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AN ACT relating to medical orders 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 "Kentucky MOST, Medical Orders for 6
Scope of Treatment" and an introductory section containing the patient's name and 7
date of birth[, the effective date of the form, including the statement "Form must be 8
reviewed at least annually"] and the statements: 9
(a) "The MOST form is voluntary."; 10
(b) "A patient is not required to complete a MOST form."; 11
(c) "A patient with capacity or their legal representative may void a MOST 12
form any time by communicating that intent to the health care provider."; 13
(d) "The original form is the personal property of the patient."; 14
(e) "A facsimile, paper, or electronic copy is a legally valid form."; 15
(f) "HIPAA permits disclosure of MOST to [other ]health care professionals as 16
necessary for treatment."; and 17
(g) "[This document is based on this person's medical condition and wishes. ]Any 18
section not completed does not invalidate the form and indicates a preference 19
for full treatment for that section.". 20
(2) The remainder of the form shall be in substantially the following order and format 21
and shall have the following contents: 22
(a) Section A of the form shall direct cardiopulmonary resuscitation when a 23
person has no pulse and is not breathing by selection of one (1) of the 24
following: 25
1. "Attempt Resuscitation (CPR)"; or 26
2. "Do Not Attempt Resuscitation"; and 27 UNOFFICIAL COPY 24 RS HB 645/GA
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include the statement "When not in cardiopulmonary arrest, follow orders in 1
B, C, and D."; 2
(b) Section B of the form shall direct the medical interventions[scope of 3
treatment] when a person has a pulse or is breathing by selection of one (1) of 4
the following: 5
1. Full [scope of ]treatment, required if CPR is chosen in Section A, 6
including providing appropriate medical and surgical treatments as 7
indicated to attempt to prolong life, including intensive care. This 8
option shall include the statement "Goal: Attempt to sustain life by all 9
medically effective means[the use of intubation, advanced airway 10
interventions, mechanical ventilation, defibrillation or cardioversion as 11
indicated, medical treatment, intravenous fluids, and comfort measures. 12
This option shall include the statement "Transfer to a hospital if 13
indicated. Includes intensive care. Treatment Plan: Full treatment, 14
including life support measures]."; 15
2. Limited additional intervention, which may include use of non-invasive 16
positive airway pressure, antibiotics, and IV fluids as indicated, and 17
requires avoidance of intensive care and transfer to a hospital if 18
treatment needs cannot be met in the current location. This option 19
shall include the statement "Goal: Attempt to restore function while 20
avoiding intensive care and resuscitation efforts (ventilator, 21
defibrillation, and cardioversion)[including the use of medical 22
treatment, oral and intravenous medications, intravenous fluids, cardiac 23
monitoring as indicated, noninvasive bi-level positive airway pressure, a 24
bag valve mask, and comfort measures. This option excludes the use of 25
intubation or mechanical ventilation. This option shall include the 26
statement "Transfer to a hospital if indicated. Avoid intensive care. 27 UNOFFICIAL COPY 24 RS HB 645/GA
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Treatment Plan: Provide basic medical treatments]."; or 1
3. Comfort measures, including use of oxygen, suction, and manual 2
treatment of airway obstruction as needed for comfort, avoidance of 3
treatments listed in full or limited additional interventions and transfer 4
to a hospital only if comfort cannot be achieved in the current setting. 5
This option shall include the statement "Goal: Maximize comfort 6
through symptom management; allow natural death[keeping the 7
patient clean, warm, and dry; use of medication by any route; 8
positioning, wound care, and other measures to relieve pain and 9
suffering; and the use of oxygen, suction, and manual treatment of 10
airway obstruction as needed for comfort. This option shall include the 11
statement "Do not transfer to a hospital unless comfort needs cannot be 12
met in the patient's current location (e.g. hip fracture)]."[. 13
These options shall be followed by a space for other instructions]; 14
(c) Section C of the form shall direct the use of artificially administered fluids 15
and nutrition, including always offering food and fluids by mouth as 16
tolerated, and shall include a statement that medically assisted nutrition and 17
hydration when it cannot reasonably be expected to prolong life, would be 18
more burdensome than beneficial, or would cause significant physical 19
discomfort. The following options shall be provided: 20
1. No artificial nutrition by tube; 21
2. Trial period of artificial nutrition by tube. This option shall be 22
followed by: "Goal................."; or 23
3. Long-term artificial nutrition and hydration by tube[oral and 24
intravenous antibiotics by selection of one (1) of the following: 25
1. Antibiotics if indicated for the purpose of maintaining life; 26
2. Determine use or limitation of antibiotics when infection occurs; 27 UNOFFICIAL COPY 24 RS HB 645/GA
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3. Use of antibiotics to relieve pain and discomfort; or 1
