CHAPTER 117
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1
CHAPTER 117
( SB 173 )
AN ACT relating to medical order for scope of treatment.
Be it enacted by the General Assembly of the Commonwealth of Kentucky:
ď˘Section 1. KRS 311.6225 is amended to read as follows:
(1) An adult with decisional capacity, an adult's legal surrogate, or a responsible party may complete a medical
order for scope of treatment directing medical interventions. The form shall have the title "MOST, Medical
Orders for Scope of Treatment" and an introductory section containing the patient's name and date of birth, the
effective date of the form, including the statement "Form must be reviewed at least annually" and the
statements "HIPAA permits disclosure of MOST to other health care professionals as necessary" and "This
document is based on this person's medical condition and wishes. Any section not completed indicates a
preference for full treatment for that section." 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 scope of treatment when a person has a pulse or is breathing by
selection of one (1) of the following:
1. Full scope of treatment, including the use of intubation, advanced airway interventions,
mechanical ventilation, defibrillation or cardioversion as indicated, medical treatment,
intravenous fluids, and comfort measures. This option shall include the statement "Transfer to a
hospital if indicated. Includes intensive care. Treatment Plan: Full treatment, including life
support measures.";
2. Limited additional intervention, including the use of medical treatment, oral and intravenous
medications, intravenous fluids, cardiac monitoring as indicated, noninvasive bi-level positive
airway pressure, a bag valve mask, and comfort measures. This option excludes the use of
intubation or mechanical ventilation. This option shall include the statement "Transfer to a
hospital if indicated. Avoid intensive care. Treatment Plan: Provide basic medical treatments.";
or
3. Comfort measures, including keeping the patient clean, warm, and dry; use of medication by any
route; positioning, wound care, and other measures to relieve pain and suffering; and the use of
oxygen, suction, and manual treatment of airway obstruction as needed for comfort. This option
shall include the statement "Do not transfer to a hospital unless comfort needs cannot be met in
the patient's current location (e.g. hip fracture).".
These options shall be followed by a space for other instructions;
(c) Section C of the form shall direct the use of oral and intravenous antibiotics by selection of one (1) of
the following:
1. Antibiotics if indicated for the purpose of maintaining life;
2. Determine use or limitation of antibiotics when infection occurs;
3. Use of antibiotics to relieve pain and discomfort; or
4. No antibiotics, use other measures to relieve symptoms.
This option shall include a space for other instructions;
(d) Section D of the form shall: ACTS OF THE GENERAL ASSEMBLY 2
1. Have the heading "Medically Administered Fluids and Nutrition: 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. Direct the administration of fluids if physically possible as determined by the patient's physician
in accordance with reasonable medical judgment and in consultation with the patient, surrogate,
or responsible party by selecting one (1) of the following:
a. Long-term intravenous fluids if indicated;
b. Intravenous fluids for a defined trial period. This option shall be followed by
"Goal:................."; or
c. No intravenous fluids, provide other measures to ensure comfort; and
3. Direct the administration of nutrition if physically possible as determined by the patient's
physician in accordance with reasonable medical judgment and in consultation with the patient,
surrogate, or responsible party by selecting one (1) of the following:
a. Long-term feeding tube if indicated;
b. Feeding tube for a defined trial period. This option shall be followed by
"Goal:................."; or
c. No feeding tube. This option shall be followed by a space for special instructions;
(e) Section E of the form shall:
1. Have the heading "Patient Preferences as a Basis for this MOST Form" and shall include the
language "Basis for order must be documented in medical record";
2. Provide direction to indicate whether or not the patient has an advance medical directive such as
a health care power of attorney or living will and, if so, a place for the printed name, position,
and signature of the individual certifying that the MOST is in accordance with the advance
directive; and
3. Indicate whether oral or written directions were given and, if so, by which one (1) or more of the
following:
a. Patient;
b. Parent or guardian if patient is a minor;
c. Surrogate appointed by the patient's advance directive;
d. The judicially appointed guardian of the patient, if the guardian has been appointed and if
medical decisions are within the scope of the guardianship;
e. The attorney-in-fact named in a durable power of attorney, if the durable power of
attorney specifically includes authority for health care decisions;
f. The spouse of the patient;
g. An adult child of the patient or, if the patient has more than one (1) child, the majority of
the adult children who are reasonably available for consultation;
h. The parents of the patient; and
i. The nearest living relative of the patient or, if more than one (1) relative of the same
relation is reasonably available for consultation, a majority of the nearest living relatives;
(f) A signature portion of the form shall include spaces for the printed name, signature, and date of signing
for:
1. The patient's physician;
2. The patient, parent of minor, guardian, health care agent, surrogate, spouse, or other responsible
party, with a description of the relationship to the patient and contact information, unless based
solely on advance directive; and CHAPTER 117
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3. The health care professional preparing the form, with contact information;
(g) A section of the form shall be titled "Information for patient, surrogate, or responsible party named on
this form" with the following language: "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. 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 time. 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 directive 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.";
(h) 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, prepared, and signed by the patient's physician in personal
communication with the patient, the patient's surrogate, or responsible party.
MOST must be reviewed and contain the original or electronic 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 the 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.
Use of original form is required. Be sure to send the original form with the patient.
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 reviewed at least annually or earlier if:
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-E 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 be revoked by the patient, the surrogate, or the responsible party.";
and
(i) 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 and Location of Review";
3. "MD/DO Signature (Required)"; ACTS OF THE GENERAL ASSEMBLY 4
4. "Signature of Patient, Surrogate, or Responsible Party (Required)"; and
5. "Outcome of Review, describing the outcome in each row by selecting one (1) of the following:
a. No Change;
b. FORM VOIDED, new form completed; or
c. FORM VOIDED, no new form".
(2) The Kentucky Board of Medical Licensure shall promulgate administrative regulations in accordance with
KRS Chapter 13A to develop 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 Web site. The
board may not alter the wording or order of wording provided in subsection (1) of this 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.
The board shall provide a translation of the MOST form in print and in an electronically fillable version
into Spanish, and other languages as needed. The board shall consult with appropriate professional
organizations to develop the format for the medical order for scope of treatment form, 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.
(3) The medical order for scope of treatment form developed under subsection (2) of this section shall include but
not be limited to:
(a) An advisory that completing the medical order for scope of treatment form is voluntary and not required
for treatment;
(b) Identification of the person who discussed and agreed to the options for medical intervention that are
selected;
(c) All necessary information necessary to comply with subsection (1) of this section;
(d) The effective date of the form;
(e) The expiration or review date of the form, which shall be no more than one (1) calendar year from the
effective date of the form;
(f) Indication of whether the patient has a living will directive or health care power of attorney, a copy of
which shall be attached to the form if available;
(g) An advisory that the medical order for scope of treatment may be revoked by the patient, the surrogate,
or a responsible party at any time; and
(h) A statement written in boldface type directly above the signature line for the patient that states "You are
not required to sign this form to receive treatment."
(4) A physician shall document the medical basis for completing a medical order for scope of treatment in the
patient's medical record.
(5) The patient, the surrogate, or a responsible party shall sign the medical order for scope of treatment form;
however, if it is not practicable for the patient's surrogate or a responsible party to sign the original form, the
surrogate or a responsible party shall sign a copy of the completed form and return it to the health care
provider completing the form. The copy of the form with the signature of the surrogate or a responsible party,
whether in electronic or paper form, shall be signed by the physician and shall be placed in the patient's CHAPTER 117
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medical record. When the signature of the surrogate or a responsible party is on a separate copy of the form,
the original form shall indicate in the appropriate signature field that the signature is attached.
(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.
Signed by Governor April 8, 2022.