KRS 311.6225: Kentucky medical order for scope of treatment (MOST) form -- Eligible

persons -- Scope -- Effect.

(1) An adult with decisional capacity, an adult's legal surrogate, or a responsible party

may complete a medical order for scope of treatme nt directing medical

interventions. The form shall have the title "Kentucky MOST, Medical Orders for

Scope of Treatment" and an introductory section containing the patient's name and

date of birth and the statements:

(a) "The MOST form is voluntary.";

(b) "A patient is not required to complete a MOST form.";

(c) "A patient with capacity or their legal representative may void a MOST form

any time by communicating that intent to the health care provider.";

(d) "The original form is the personal property of the patient.";

(e) "A facsimile, paper, or electronic copy is a legally valid form.";

(f) "HIPAA permits disclosure of MOST to health care professionals as

necessary for treatment."; and

(g) "Any section not completed does not invalidate the form and indicat es a

preference for full treatment for that section.".

(2) The remainder of the form shall be in substantially the following order and format

and shall have the following contents:

(a) Section A of the form shall direct cardiopulmonary resuscitation when a

person has no pulse and is not breathing by selection of one (1) of the

following:

1. "Attempt Resuscitation (CPR)"; or

2. "Do Not Attempt Resuscitation"; and

include the statement "When not in cardiopulmonary arrest, follow orders in

B, C, and D.";

(b) Section B of the form shall direct the medical interventions when a person has

a pulse or is breathing by selection of one (1) of the following:

1. Full treatmen t, required if CPR is chosen in Section A, including

providing appropriate medical and surgical treatments as indicated to

attempt to prolong life, including intensive care. This option shall

include the statement "Goal: Attempt to sustain life by all medi cally

effective means.";

2. Limited additional intervention, which may include use of non -invasive

positive airway pressure, antibiotics, and IV fluids as indicated, and

requires avoidance of intensive care and transfer to a hospital if

treatment needs cannot be met in the current location. This option shall

include the statement "Goal: Attempt to restore function while avoiding

intensive care and resuscitation efforts (ventilator, defibrillation, and

cardioversion)."; or

3. Comfort measures, including use of oxygen, suction, and manual

treatment of airway obstruction as needed for comfort, avoidance of

treatments listed in full or limited additional interventions and transfer to

a hospital only if comfort cannot be achieved in the current setting. This

option shall include the statement "Goal: Maximize comfort through

symptom management; allow natural death.";

(c) Section C of the form shall direct the use of artificially administered fluids

and nutrition, including always offering food and fluids by mouth as tolerated,

and shall include a statement that medically assisted nutrition and hydration

when it cannot reasonably be expected to prolong life, would be more

burdensome than beneficial, or would cause significant physical discomfort.

The following options shall be provided:

1. No artificial nutrition by tube;

2. Trial period of artificial nutrition by tube. This option shall be followed

by: "Goal................."; or

3. Long-term artificial nutrition and hydration by tube;

(d) Section D of the form shall direct the use of antibiotics. The following options

shall be provided:

1. Use of antibiotics as medically indicated; or

2. No antibiotics;

(e) A section of the form shall provide space to include any additional treatment

preferences;

(f) A section of the form shall be titled "Attestation by a Licensed Health Care

Professional" and shall include:

1. Space for the printed name and the signature of the licensed health care

professional and the date of completion; and

2. A statement that in completing the for m the licensed health care

professional is attesting that:

a. He or she has reviewed the patient's pre -existing advance directive

and found it in accordance with the selections on the MOST form;

or

b. The patient does not have a pre-existing advance directive;

(g) A section of the form shall be titled "Signature: Patient or Patient

Representative (E-Signed Documents Are Valid)" and shall include:

1. The printed name, signature, and contact telephone number of the

patient, surrogate, or responsible party;

2. An indication that the signing party is the:

a. Adult patient with decisional capacity;

b. Surrogate decision maker per advance directive; or

c. Responsible party in accordance with KRS 311.631; and

3. The following statements:

a. "I agree that adequate information has been provided and

significant thought has been given to decisions outlined in this

form. Treatment preferences have been expressed to the physician.

This document reflects those treatment preferences and indicates

informed consent. If signed by a surrogate or responsible party, the

preferences expressed reflect the patient's wishes as best

understood by that surrogate or responsible party."; and

b. "Your signature is not required on this form to receive treatment.";

(h) A section of the form shall be titled "Physician Signature (E -Signed

Documents Are Valid)" and shall include:

1. Space for the physician's printed name, signature, contact telephone

number, and the effective date; and

2. The following statement: "My sign ature below indicates that I or my

designee have discussed with the patient, the patient's surrogate, or the

responsible party, the patient's goals and available treatment options

based on the patient's medical conditions. My signature below indicates

to the best of my knowledge, that these orders indicated on this form are

consistent with the patient's current medical condition and preferences.";

(i) A section of the form shall be titled "Information for Patient, Surrogate, or

Responsible Party Named on This Form" with the following language:

1. "The MOST form is always voluntary and is usually for persons with

advanced illness. MOST records your wishes for medical treatment in

your current state of health. The provision of nutrition and fluids, even if

medically administered, is a basic human right and authorization to deny

or withdraw shall be limited to the patient, the surrogate in accordance

with KRS 311.629, or the responsible party in accordance with KRS

311.631.";

