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AN ACT relating to medical order for scope of treatment. 1
Be it enacted by the General Assembly of the Commonwealth of Kentucky: 2
ď˘Section 1. KRS 311.6225 is amended to read as follows: 3
(1) An adult with decisional capacity, an adult's legal surrogate, or a responsible party 4
may complete a medical order for scope of treatment directing medical 5
interventions. The form shall have the title "MOST, Medical Orders for Scope of 6
Treatment" and an introductory section containing the patient's name and date of 7
birth, the effective date of the form, including the statement "Form must be 8
reviewed at least annually" and the statements "HIPAA permits disclosure of 9
MOST to other health care professionals as necessary" and "This document is based 10
on this person's medical condition and wishes. Any section not completed indicates 11
a preference for full treatment for that section." The form shall be in substantially 12
the following order and format and shall have the following contents: 13
(a) Section A of the form shall direct cardiopulmonary resuscitation when a 14
person has no pulse and is not breathing by selection of one (1) of the 15
following: 16
1. "Attempt Resuscitation (CPR)"; or 17
2. "Do Not Attempt Resuscitation"; and 18
include the statement "When not in cardiopulmonary arrest, follow orders in 19
B, C, and D."; 20
(b) Section B of the form shall direct the scope of treatment when a person has a 21
pulse or is breathing by selection of one (1) of the following: 22
1. Full scope of treatment, including the use of intubation, advanced airway 23
interventions, mechanical ventilation, defibrillation or cardioversion as 24
indicated, medical treatment, intravenous fluids, and comfort measures. 25
This option shall include the statement "Transfer to a hospital if 26
indicated. Includes intensive care. Treatment Plan: Full treatment, 27 UNOFFICIAL COPY 22 RS BR 1934
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including life support measures."; 1
2. Limited additional intervention, including the use of medical treatment, 2
oral and intravenous medications, intravenous fluids, cardiac monitoring 3
as indicated, noninvasive bi-level positive airway pressure, a bag valve 4
mask, and comfort measures. This option excludes the use of intubation 5
or mechanical ventilation. This option shall include the statement 6
"Transfer to a hospital if indicated. Avoid intensive care. Treatment 7
Plan: Provide basic medical treatments."; or 8
3. Comfort measures, including keeping the patient clean, warm, and dry; 9
use of medication by any route; positioning, wound care, and other 10
measures to relieve pain and suffering; and the use of oxygen, suction, 11
and manual treatment of airway obstruction as needed for comfort. This 12
option shall include the statement "Do not transfer to a hospital unless 13
comfort needs cannot be met in the patient's current location (e.g. hip 14
fracture).". 15
These options shall be followed by a space for other instructions; 16
(c) Section C of the form shall direct the use of oral and intravenous antibiotics 17
by selection of one (1) of the following: 18
1. Antibiotics if indicated for the purpose of maintaining life; 19
2. Determine use or limitation of antibiotics when infection occurs; 20
3. Use of antibiotics to relieve pain and discomfort; or 21
4. No antibiotics, use other measures to relieve symptoms. 22
This option shall include a space for other instructions; 23
(d) Section D of the form shall: 24
1. Have the heading "Medically Administered Fluids and Nutrition: The 25
provision of nutrition and fluids, even if medically administered, is a 26
basic human right and authorization to deny or withdraw shall be limited 27 UNOFFICIAL COPY 22 RS BR 1934
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to the patient, the surrogate in accordance with KRS 311.629, or the 1
responsible party in accordance with KRS 311.631."; 2
2. Direct the administration of fluids if physically possible as determined 3
by the patient's physician in accordance with reasonable medical 4
judgment and in consultation with the patient, surrogate, or responsible 5
party by selecting one (1) of the following: 6
a. Long-term intravenous fluids if indicated; 7
b. Intravenous fluids for a defined trial period. This option shall be 8
followed by "Goal:................."; or 9
c. No intravenous fluids, provide other measures to ensure comfort; 10
and 11
3. Direct the administration of nutrition if physically possible as 12
determined by the patient's physician in accordance with reasonable 13
medical judgment and in consultation with the patient, surrogate, or 14
responsible party by selecting one (1) of the following: 15
a. Long-term feeding tube if indicated; 16
b. Feeding tube for a defined trial period. This option shall be 17
followed by "Goal:................."; or 18
c. No feeding tube. This option shall be followed by a space for 19
special instructions; 20
(e) Section E of the form shall: 21
1. Have the heading "Patient Preferences as a Basis for this MOST Form" 22
