C o l o r ad o A d va n c e Dir ec ti ve s C o n s o rt i u m , P O B o x 2 7 0 2 0 2 , L ittl e t o n , CO 8 0 1 2 7 v . 7. 1 0SEND FORM WITH PERSON W HENEV ER TRA NS FERRED OR DISCHARGEDC o l orado Med i c al O rders
f or Scope o f T r e atment ( M O S T )
•
F I RST fo ll o w t h e s e or d er s , T H E N co n tac t P h y s i c i a n, A d va n ce d Pract i c e
Nu r s e ( A P N ) , o r P h y s i c i a n A ss i s ta nt (P A ) , fo r f u rt h e r o r d er s if indi cate d.
•
T h e s e Med i ca l O rder s ar e ba s e d o n t h e per s o n ’ s m ed i ca l c o n d iti o n & w i s h e s .
•
A n y s ec ti o n n o t c o m p l e t e d i mp li e s f u ll t rea t m e n t f o r t h a t s e c ti o n .
•
M a y o n l y b e c o m p l e t e d b y , o r o n be h a lf o f , a per s o n 1 8 y ea r s o f a g e o r o l der .
•
E veryo ne s h a ll be treate d w i t h di g ni t y a nd re s p ect . L a st N a me
F i r st N a m e / M i d d l e N a me
D at e o f Bi r t h S e x
H ai r C olo r E y e C olo r Rac e / E t h n i c it y
A
C h ec k
O n e
Box
On
ly C ARD IO P UL M O NAR Y R ES U S CI T A T I O N ( C PR ) P er son h as n o p u l se a n d i s n ot b re a t hin g.
No C P R Do Not R e sus c it a t e / DN R/ A ll ow N a t u ra l D ea t h
Y e s C P R A tt e m pt R e sus c it a ti on/ CP R
W h e n n o t i n C ar d i op u l m ona r y a r re s t , f o l l o w o r d e r s B , C , and D
B
Ch
ec k
O n e
Box
On
ly M ED I CA L I NTERVE N T IO N S P er son h as pu l se a nd/ or i s b r e a t hin g.
Co m f o r t Me as u re s Onl y: U s e m e d ic a t i on by a ny r ou te , p o s i t i on i n g , a nd o t h e r m eas u re s t o r e lie v e
p a i n a nd s u ff e r i n g . U s e ox yg e n, s u c t i on a nd m a nu a l t r eat m e nt of a i r w a y ob s t r u c t i on a s n ee d e d f o r
c o m f o r t .
D o not tr a n s f e r t o h o s p i t a l f o r l i f e - s u sta i n i ng tre a t m e n t .
T r an s fe r o n l y i f c o m f o r t n ee d s c a nnot be m e t i n c u r re n t l o c a ti o n; E M S - C on tac t m e d ic a l c o n t r o l .
Li m i te d A ddi t i o n al I n ter v e n t i o n s: I n cl ud e s c a r e d e sc r i b e d a bo v e . U s e m e d ic a l t r e at m e n t , I V
fl u i ds a nd car d i a c m on it or a s i nd ic a te d . D o n o t u s e i n t ub a ti on, a d v a n ce d a i r w a y i n t e r v e n ti on s , or
m ec h a n ic a l v e n t i l a ti on. T r a n sf e r t o ho s p i t al i f i n d ic a te d . A v o i d i n te n s i v e c a r e ; E M S - C on ta c t
m e d ic a l c o n t r o l .
F ul l T re a t m e n t : I n c l ud e s c ar e d e s c r i b e d a bo v e . U s e i n t ub a t i on, a d v a n c e d a i r w a y i n t e r v e n t i on s ,
m ec h a n ic a l v e n t i l a ti o n, a nd car d i o v er s i on a s i nd i ca t e d.
C
C h ec k
O n e
Box
On
ly A NT I B I O T I C S
N o a n t i b i o t i cs . U s e o t h e r m eas u re s t o r e lie v e s y m p t o m s .
U s e a n t i b i o t ic s w h e n co m f o r t i s t he g o a l .
U s e a n t i b i o t ic s .
Add i t i on a l O r d er s :
D
Ch
ec k
O n e
Box
On
ly A RT I F I C I ALL Y A D M I N I S TERE D N UTR I T IO N AN D H Y DRAT IO N
**** A l w a y s o f f e r f o o d & w a te r b y m ou t h i f fe a si b l e *****
N o a r t i f i c ia l nu t r i t i on / hy d rati on by t ub e . ( N O T E : Sp eci a l r u le s f or p r o x y by st a t u t e on page 2)
P a t i e nt h a s e x e c u t e d a “ L i v i ng W i l l ” P at i e nt h a s n ot e x e c u t e d a “ L i v i ng Wi l l ”
D e f i n e d t r i a l p e r i od o f a r t i f ic i a l n u t r i ti o n / h y d r a t i on by t ub e .
( L e n g t h o f t r ia l : G o a l : )
Lon g - ter m arti f i c ia l nu t r i ti o n / h y d r a ti o n by t ub e .