4. No antibiotics, use other measures to relieve symptoms. 2
This option shall include a space for other instructions]; 3
(d) Section D of the form shall direct the use of antibiotics. The following 4
options shall be provided: 5
1. Use of antibiotics as medically indicated; or 6
2. No antibiotics; 7
(e) A section of the form shall provide space to include any additional 8
treatment preferences; 9
(f) A section of the form shall be titled "Attestation by a Licensed Health Care 10
Professional". This section shall include: 11
1. Space for the printed name and the signature of the licensed health 12
care professional and the date of completion; and 13
2. A statement that in completing the form the licensed health care 14
professional is attesting that: 15
a. He or she has reviewed the patient's pre-existing advance 16
directive and found it in accordance with the selections on the 17
MOST form; or 18
b. The patient does not have a pre-existing advance directive; 19
(g) A section of the form shall be titled "Signature: Patient or Patient 20
Representative (E-Signed Documents Are Valid)". This section shall 21
include: 22
1. The printed name, signature, and contact telephone number of the 23
patient, surrogate, or responsible party; 24
2. An indication that the signing party is the: 25
a. Adult patient with decisional capacity; 26
b. Surrogate decision maker per advance directive; or 27 UNOFFICIAL COPY 24 RS HB 645/GA
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c. Responsible party in accordance with KRS 311.631; and 1
3. The following statements: 2
a. "I agree that adequate information has been provided and 3
significant thought has been given to decisions outlined in this 4
form. Treatment preferences have been expressed to the 5
physician. This document reflects those treatment preferences 6
and indicates informed consent. If signed by a surrogate or 7
responsible party, the preferences expressed reflect the patient's 8
wishes as best understood by that surrogate or responsible 9
party."; and 10
b. "Your signature is not required on this form to receive 11
treatment."; 12
(h) A section of the form shall be titled "Physician Signature (E-Signed 13
Documents Are Valid)" and shall include: 14
1. Space for the physician's printed name, signature, contact telephone 15
number, and the effective date; and 16
2. The following statement: "My signature below indicates that I or my 17
designee have discussed with the patient, the patient's surrogate, or 18
the responsible party, the patient's goals and available treatment 19
options based on the patient's medical conditions. My signature below 20
indicates to the best of my knowledge, that these orders indicated on 21
this form are consistent with the patient's current medical condition 22
and preferences."; 23
(i)[1. Have the heading "Medically Administered Fluids and Nutrition: The 24
provision of nutrition and fluids, even if medically administered, is a basic 25
human right and authorization to deny or withdraw shall be limited to the 26
patient, the surrogate in accordance with KRS 311.629, or the responsible 27 UNOFFICIAL COPY 24 RS HB 645/GA
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party in accordance with KRS 311.631."; 1
2. Direct the administration of fluids if physically possible as determined by the 2
patient's physician in accordance with reasonable medical judgment and in 3
consultation with the patient, surrogate, or responsible party by selecting one 4
(1) of the following: 5
a. Long-term intravenous fluids if indicated; 6
b. Intravenous fluids for a defined trial period. This option shall be followed by 7
"Goal:................."; or 8
c. No intravenous fluids, provide other measures to ensure comfort; and 9
3. Direct the administration of nutrition if physically possible as determined by 10
the patient's physician in accordance with reasonable medical judgment and in 11
consultation with the patient, surrogate, or responsible party by selecting one 12
(1) of the following: 13
a. Long-term feeding tube if indicated; 14
b. Feeding tube for a defined trial period. This option shall be followed by 15
"Goal:................."; or 16
c. No feeding tube. This option shall be followed by a space for special 17
instructions; 18
(e) Section E of the form shall: 19
1. Have the heading "Patient Preferences as a Basis for this MOST Form" and 20
shall include the language "Basis for order must be documented in medical 21
record"; 22
2. Provide direction to indicate whether or not the patient has an advance 23
medical directive such as a health care power of attorney or living will and, if 24
so, a place for the printed name, position, and signature of the individual 25
certifying that the MOST is in accordance with the advance directive; and 26
3. Indicate whether oral or written directions were given and, if so, by which one 27 UNOFFICIAL COPY 24 RS HB 645/GA
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(1) or more of the following: 1
a. Patient; 2
b. Parent or guardian if patient is a minor; 3
c. Surrogate appointed by the patient's advance directive; 4
d. The judicially appointed guardian of the patient, if the guardian has been 5
appointed and if medical decisions are within the scope of the guardianship; 6
e. The attorney-in-fact named in a durable power of attorney, if the durable 7
power of attorney specifically includes authority for health care decisions; 8
f. The spouse of the patient; 9