and shall include the language "Basis for order must be documented in 23
medical record"; 24
2. Provide direction to indicate whether or not the patient has an advance 25
medical directive such as a health care power of attorney or living will 26
and, if so, a place for the printed name, position, and signature of the 27 UNOFFICIAL COPY 22 RS BR 1934
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individual certifying that the MOST is in accordance with the advance 1
directive; and 2
3. Indicate whether oral or written directions were given and, if so, by 3
which one (1) or more of the following: 4
a. Patient; 5
b. Parent or guardian if patient is a minor; 6
c. Surrogate appointed by the patient's advance directive; 7
d. The judicially appointed guardian of the patient, if the guardian has 8
been appointed and if medical decisions are within the scope of the 9
guardianship; 10
e. The attorney-in-fact named in a durable power of attorney, if the 11
durable power of attorney specifically includes authority for health 12
care decisions; 13
f. The spouse of the patient; 14
g. An adult child of the patient or, if the patient has more than one (1) 15
child, the majority of the adult children who are reasonably 16
available for consultation; 17
h. The parents of the patient; and 18
i. The nearest living relative of the patient or, if more than one (1) 19
relative of the same relation is reasonably available for 20
consultation, a majority of the nearest living relatives; 21
(f) A signature portion of the form shall include spaces for the printed name, 22
signature, and date of signing for: 23
1. The patient's physician; 24
2. The patient, parent of minor, guardian, health care agent, surrogate, 25
spouse, or other responsible party, with a description of the relationship 26
to the patient and contact information, unless based solely on advance 27 UNOFFICIAL COPY 22 RS BR 1934
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directive; and 1
3. The health care professional preparing the form, with contact 2
information; 3
(g) A section of the form shall be titled "Information for patient, surrogate, or 4
responsible party named on this form" with the following language: "The 5
MOST form is always voluntary and is usually for persons with advanced 6
illness. MOST records your wishes for medical treatment in your current state 7
of health. The provision of nutrition and fluids, even if medically 8
administered, is a basic human right and authorization to deny or withdraw 9
shall be limited to the patient, the surrogate in accordance with KRS 311.629, 10
or the responsible party in accordance with KRS 311.631. Once initial 11
medical treatment is begun and the risks and benefits of further therapy are 12
clear, your treatment wishes may change. Your medical care and this form can 13
be changed to reflect your new wishes at any time. However, no form can 14
address all the medical treatment decisions that may need to be made. An 15
advance directive, such as the Kentucky Health Care Power of Attorney, is 16
recommended for all capable adults, regardless of their health status. An 17
advance directive allows you to document in detail your future health care 18
instructions or name a surrogate to speak for you if you are unable to speak for 19
yourself, or both. If there are conflicting directions between an enforceable 20
living will and a MOST form, the provisions of the living will shall prevail."; 21
(h) A section of the form shall be titled "Directions for Completing and 22
Implementing Form" with these four (4) subdivisions: 23
1. The first subdivision shall be titled "Completing MOST" and shall have 24
the following language: 25
"MOST must be reviewed, prepared, and signed by the patient's 26
physician in personal communication with the patient, the patient's 27 UNOFFICIAL COPY 22 RS BR 1934
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surrogate, or responsible party. 1
MOST must be reviewed and contain the original or electronic signature 2
of the patient's physician to be valid. Be sure to document the basis in 3
the progress notes of the medical record. Mode of communication (e.g., 4
in person, by telephone, etc.) should also be documented. 5
The signature of the patient, surrogate, or a responsible party is required; 6
however, if the patient's surrogate or a responsible party is not 7
reasonably available to sign the original form, a copy of the completed 8
form with the signature or electronic signature of the patient's surrogate 9
or a responsible party must be signed by the patient's physician and 10
placed in the medical record. 11
Use of original form is required. Be sure to send the original form with 12
the patient. 13
There is no requirement that a patient have a MOST."; 14
2. The second subdivision shall be titled "Implementing MOST" and shall 15
have the following language: "If a health care provider or facility cannot 16
comply with the orders due to policy or personal ethics, the provider or 17
facility must arrange for transfer of the patient to another provider or 18
facility."; 19
3. The third subdivision shall be titled "Reviewing MOST" and shall have 20