E
Ch
ec k
A ll
Th a t
App
l y D I S CU SS ED W IT H :
P a t i e nt
A g e nt un d e r Me d ic a l D u ra b l e Po w e r o f A t t o r n e y
P r oxy ( p e r s ta t u t e C . R . S . 15 - 18. 5 - 103 ( 6 ) )
G u ar d ia n
Ot h e r : S U MM ARY O F M E D I CAL C O ND ITI O N ( S ) :
( S EC TI O N R E S ER V E D F O R F U T U R E U S E )
P h y si c i an /A P N / P A S i g na t ur e ( ma nd a t o r y )
P r i n t P h y si c i a n /A P N/ P A N a m e , A dd r e ss a n d Ph o n e N u m b e r D a te
C o l o r a d o Li c e n se # :
HIPAA PER MI TS DISCLOSURE
OF THIS INFO RMATION TO OTHER HEALTH CAR E PROFESS IONALS AS NECESS AR Y
C o l o r ad o A d va n c e Dir ec ti ve s C o n s o rt i u m , P O B o x 2 7 0 2 0 2 , L ittl e t o n , CO 8 0 1 2 7 v . 7. 1 0SEND FORM WITH PERSON W HENEV ER TRA NS FERRED OR DISCHARGEDS I GNATUR E O F P AT I ENT , A GE N T , G UAR D I AN , O R P R O X Y B Y S T ATUT E ( M AN D AT O RY )
S i g n if i ca n t t h ou g ht h a s b e e n g i v e n t o t he d e s i r e d s c ope of e nd - o f - lif e t r e at m e nt a n d t h e s e i n s tr u c t i on s . P r e fe r e n ce s h a v e
b ee n d is c u ss e d a nd e x p re ss e d t o a h e a l t h c a r e p r o fe s s i on al . T h i s do c u m e nt r e f le c t s t h o s e tr e at m e nt p re f er e n c es , w h i c h
m a y als o be d o c u m e n te d i n a M D P OA , C PR D ir e c t i v e , L i v i ng Wi l l , o r o t h e r a d v a n c e d ir e c t i v e ( a tt a c h e d i f a v ai l a b l e) . To
t he e x t e nt t h a t m y p ri or a d v a n c e d i r ec t i v e s do n ot c on fl ic t w it h t h es e Me d ic a l O r de r s f o r S c o pe o f T r e a t m e n t , m y p ri or
a d v a n c e d ir e c t i v e s s h a l l r e m ai n i n f u l l f o r c e a nd e ff ec t .
(I f si g n e d by s u r r og a te , p r efe r e n c e s e x p re s se d m u s t r ef l ec t pa t ie n t ’ s w is h e s a s b es t un d er s t ood by s u rr o g a t e .)
S i g na t u re N a me ( P ri n t) R e l a ti o n s h i p / Su rr o g a te st a t u s
( write “ s e lf” if pa t i e n t) D a te S i gn e d
(R ev o ke s a ll
p r ev i ou s M O S T f o rms)
P rim a ry C on t a c t P e rs o n f o r t h e P a ti e n t R e l a ti o n s h i p a n d / o r M D P OA , P r ox y Ph o n e N u m b e r/ C on t a c t I n f o rm a t i o n
H e a lth C a re P r o f e ssi o n a l P r e pa r i n g F o rm P r e pa r e r T itle Ph o n e N u m b e r D a te P r e pa r e d
H o s p i c e P r og r a m ( if a p p li ca b l e ) Add r e ss Ph o n e N u m b e r D a te En r o ll e d
D I R E C TI O NS F O R H E A LT H
CARE PROFESS IONA LS
C O M P LETING T H E S E M E D ICAL O RDERS
•
M us t b e c o m p l e t e d b y a h ea lt h car e pro f e ss i o n a l ba s e d o n p a ti e n t pre f er e n ce s a n d m ed i ca l i n d i ca ti on s .
•
T h e s e M ed i ca l O r de r s m u s t b e s i g n e d b y a ph ys i c i a n , ad v ance d prac ti c e nu r s e , o r p hys i c i a n a s s i s t a n t to b e v a li d . Phy s i c i a n
A ss i s t an ts m u s t i nc l ud e phy s i c i a n na me an d c on t ac t i n f o r m a ti on .
•
V erba l ord e r s ar e accep t ab le w i t h f o ll o w - u p s i gn a t u r e b y p h ys i c i a n o r ad v a n ce d prac ti c e nu r s e in accorda n c e w i t h f ac i l it y po li c y .
•
O r i g i n a l f o r m s t ron g l y e n co u r a g ed . P h o t ocop y , f a x , a n d e l e c t ro n ic i m a g e o f s i g n e d MO S T f o r m s ar e l e g a l a n d v a li d .
U S ING T H E S E M EDICAL O RDERS
•
A n y s ec ti o n o f t h e s e M ed i ca l O r de r s n o t c o m p l e t e d i m p li e s f u ll t rea t m e n t f o r t h a t s ec t i o n .
