment (POLST) Paradigm program is designed to improve the quality of care people receive at the end of life. It is based on effective communication of patient wishes, documentation of medical orders on a brightly colored form and a promise by health care professionals to honor these wishes."
The POLST website contains program contacts, legal and regulatory information, educational materials and more.
POLST – Honoring the wishes of those with serious illness and frailty.
The MOST Form
Here's a look at the MOST form.
Section A: Cardiopulmonary Resuscitation (CPR)
Section A only applies when the patient has no pulse and is not breathing (pulseless/apneic). Cardiopulmonary Resuscitation (CPR) indicates chest compressions and Advanced Cardiac Life Support (ACLS) procedures including defibrillation and intubation with resultant ventilator support. A patient not willing to accept full treatment including ventilator should not have CPR performed.
FAQ: How does MOST interface with EMS-DNR?
Section B: Medical Interventions
- Goal is life prolongation by all medically effective means
- No CPR can be consistent with Full Treatment designation
Limited Additional Interventions:
- Goal is provision of basic medical interventions
- Risk: Benefit balance - declining treatment that would result in prolonged, difficult, uncertain recovery phases
- Goal is maximizing comfort
- Every intervention weighed against potential to cause/alleviate discomfort
FAQ: Can a patient be DNR and Full Treatment?
Section C: Antibiotics
Opportunity for patient/responsible party to:
- understand that like all medications, antibiotics are optional
- discuss the benefit: burden profile of antibiotics
- side effects
- potential for improvement
- discover option of comfort medication use in setting of potential infection: antipyretics/analgesics/etc.
Section D: Medically Administered Fluids and Nutrition
These orders ONLY pertain to a patient who cannot take fluids and/or nutrition by mouth. Oral fluids and nutrition should always be offered to a patient if medically feasible. Issues of tube feeding are fairly well understood and familiar as contained in most living wills.
The role of intravenous feeding (IVF) can be more difficult.
- Goal driven
- Address the "starvation" question
- Consideration of social and functional impact of PEG/IVF
FAQ: What if the physician does not agree with orders within MOST?
Section E: Patient Preferences
Patient preferences as basis for MOST form:
- Who was involved in the discussion
- What relationship to the patient and level of responsibility
- Was a Living Will or Health Care Surrogate present
- Consistency of MOST with the Living Will and/or Health Care Surrogate
- Patient or Responsible Party
- Healthcare professional preparing the form
FAQ: What if MOST conflicts with patient's Living Will? Or orders in the chart?
FAQ: Can a NP/PA sign a MOST form?
FAQ: Does the MD have to be present for the conversation?
FAQ: How do we facilitate signing of the MOST?
FAQ: What is "Direct communication"?
Who is the MOST for?
- Any seriously ill patient
- Most applicable to patients with known disease status and predictable disease trajectory
- Completing a MOST document is entirely voluntary
- All preferences delineated within MOST are entirely voluntary
MOST Guidelines and Regulations
- Form completed by decisional patient or responsibility party (KRS 311)
- Form completed in conversation with health care provider
- May be any discipline with full understanding of medical options
- Form must be signed by patient/responsibility party
- Form must be signed by physician ONLY AFTER physician has confirmed patient preferences in direct communication with patient/responsibility party
- No restrictions regarding how the communication takes place
- Original form shall travel with patient when transferred/discharged
- Form shall be honored as a medical order wherever care is administered regardless of privilege status of physician signing form
- Facility/physician unable to honor MOST shall arrange for transfer to a facility/MD who can
- Form shall be reviewed annually and/or with any significant change in status or change in preferences
- Form can be revoked by decisional patient or responsibility part verbally or in writing at anytime
- Available to us in Kentucky:
- Living Will and KY EMS-DNR
- Most important Advance Directive any of us can execute:
- Health Care Surrogate Designation
- Most important action we can take to ensure our wishes are fulfilled when we can no longer speak for ourselves:
- 20 years of data from POST Paradigm supports the benefit of portable medical orders - MOST
- Improves and informs the conversation
- Clearly impacts care received in nursing homes, hospitals, hospices and emergency medical services
- Accurately reflects patient wishes
Common Challenges in the Use of POLST/MOST (from the Annals of Emergency Medicine 2014)
- Insufficient completion of the form or lack of authorizing provider signature
- Failure to transport the form with a patient across treatment settings
- Inadequate education regarding authorizing statute and legal protections
- Failure to read the contents and assuming to know its contents and how they apply to a patient's end-of-life care
- Following the form to the letter without confirming its contents with a patient with preserved decision-making capacity or their surrogate decision-makers when available
FAQ: Can it be copied?
FAQ: How do we keep track of it?
FAQ: Can it be scanned into the Electronic Health Record?
FAQ: How do you know it is the most recent?
FAQ: What to do if MOST conflicts with Living Will/Do Not Resuscitate or Electronic Health Record orders?
FAQ: Obligation of signing physician: Must MD Sign? Can MD revoke their signature?
FAQ: What does it mean to review with significant change, yearly?
FAQ: Is there a terminal disease requirement?
Advance Care Planning FAQs