This year Kentucky passed legislation that established Medical Orders for Scope of Treatment (MOST).  While the Kentucky Board of Medical Licensure is finalizing specifics around the document, healthcare professionals should be preparing for how MOST differs from advanced directives and Do Not Resuscitate orders and the implications for their patients and practice.

Advanced directives have been promoted in Kentucky since 1994 when the state implemented the Patient Self-Determination Act (PSDA) that was passed by Congress in late 1990.  The purpose of advanced care planning documents, such as Living Wills and Durable Power of Attorney for Health Care is to enhance congruence between the medical care people say they want and the care that is actually given.  These are legal documents typically executed far in advance of serious illness to make known an individual’s preferences regarding potential future medical circumstances.  When these documents are being written, rarely are healthcare professionals included in the discussion.  In contrast, MOST is a medical order signed by a physician closer to the time of need, after consultation with the patient, or if the patient lacks capacity, the patient’s legal surrogate.

There are four important things healthcare professionals should know about MOST and how MOST is different from other advanced directives.

1. First MOST is not for everyone. Only patients with serious illness or frailty, for whom a healthcare professional would not be surprised if they died within one year, should have a MOST form. For these patients, their current health status indicates the need for standing medical orders.

2. Second, a MOST form is completed as a result of the process of shared decision-making between the patient, healthcare professionals and those close to the patient, to determine what treatments the patients does and does not want. The patient discusses his or her values, beliefs and goals for care.  The healthcare professional presents the patient’s diagnosis, prognosis, and treatment alternatives, including the benefits and burdens of treatment.  The patient should have the opportunity to discuss and consider specific medical decisions and options that are likely to arise because of their current state of health.  Together an informed decision about desired treatment is reached.

3. Third, MOST includes actionable medical orders. The form is a brief, simple, highly visible, portable document that can be recognized by any healthcare facility.  It assures patients that healthcare professionals across settings will provide only the treatments that they individually wish to receive and their physician has ordered.  MOST allows specification of a patient’s preferences for not only cardiopulmonary resuscitation, but also use of antibiotics, artificial food and fluids and whether or not the patient would want to be hospitalized for circumstances that are likely to arise in the near future.
4. Lastly, healthcare professionals should be clear that MOST is value neutral and completely voluntary. A MOST can be created for full scope of treatment, limited additional interventions or comfort measures only.   A MOST should only be completed based upon a discussion between a patient and the ordering physician about the patient’s current medical condition, prognosis, treatment options as well as the patient’s personal values, beliefs and goals of care.

MOST is an excellent accomplishment for Kentucky.  It is a tool, that when used, brings many benefits to patients and families by removing the guessing about what a patient would want. It will reduce the burden and guilt of uninformed surrogate decision making and provide peace and acceptance for patients, families and providers.  It is designed to ensure that seriously ill or frail patients can choose the treatments they want or do not want and that their wishes are honored.  As professionals in healthcare, we need to continue to support activities that improve care for all patients including the seriously ill.  A critical component to improving care includes education to providers, patients, families and communities. If you would like to receive more information on this topic or other issues affecting the seriously ill, email .

MOST is different from other advanced directives:

1. MOST is for patients with serious illness or frailty, for whom a healthcare professional would not be surprised if they died within one year.
2. MOST form is completed as a result of the process of shared decision-making between the patient, healthcare professionals and those close to the patient, to determine what treatments the patients does and does not want.
3. MOST includes actionable medical orders. The form is a brief, simple, highly visible, portable document that can be recognized by any healthcare facility.
4. MOST is value neutral and completely voluntary.

Liz Fowler is president and CEO of Hospice of the Bluegrass & Palliative Care Center of the Bluegrass in Lexington, Ky.