•
A s e m i - a u t o m a tic e x t e r n a l def i br ill a t o r ( A E D) sh o u ld n o t b e us e d o n a per s o n w h o h a s c h o s e n “ Do N o t A tt e m p t R e s u s c i t a ti o n . ”
•
C o mf or t car e is n e v e r op ti o n a l; O ra l f l u i d s a n d n u t r iti o n m u s t a l w a y s b e of f ere d if m ed i ca l l y f e a s i b l e .
•
W h e n c o mf or t can n o t b e ac h i e v e d in t h e c u rre n t s e tt i n g , t h e per s o n , i n c l u d i n g s o m e o n e w i t h “ C o mf or t Mea s u re s O n l y , ” s h o u ld
b e t ra n s f erre d to a s e tti n g ab le to pro v i d e co mf or t (e. g . , p i nn i n g o f a h ip f rac t u re) .
•
A per s o n w h o c h oo s e s “ C o m for t Mea su re s O n l y ” o r “ L i m it e d A dd iti o n a l I n t e r v en ti on s , ” sh ou ld n o t b e e n t ere d i n to a
t rau m a s ys t e m . E MS s hou ld con t ac t M ed i ca l C on t r o l f o r f u r t he r o r de r s o r d i r ec ti o n r ega r d i n g t r an s f e rs .
•
I V m ed i ca ti o n to en h a n c e c o mf or t m a y b e appropr i a te f o r a p er s o n w h o h a s c h o s e n “ C o mf o r t Mea su re s O n l y . ”
•
T rea t m e n t o f deh y dra ti o n is a m ea s u r e t h a t m a y pro l o n g l i f e . A per s o n w h o de s i r e s I V f l u i d s sh ou ld i n d i ca te “ L i m it e d
I n t er v e n ti on s ” o r “ F u ll
Trea tment.”
•
I f a h ea l t h car e pro v i de r co ns i der s t h e s e order s m ed i ca l l y i nappr o pr i a t e , h e o r sh e m a y d i s c u s s co n cern s w i t h t h e pa ti e n t
o r a u t h or i ze d s u rro g a te a n d re v is e order s w i t h con s en t o f pa ti e n t o r su rro g a t e .
•
I f a h ea l t h car e pro v i de r o r f a c ili t y c a nn o t c o m p l y w i t h t h e order s d u e to po li c y o r per s o n a l e t h i c s , t h e pro v i de r o r f ac ili t y
m u s t arra ng e f o r t ran sf e r to t h e pa t i e n t to a n o t h e r pro v i de r o r f ac i l i t y a n d pro v i d e appropr i a te c a r e in t h e m ean t i m e .
•
P r o x y by s t a t u t e i s a d e c i s i on m ak e r se l e c te d t h r ou g h a p r o x y p r o c e s s acc o rd i n g to C . R . S. 15 - 18.5 - 103(6) , w h o m a y
no t dec li n e ar ti f i c i a l nu t r i t i o n / h y dra ti o n ( A N H) w i t h o u t a n a tt e n d i n g ph y s i c i a n a n d a s econ d ph y s i c i a n t ra i n e d i n n e u ro l og y
cer ti f y i n g t h a t pro v i s i o n o f ANH w o u ld m ere l y pro l o n g t h e ac t o f d y i n g a n d is u n l i k e l y to re su lt i n t h e re s t ora ti o n o f t h e pa ti e n t
to i n depe n de n t n e u ro l og i ca l fu n c ti o n i n g .
R EVI E W ING T H E S E M EDI C AL O RDERS
T h e s e M ed i ca l O r de r s s h o u ld b e re v i e w e d reg u l ar l y a n d w he n t h e per s o n i s t ran sf erre d f r o m o n e car e s e tt i n g o r car e l e v e l to
a n o t h er , t h er e i s a su b s t a n t i a l c h an g e i n t h e per s on ’ s h ea l t h s t a t u s , t h e per s on’ s t rea t m e n t pre f ere n ce s c h a n g e , o r w h e n
c o n t ac t i n f o r m a ti o n c h a ng e s .
R E V IE W O F T H I S M O S T F O RM
R ev i e w D at e R ev i e w e r L ocat i o n o f R ev i e w R ev i e w O u tco m e
No C h a n g e F o rm V o i d e d N e w Fo r m C
omp l e t e d
No C h a n g e F o rm V o i d e d N e w Fo r m
Comp l e t e d
No C h a n g e F o rm V o i d e d N e w Fo r m
Comp l e t e d
No C h a n g e F o rm V o i d e d N e w Fo r m
Comp l e t e d
HIPAA PER MI TS DISCLOSURE
OF THIS INFO RMATION TO OTHER HEALTH CAR E PROFESS IONALS AS NECESS AR Y
Valuable advice on preparing your ‘Colorado Most Form’ digitally
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FAQs
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How to fill out and sign documents online
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Follow the step-by-step guidelines to eSign your colorado most form in Gmail:
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