2. "KRS 311.631: Responsible parties authorized to make health care

decisions: (1) The judicially appointed guardian of the patient; (2) The

health care power of attorney; (3) The spouse of the patient; (4) An adult

child of the patient, or if the patient has more than one child, the

majority of the adult children who are reasonably available for

consultation; (5) The parents of the patient; (6) The nearest living

relative of the patient, or if more than one relative of the same relation is

reasonably available for consultation, a majority of the nearest living

relatives."; and

3. "Once initial medical treatment is begun and the risks and benefits of

further therapy are clear, your treatment wishes may change. Your

medical care and this form can be changed to reflect your new wishes at

any tim e. However, no form can address all the medical treatment

decisions that may need to be made. An advance directive, such as the

Kentucky Health Care Power of Attorney, is recommended for all

capable adults, regardless of their health status. An advance dir ective

allows you to document in detail your future health care instructions or

name a surrogate to speak for you if you are unable to speak for

yourself, or both. If there are conflicting directions between an

enforceable living will and a MOST form, the provisions of the living

will shall prevail.";

(j) A section of the form shall be titled "Directions for Completing and

Implementing Form" with these four (4) subdivisions:

1. The first subdivision shall be titled "Completing MOST" and shall have

the following language:

"MOST must be reviewed and signed by the patient's physician.

MOST must be reviewed and contain the original signature of the

patient's physician to be valid. Be sure to document the basis in the

progress notes of the medical record. Mode of communication (e.g., in

person, by telephone, etc.) should also be documented.

The signature of the patient, surrogate, or a responsible party is required;

however, if the patient's surrogate or a responsible party is not

reasonably available to sign t he original form, a copy of the completed

form with the signature or electronic signature of the patient's surrogate

or a responsible party must be signed by the patient's physician and

placed in the medical record.

Copies of the original form are equally as valid as the original form.

There is no requirement that a patient have a MOST.";

2. The second subdivision shall be titled "Implementing MOST" and shall

have the following language: "If a health care provider or facility cannot

comply with the orders due to policy or personal ethics, the provider or

facility must arrange for transfer of the patient to another provider or

facility.";

3. The third subdivision shall be titled "Reviewing MOST" and shall have

the following language:

"This MOST must be rev iewed at least annually, at any time the patient

or patient's representative requests, and when:

The patient is admitted and/or discharged from a health care facility;

There is a substantial change in the patient's health status; or

The patient's treatment preferences change.

If MOST is revised or becomes invalid, draw a line through Sections A -

D and write "VOID" in large letters."; and

4. The fourth subdivision shall be titled "Revocation of MOST" and shall

have the following language: "This MOST may b e revoked by the

patient or the responsible party."; and

(k) A section of the form shall be titled "Review of MOST" and shall have the

following columns and a number of rows as determined by the Kentucky

Board of Medical Licensure:

1. "Review Date";

2. "Reviewer (print)";

3. "Physician Signature";

4. "Signature of Patient, Surrogate, or Responsible Party"; and

5. "Outcome of Review, describing the outcome in each row by selecting

one (1) of the following:

a. No Change; or

b. FORM VOIDED".

(3) The Kentucky Board of Medical Licensure shall promulgate administrative

regulations in accordance with KRS Chapter 13A to develop:

(a) The format for a standardized medical order for scope of treatment form to be

approved by the board, including spacing, size, borders, fill and location of

boxes, type of fonts used and their size, and placement of boxes on the front

or back of the form so as to fit on a single sheet. The board shall create an

electronically fillable version of the MOST form that can be accessed on the

board's website. The board may not alter the wording or order of wording

provided in subsection (1) or (2) of th is section, except to provide translated

versions of the MOST form or add identifying data such as form number and

date of promulgation or revision and instructions for completing, reviewing,

and revoking the election of the form; and

(b) A guide to advanc e care planning that describes the following three (3)

options for advance care planning:

1. An advance directive as defined in KRS 311.621;

2. A power of attorney including advance health care instructions; and

3. A medical order for scope of treatment.

(4) The board shall:

(a) Provide a translation of the MOST form in print and in an electronically

fillable version into Spanish, and other languages as needed;

(b) Provide a translation of the guide to advance care planning into Spanish, and

other languages as needed; and

(c) Make the MOST form and the guide to advance care planning accessible on

its website.

(5) The board shall consult with appropriate professional organizations to develop the

format for the medical order for scope of treatment form and the guide to advance

care planning, including:

(a) The Kentucky Association of Hospice and Palliative Care;

(b) The Kentucky Board of Emergency Medical Services;

(c) The Kentucky Hospital Association;

(d) The Kentucky Association of Health Care Facilities;

(e) LeadingAge Kentucky;

(f) The Kentucky Right to Life Association; and

(g) Other groups interested in end-of-life care.

(6) The MOST form may be electronic or printed on any color of paper and the form

shall be honored on any color of paper.

(7) Health care professionals are encouraged to provide a copy of the guide to advance

care planning to the patient, surrogate, or responsible party at the time a MOST

form is being completed.