the following language: 21
"This MOST must be reviewed at least annually or earlier if: 22
The patient is admitted and/or discharged from a health care facility; 23
There is a substantial change in the patient's health status; or 24
The patient's treatment preferences change. 25
If MOST is revised or becomes invalid, draw a line through Sections A-26
E and write "VOID" in large letters."; and 27 UNOFFICIAL COPY 22 RS BR 1934
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4. The fourth subdivision shall be titled "Revocation of MOST" and shall 1
have the following language: "This MOST may be revoked by the 2
patient, the surrogate, or the responsible party."; and 3
(i) A section of the form shall be titled "Review of MOST" and shall have the 4
following columns and a number of rows as determined by the Kentucky 5
Board of Medical Licensure: 6
1. "Review Date"; 7
2. "Reviewer and Location of Review"; 8
3. "MD/DO Signature (Required)"; 9
4. "Signature of Patient, Surrogate, or Responsible Party (Required)"; and 10
5. "Outcome of Review, describing the outcome in each row by selecting 11
one (1) of the following: 12
a. No Change; 13
b. FORM VOIDED, new form completed; or 14
c. FORM VOIDED, no new form". 15
(2) The Kentucky Board of Medical Licensure shall promulgate administrative 16
regulations in accordance with KRS Chapter 13A to develop the format for a 17
standardized medical order for scope of treatment form to be approved by the board, 18
including spacing, size, borders, fill and location of boxes, type of fonts used and 19
their size, and placement of boxes on the front or back of the form so as to fit on a 20
single sheet. The board shall create an electronically fillable version of the MOST 21
form that can be accessed on the board's Web site. The board may not alter the 22
wording or order of wording provided in subsection (1) of this section, except to 23
provide translated versions of the MOST form or add identifying data such as form 24
number and date of promulgation or revision and instructions for completing, 25
reviewing, and revoking the election of the form. The board shall provide a 26
translation of the MOST form in print and in an electronically fillable version 27 UNOFFICIAL COPY 22 RS BR 1934
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into Spanish, and other languages as needed. The board shall consult with 1
appropriate professional organizations to develop the format for the medical order 2
for scope of treatment form, including: 3
(a) The Kentucky Association of Hospice and Palliative Care; 4
(b) The Kentucky Board of Emergency Medical Services; 5
(c) The Kentucky Hospital Association; 6
(d) The Kentucky Association of Health Care Facilities; 7
(e) LeadingAge Kentucky; 8
(f) The Kentucky Right to Life Association; and 9
(g) Other groups interested in end-of-life care. 10
(3) The medical order for scope of treatment form developed under subsection (2) of 11
this section shall include but not be limited to: 12
(a) An advisory that completing the medical order for scope of treatment form is 13
voluntary and not required for treatment; 14
(b) Identification of the person who discussed and agreed to the options for 15
medical intervention that are selected; 16
(c) All necessary information necessary to comply with subsection (1) of this 17
section; 18
(d) The effective date of the form; 19
(e) The expiration or review date of the form, which shall be no more than one (1) 20
calendar year from the effective date of the form; 21
(f) Indication of whether the patient has a living will directive or health care 22
power of attorney, a copy of which shall be attached to the form if available; 23
(g) An advisory that the medical order for scope of treatment may be revoked by 24
the patient, the surrogate, or a responsible party at any time; and 25
(h) A statement written in boldface type directly above the signature line for the 26
patient that states "You are not required to sign this form to receive 27 UNOFFICIAL COPY 22 RS BR 1934
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treatment." 1
(4) A physician shall document the medical basis for completing a medical order for 2
scope of treatment in the patient's medical record. 3
(5) The patient, the surrogate, or a responsible party shall sign the medical order for 4
scope of treatment form; however, if it is not practicable for the patient's surrogate 5
or a responsible party to sign the original form, the surrogate or a responsible party 6
shall sign a copy of the completed form and return it to the health care provider 7
completing the form. The copy of the form with the signature of the surrogate or a 8
responsible party, whether in electronic or paper form, shall be signed by the 9
physician and shall be placed in the patient's medical record. When the signature of 10
the surrogate or a responsible party is on a separate copy of the form, the original 11
form shall indicate in the appropriate signature field that the signature is attached. 12
(6) The MOST form may be electronic or printed on any color of paper and the form 13
shall be honored on any color of paper. 14