Introducing a “MOST” Beneficial Physician’s Order

Doctors have just been given an important new tool for navigating through “end of life” advance care planning with patients and their families. The new MOST (Medical Orders for Scope of Treatment) form recently received a resounding stamp of approval from North Carolina’s physician and physician assistant community after legislators passed it in 2007.

The MOST form is primarily geared toward patients who have advanced chronic progressive illness, or, in other words, for patients who are seriously ill. It is also appropriate for patients whose life expectancy is less than one year.

It is important to note that there is a fundamental distinction between a physician’s order like MOST and advance directives such as a Living Will or Health Care Power of Attorney. Physician orders instruct other health care providers as to what level of care to provide, whereas advance directives inform physicians about the level of care desired by the patient.

A MOST physician’s order must be filled out by a health care professional in direct consultation with the patient or the patient’s representative. Advance directives generally do not involve a health care professional’s input or guidance.

More than 70 percent of Americans surveyed said that they would not want to be kept alive artificially by medical interventions if they suffered from a terminal illness or had severe dementia.1 However, relatively few ever plan for end-of-life issues by expressing their wishes through advance care directives or discussing this with their physicians.

The 2007 North Carolina General Assembly recently overhauled the advance directive laws providing more choices for NC citizens. The new MOST legislation provides a mechanism to communicate patient’s preferences for end-of-life treatment across settings. Similar to the current DNR (Do Not Resuscitate) form, the MOST form includes additional specific wishes including the right to request CPR (Cardio Pulmonary Resuscitation). Sections A & B of the MOST form deal with choices related to emergent decisions like CPR, full scope of treatment, limited additional treatment (aimed at avoiding intensive care), and comfort measures (for example: do not transfer to hospital unless needed for comfort measures). Sections C & D deal with choices related to antibiotics and medically administered fluids and nutrition.

Due to clarity and the legal status of this form, the utilization of a MOST physician order will be very beneficial in long-term care settings by hopefully reducing unwanted hospitalizations, increasing patient satisfaction, and reducing risk. MOST will provide a bridge between advance directives and physician orders and will improve implementation of end-of-life care planning. Together with a valid Living Will or Health Care Power of Attorney, a MOST form allows providers to act immediately or withhold life prolonging treatment, according to the patient’s specific instructions.

It is important to recognize that neither advance directives nor the new MOST physician order will ensure that all conflicts will be avoided or that a patient’s wishes will always be honored. These forms can’t talk for us and often these situations are compounded by the fact that both family and health care providers wrongly guess or assume what their loved ones or patients would want. What they do aim to help us all achieve is an ongoing honest dialogue between patient, family and physicians. That kind of communication can be “MOST” beneficial in advance care planning.

Physicians Only
To order the MOST form:

NC Office of Emergency Medical Services
Division of Health Service Regulation
Attention: DNR/MOST order
2707 Mail Service Center
Raleigh, NC 27699

Or call the Director of Emergency Medical Services at 919 855-3935.