g. An adult child of the patient or, if the patient has more than one (1) child, the 10
majority of the adult children who are reasonably available for consultation; 11
h. The parents of the patient; and 12
i. The nearest living relative of the patient or, if more than one (1) relative of the 13
same relation is reasonably available for consultation, a majority of the 14
nearest living relatives; 15
(f) A signature portion of the form shall include spaces for the printed name, 16
signature, and date of signing for: 17
1. The patient's physician; 18
2. The patient, parent of minor, guardian, health care agent, surrogate, spouse, or 19
other responsible party, with a description of the relationship to the patient 20
and contact information, unless based solely on advance directive; and 21
3. The health care professional preparing the form, with contact information; 22
(g)] A section of the form shall be titled "Information for patient, surrogate, or 23
responsible party named on this form" with the following language: 24
1. "The MOST form is always voluntary and is usually for persons with 25
advanced illness. MOST records your wishes for medical treatment in 26
your current state of health. The provision of nutrition and fluids, even if 27 UNOFFICIAL COPY 24 RS HB 645/GA
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medically administered, is a basic human right and authorization to deny 1
or withdraw shall be limited to the patient, the surrogate in accordance 2
with KRS 311.629, or the responsible party in accordance with KRS 3
311.631."; 4
2. "KRS 311.631: Responsible parties authorized to make health care 5
decisions: (1) The judicially appointed guardian of the patient; (2) The 6
health care power of attorney; (3) The spouse of the patient; (4) An 7
adult child of the patient, or if the patient has more than one child, the 8
majority of the adult children who are reasonably available for 9
consultation; (5) The parents of the patient; (6) The nearest living 10
relative of the patient, or if more than one relative of the same relation 11
is reasonably available for consultation, a majority of the nearest 12
living relatives."; and 13
3. "Once initial medical treatment is begun and the risks and benefits of 14
further therapy are clear, your treatment wishes may change. Your 15
medical care and this form can be changed to reflect your new wishes at 16
any time. However, no form can address all the medical treatment 17
decisions that may need to be made. An advance directive, such as the 18
Kentucky Health Care Power of Attorney, is recommended for all 19
capable adults, regardless of their health status. An advance directive 20
allows you to document in detail your future health care instructions or 21
name a surrogate to speak for you if you are unable to speak for 22
yourself, or both. If there are conflicting directions between an 23
enforceable living will and a MOST form, the provisions of the living 24
will shall prevail."; 25
(j)[(h)] A section of the form shall be titled "Directions for Completing and 26
Implementing Form" with these four (4) subdivisions: 27 UNOFFICIAL COPY 24 RS HB 645/GA
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1. The first subdivision shall be titled "Completing MOST" and shall have 1
the following language: 2
"MOST must be reviewed[, prepared,] and signed by the patient's 3
physician[ in personal communication with the patient, the patient's 4
surrogate, or responsible party]. 5
MOST must be reviewed and contain the original [or electronic] 6
signature of the patient's physician to be valid. Be sure to document the 7
basis in the progress notes of the medical record. Mode of 8
communication (e.g., in person, by telephone, etc.) should also be 9
documented. 10
The signature of the patient, surrogate, or a responsible party is required; 11
however, if the patient's surrogate or a responsible party is not 12
reasonably available to sign the original form, a copy of the completed 13
form with the signature or electronic signature of the patient's surrogate 14
or a responsible party must be signed by the patient's physician and 15
placed in the medical record. 16
[Use of original form is required. Be sure to send the original form with 17
the patient.] 18
Copies of the original form are equally as valid as the original form. 19
There is no requirement that a patient have a MOST."; 20
2. The second subdivision shall be titled "Implementing MOST" and shall 21
have the following language: "If a health care provider or facility cannot 22
comply with the orders due to policy or personal ethics, the provider or 23
facility must arrange for transfer of the patient to another provider or 24
facility."; 25
3. The third subdivision shall be titled "Reviewing MOST" and shall have 26
the following language: 27 UNOFFICIAL COPY 24 RS HB 645/GA
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"This MOST must be reviewed at least annually, at any time the patient 1
or patient's representative requests and when[ or earlier if]: 2
The patient is admitted and/or discharged from a health care facility; 3
There is a substantial change in the patient's health status; or 4
The patient's treatment preferences change. 5
If MOST is revised or becomes invalid, draw a line through Sections A-6
D[E] and write "VOID" in large letters."; and 7
4. The fourth subdivision shall be titled "Revocation of MOST" and shall 8
have the following language: "This MOST may be revoked by the 9
