Enhancing EMS Practice Through Data and Performance Improvement

Medical Orders for Scope of Treatment

In January, 2008 North Carolina implemented a standardized statewide form to legally document a patient’s wishes concerning end of life care. Both the information provided on this page and the online Emergency Medical Services MOST Educational Program were developed by the NC OEMS and the EMSPIC to assist EMS agencies and personnel in understanding how the MOST form is to be used.

EMS personnel are encouraged to complete the MOST Online Educational Program by clicking on the link below. This program can be completed in approximately 30 minutes. To receive one hour/unit of CME/CEU awarded by the NC OEMS, please enter your NC EMS State ID (their P number) when prompted. After the program has been successfully completed, a certificate will be displayed which can be printed for documentation.

MOST Frequently Asked Questions
Click the links below to go to the appropriate section of the FAQ

What is MOST?
 

1. What does "MOST" mean?
2. Who should use MOST?
3. What is the goal of MOST?
4. MOST is what color?
5. What does the MOST form look like and where can I obtain copies of it?

What Should EMS Agencies and Personnel Know About MOST?

6. Why not just use the current portable (yellow) DNR?
7. If a patient has a MOST Form and a DNR Form, how do you determine which one to honor?
8. How can EMS personnel verify that a MOST Form has been completed correctly and is valid?
9. Who can give a verbal order to NOT honor a MOST Form?
10. If a MOST Form has not been reviewed within one year of its effective date, should it still be honored?
11. What if one of the Sections A-D is not completed?
12. Does CPR include any treatment other than chest compressions and bag‐valve ventilation?
13. Is Defibrillation considered part of CPR in Section A or part of Section B Full Scope of Treatment?
14. Is Defibrillation considered a part of Section B “Limited Additional Interventions?”

Other General Questions Related to MOST

• Are copies of MOST acceptable?
• How long is MOST valid?
• When should MOST be reviewed?
• How can MOST be revoked?
• Where should MOST be posted?

What is MOST?
 

1. What does "MOST" mean?

MOST stands for Medical Orders for Scope of Treatment. It is a physician’s order that outlines a plan of care respecting the patient’s wishes concerning care at life’s end.

2. Who should use MOST?

MOST is primarily geared toward patients who have an advanced chronic progressive illness. In addition to those who are seriously ill, MOST is appropriate for patients whose life expectancy is less than one year. Unless it is the patient’s preference, use of MOST is not appropriate for individuals with stable medical conditions or functionally disabling problems who have many years of life expectancy.

3. What is the goal of MOST?

The goal of MOST is to inform and empower patients to clearly state their end-of-life care wishes, and to authorize health care providers to carry out those wishes. Because it is a medical order, health care providers at every level of health care can implement the decisions outlined in MOST.

4. MOST is what color?

MOST is bright pink to increase its visibility.

5. What does the MOST form look like and where can I obtain copies of it?

Click here to go to the OEMS DNR and MOST form site for samples and purchase information

What Should EMS Agencies and Personnel Know About MOST?

6. Why not just use the current portable (yellow) DNR?

The current portable (yellow) DNR has been an effective step in support of patient’s decisions, specifically about CPR. It may continue to be an important tool for some patient populations. MOST, however, allows seriously ill patients to outline more comprehensive choices about end-of-life care, with respect to CPR, medical interventions, antibiotics, and artificial nutrition and hydration.

7. If a patient has a MOST Form and a DNR Form, how do you determine which one to honor?

The form with most recent Effective Date should be honored.

8. How can EMS personnel verify that a MOST Form has been completed correctly and is valid?

• The Effective Date of form should be less than one year unless the form has been reviewed and renewed. If the Effective Date is more than one year from the current date and the form has been reviewed and renewed, a Renewal Date on the back of the form should be less than one year from the current date.
  
   
• The MOST form must be signed by an MD/DO, PA or NP
  
   
• The MOST form must have the patient’s name on it
  
   
• Sections A and/or B must be completed on the MOST form
  
   
• The patient's or the patient’s representative signature must be on the MOST form

9. Who can give a verbal order to NOT honor a MOST Form?

The MOST form represents the wishes of the patient. If the patient or anyone associated with the patient requests that the MOST form not be honored, EMS personnel should contact EMS Medical Control to obtain assistance and direction.

10. If a MOST Form has not been reviewed within one year of its effective date, should it still be honored?

If any one of the 5 items described above is not present on the form, the MOST form is not valid. If End of Life Orders are needed or requested at the time of EMS care, a physician and/or EMS Medical Control must provide those orders directly to EMS personnel.

11. What if one of the Sections A-D is not completed?

Any MOST section addressing medical treatments or interventions that is not completed will result in full treatment for that category of care.

12. Does CPR include any treatment other than chest compressions and bag‐valve ventilation?

Cardiopulmonary Resuscitation (CPR) means chest compressions and non-invasive ventilations including the use of a bag valve mask (BVM).

13. Is Defibrillation considered part of CPR in Section A or part of Section B Full Scope of Treatment?

Defibrillation is not considered a component of CPR. Defibrillation should be provided only if Section B of the MOST indicates “Full Scope of Treatment”

14. Is Defibrillation considered a part of Section B “Limited Additional Interventions?”

No, defibrillation is a component of “Full Scope of Treatment”

Other General Questions Related to MOST

Are copies of MOST acceptable?

In order for MOST to be followed by emergency medical services and other health care personnel in another setting, the original form is needed. Copies of MOST are appropriate for inclusion in the patient’s medical record for documentation purposes.

How long is MOST valid?

MOST is valid for one year from the date of issuance, or if it has been reviewed, it is valid for one year from the date of its last review as indicated on the back of the form. As long as MOST has been reviewed within a year of the last effective review date, this review is appropriately documented on the form, and there is no indication that the MOST has been revoked, then the MOST is valid.

When should MOST be reviewed?

MOST must be reviewed 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, which generally involve a change of health status, the MOST should be followed and any necessary review should occur afterward

How can MOST be revoked?

MOST can be revoked in a number of ways including destruction, putting a line through the front page and writing void on the form, or by indicating in the review section on the back that MOST has been revoked.

Where should MOST be posted?

If the patient is in a health care facility, the posting of MOST will be determined by facility policy. If the patient is at home, MOST should either be above the patient’s bed, on the door to the patient’s bedroom, or on the refrigerator in the home where the patient resides.