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S
igna
tures
:
The signatures below verify that these orders are consistent with the patient’s medical condition, known
preferences and best known information. If signed by an authorized representative, the patient must be mentally incapacitated
and the person signing is the legal authorized representative.
Discussed
with:
P
a
tien
t
P
aren
t
of Minor
Guardian
with
Health Care
Authority
Spouse/Domestic Partner
Health Care
Agent
(Durable Power of
Attorney for Healthcare)
Adult child of patient
PRINT
—
MD/DO/APRN
Name (required)
MD/DO/APRN Signature
(required)
MD/DO/APRN License Number
(required)
PRINT
—
P
a
tien
t
or
Legal
Authorized Representative N
ame
P
a
tien
t
or
Legal
Authorized Representative
Signature
(required)
Person
has:
Health Care Directive (Living Will)
Encourage all advance care
planning
Durable Power
of
Attorney
for
Health Care
documents
to
accompany
MOST
KEEP ORIGINAL DC MOST FORM WITH PATIENT’S MEDICAL RECORDS
Health Care Professional Information: NOTE: A person with capacity may always consent to or refuse medical
care interventions, regardless of information represented on any
document, including this one.
SECTIONS A, B and C:
• No defibrillator should be used on a person who has chosen “Do Not Attempt
Resuscitation”
•
Completing a MOST form is always voluntary.
• Treatment choices documented on this form should be the result of shared decision-
making by an individual or their authorized representative and medical provider
based on the person’s preferences and medical condition.
• When comfort cannot be achieved in the current setting, the person should be
transferred to a setting able to provide comfort (e.g., treatment of a hip fracture).
• An IV medication to enhance comfort may be appropriate for a person who has
chosen “Comfort-Focused Treatment”.
• Treatment of dehydration is a measure which may prolong life. A person who
desires IV fluids should indicate “Selective” or “Full Treatment”.
• Oral fluids and nutrition must always be offered if medically feasible.
SECTION D:
• Patient/Authorized Representative and MD/DO/APRN signatures.
Reviewing MOST
This MOST should be reviewed periodically whenever:
1.The person is transferred from one care setting or care level to another,
or
2.There is a substantial change in the person’s health status,
or
3.The person’s treatment preferences change.
To void this form, draw a line through “Medical Orders” and write “VOID”
in large letters. Any changes require a new MOST.
• MOST must be signed by a MD/DO/APRN and patient, or their authorized
representative, to be valid. Verbal orders are acceptable with follow-up signature by
a MD/DO/APRN in accordance with facility/community policy.
Using MOST
•
Any incomplete section of MOST implies full treatment for that section.
•
This MOST is valid in all care settings including hospitals until replaced
by new physician orders.
•
The MOST is a set of medical orders.
•
The MOST does not replace an advanced directive.
•
An advance directive is encouraged for all competent adults regardless
of their health status. An advance directive allows a person to document
in detail his/her future health care instructions and/or name an authorized
representative decision maker to speak on his/her behalf. When
available, all documents should be reviewed to ensure consistency, and
the forms updated appropriately to resolve any conflicts.
No
Change
Form Voided
New
form completed
No
Change
Form Voided
New
form completed
Version 8 18 2021 Photocopies and faxes of signed MOST forms are legal and valid. May make copies for records.