patient[, the surrogate,] or the responsible party."; and 10
(k)[(i)] A section of the form shall be titled "Review of MOST" and shall have 11
the following columns and a number of rows as determined by the Kentucky 12
Board of Medical Licensure: 13
1. "Review Date"; 14
2. "Reviewer (print)[and Location of Review]"; 15
3. "Physician[MD/DO] Signature[ (Required)]"; 16
4. "Signature of Patient, Surrogate, or Responsible Party[ (Required)]"; 17
and 18
5. "Outcome of Review, describing the outcome in each row by selecting 19
one (1) of the following: 20
a. No Change; or 21
b. FORM VOIDED[, new form completed; or 22
c. FORM VOIDED, no new form]". 23
(3)[(2)] The Kentucky Board of Medical Licensure shall promulgate administrative 24
regulations in accordance with KRS Chapter 13A to develop: 25
(a) The format for a standardized medical order for scope of treatment form to be 26
approved by the board, including spacing, size, borders, fill and location of 27 UNOFFICIAL COPY 24 RS HB 645/GA
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boxes, type of fonts used and their size, and placement of boxes on the front 1
or back of the form so as to fit on a single sheet. The board shall create an 2
electronically fillable version of the MOST form that can be accessed on the 3
board's website[Web site]. The board may not alter the wording or order of 4
wording provided in subsection (1) or (2)[subsection (1)] of this section, 5
except to provide translated versions of the MOST form or add identifying 6
data such as form number and date of promulgation or revision and 7
instructions for completing, reviewing, and revoking the election of the form; 8
and 9
(b) A guide to advance care planning that describes the following three (3) 10
options for advance care planning: 11
1. An advance directive as defined in KRS 311.621; 12
2. A power of attorney including advance health care instructions; and 13
3. A medical order for scope of treatment. 14
(4) The board shall: 15
(a) Provide a translation of the MOST form in print and in an electronically 16
fillable version into Spanish, and other languages as needed; 17
(b) Provide a translation of the guide to advance care planning into Spanish, 18
and other languages as needed; and 19
(c) Make the MOST form and the guide to advance care planning accessible on 20
its website. 21
(5) The board shall consult with appropriate professional organizations to develop the 22
format for the medical order for scope of treatment form and the guide to advance 23
care planning, including: 24
(a) The Kentucky Association of Hospice and Palliative Care; 25
(b) The Kentucky Board of Emergency Medical Services; 26
(c) The Kentucky Hospital Association; 27 UNOFFICIAL COPY 24 RS HB 645/GA
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(d) The Kentucky Association of Health Care Facilities; 1
(e) LeadingAge Kentucky; 2
(f) The Kentucky Right to Life Association; and 3
(g) Other groups interested in end-of-life care. 4
[(3) The medical order for scope of treatment form developed under subsection (2) of 5
this section shall include but not be limited to: 6
(a) An advisory that completing the medical order for scope of treatment form is 7
voluntary and not required for treatment; 8
(b) Identification of the person who discussed and agreed to the options for 9
medical intervention that are selected; 10
(c) All necessary information necessary to comply with subsection (1) of this 11
section; 12
(d) The effective date of the form; 13
(e) The expiration or review date of the form, which shall be no more than one 14
(1) calendar year from the effective date of the form; 15
(f) Indication of whether the patient has a living will directive or health care 16
power of attorney, a copy of which shall be attached to the form if available; 17
(g) An advisory that the medical order for scope of treatment may be revoked by 18
the patient, the surrogate, or a responsible party at any time; and 19
(h) A statement written in boldface type directly above the signature line for the 20
patient that states "You are not required to sign this form to receive 21
treatment." 22
(4) A physician shall document the medical basis for completing a medical order for 23
scope of treatment in the patient's medical record. 24
(5) The patient, the surrogate, or a responsible party shall sign the medical order for 25
scope of treatment form; however, if it is not practicable for the patient's surrogate 26
or a responsible party to sign the original form, the surrogate or a responsible party 27 UNOFFICIAL COPY 24 RS HB 645/GA
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shall sign a copy of the completed form and return it to the health care provider 1
completing the form. The copy of the form with the signature of the surrogate or a 2
responsible party, whether in electronic or paper form, shall be signed by the 3
physician and shall be placed in the patient's medical record. When the signature of 4
the surrogate or a responsible party is on a separate copy of the form, the original 5
form shall indicate in the appropriate signature field that the signature is attached.] 6
(6) The MOST form may be electronic or printed on any color of paper and the form 7
shall be honored on any color of paper. 8
(7) Health care professionals are encouraged to provide a copy of the guide to 9
advance care planning to the patient, surrogate, or responsible party at the time a 10
MOST form is being completed. 11