Delaware Medical Orders for Scope of Treatment (DMOST) - Overview

The Delaware Medical Orders for Scope of Treatment (DMOST) program is designed to improve the quality of care people receive at the end of life by translating patient or resident goals and preferences into medical orders.

The DMOST form is based on communication between the patient or resident, health care agent or other designated decision-maker, and health care professionals that ensures informed medical decision-making.

Honoring patient preferences is a critical element in providing quality end-of-life care. To enable physicians and other health care providers to discuss and convey a patient’s wishes regarding cardiopulmonary resuscitation (CPR) and life-sustaining treatment, this coalition is working to implement and improve the statute and regulations that were developed to be used statewide by health care providers and facilities as the legal equivalent of an inpatient Do Not Resuscitate (DNR) form.

DMOST provides a single document that functions as an actionable medical order and transitions with a patient through all health care settings in order that their wishes for life-sustaining treatment and CPR will be clearly indicated.

The DMOST statute, House Bill 64, was passed on May 7, 2015 and signed into law by Governor Jack Markell later that month on May 28, 2015. HB 64 was sponsored by Representative Michael Barbieri and co-sponsored by Senator Bethany Hall-Long.

Section A

Section A discusses your goals of care. This is the only section on the DMOST form that is not a medical order. In section A, you can say things like “I want to play 9 holes of golf,” or, “I want to attend my granddaughter’s birthday party.” Discussing your goals of care with your health care team helps them understand where you are coming from, and helps them help you make the best decisions for your care.

Section B

Section B discusses your goals for cardiopulmonary resuscitation, or CPR. CPR is given when your heart stops beating and/or you stop breathing. It can consist of pushing on your chest and breathing into your mouth for you, but it can also include shocking your heart to get it to beat and a machine breathing for you. Do Not Resuscitate means that if you are found with no pulse and are not breathing, medical teams will not do CPR to try and get your heart beating again. They will keep you comfortable until you die a natural death.

Section C

In section C, your medical team will discuss different levels of treatment options with you. If you chose CPR in section B, you MUST choose Full Treatment in section C. Electrical stimulation of your heart and machines breathing for you are called Advanced Cardiac Life Support, or ACLS. ACLS must occur in the Intensive Care Unit (ICU) of a hospital.

Choosing Do Not Resuscitate (DNR) in section B means that you cannot choose Full Treatment in section C. You may wish to have everything possible done to keep you alive including fluids and antibiotics, but forgo resuscitation. You may also wish to be kept comfortable until you die a natural death.

In discussing section C, your medical team may also talk about dialysis, chemotherapy, or antibiotics for infections. You may base your decisions on the type of treatment, OR the location of treatment – full treatment may require a hospital stay, partial treatment may mean staying at home or in some form of long-term care facility – you should discuss these options with your health care team. Comfort measures will ALWAYS be given, even if you choose to stay at home.

Section D

Your health care team will also discuss artificial hydration and nutrition with you. They should let you know that hydration and nutrition will ALWAYS be offered by mouth first if it is feasible. An IV may be inserted into your vein to provide adequate hydration in a healthcare setting, if you choose it. There are two ways of giving you nutrition artificially: NG tubes and PEG tubes. Your health team should discuss both of these options with you, but in short:

• An NG (Naso-Gastric) Tube goes from your nose into your stomach. Food is liquified and passed to your stomach this way if you have problems chewing or swallowing. This is only done in a healthcare setting.

• A PEG (percutaneous endoscopic gastrostomy) tube is surgically inserted into your stomach. Liquified food is then injected directly into your stomach, bypassing the mouth and throat entirely.

Artificial nutrition and hydration may be tried for a certain time, after which you may elect to stop them, this is called a “time trial.” If this is something you feel you might like to try, you should discuss it with your health care team.

Section E

In section E, you may identify an Authorized Representative. This person may make changes to your DMOST form if you allow them, and may discuss your treatments with your health care team.

Section F

The final section of the DMOST form is section F. Here, you or your representative must sign the form, stating you consent to the treatment options outlined on the form. Your doctor, advance practice nurse, or physician assistant will sign after you, making the form medical orders that must be honored in every hospice, hospital, long term care facility, ambulance, or other medical institutions.

What is DMOST?

The Delaware Medical Orders for Scope of Treatment (DMOST) form is a portable medical order form. It allows you to make choices about life-sustaining treatments like CPR (cardiopulmonary resuscitation) and artificial nutrition. You may request full treatment, limited treatment, or comfort care only. 

Who is it for?

A DMOST form can be used by a person with a serious illness or frailty, whose health-care practitioner would not be surprised if they died within the next year.

When should it be discussed and signed? Who signs it?

A DMOST form is completed after a conversation you have with a health care practitioner. It is signed by you and a physician, an advanced practice registered nurse (APRN), or a physician assistant (PA). The health care provider's signature makes the choices into portable medical orders.

Who is required to follow the wishes documented on the DMOST form?

These orders will be followed by health care providers in any setting (ambulance, long-term care facility, emergency room, hospital, hospice, home, assisted living facility, etc.). It travels with you and is honored when you move to a new setting.

Can someone else make DMOST decisions for me?

You make health care decisions for yourself as long as you have decision-making capacity. You have the right to change your authorized representative at any time while you have decision making capacity. If a physician determines that a person lacks decision-making capacity, an authorized representative can sign a DMOST form on behalf of that person. A DMOST form does not change the decision-maker designated by an advance health care directive, a health care power of attorney document, a guardian of person appointed by a Court, or Delaware law on health care surrogates. If you have capacity and complete a DMOST form, you can sign on the form saying that if you lose capacity, your authorized representative cannot void the form you signed.

What if I change my mind?

If your condition or your choices change, you or your authorized representative should void (cancel) your DMOST form and request a new DMOST be completed with your new choices. You can void a DMOST form if you change your mind but do not want to create a new one. You may not make any changes to the content of the DMOST form. If you want to change your DMOST form you must void your previous form and complete a new one with your health-care practitioner. If your DMOST form does not agree with your advance directive, the most recent document will be followed.

Must I do this?

The DMOST form is always voluntary and can be voided at any time. A health care organization is prohibited from requiring you to complete a DMOST form for any reason, including as part of a person’s admission to a health care facility. It is important to understand that this form contains medical orders. It will be followed by health care providers. For example, if you choose “Do Not Attempt Resuscitation” and your heart stops, no attempt will be made to restart your heart. If you choose “Intubate/Use Artificial Ventilation” then you may be placed on a breathing machine with a tube in your throat and transferred to an intensive care setting in a hospital.

What will happen to my choices if I travel out of state?

Many states, including all the states in our region, currently use a form similar to the DMOST form. Forms from those states which are valid under the Delaware Law will be honored in Delaware. DMOST forms will be honored in other states which have reciprocity.

Does a DMOST form replace the Advance Directive?

The DMOST form complements the Advance Directive and is not intended to replace it. An Advance Directive is necessary to appoint a legal health care representative and provide instructions for future life-sustaining treatments. The Advance Directive is recommended for all adults, regardless of their health status. A DMOST form should accompany an Advance Directive when appropriate, you can learn more about Advance Care Planning here. For more information go to: www.caringinfo.org. Advance Health Care Directive Form - English || Directrices Anticipadas de Asistencia Médica - Spanish

What are the primary differences between an Advance Directive and a DMOST form?

Advance Directive

• Who has one? Anyone over 18

• Where is it stored? With other legal documents

• What is it for? Future care

• Form is: A legal document, it must be translated to medical orders before it can be honored

• Can it be changed? Yes - with a lawyer

• Authorized representative: cannot change anything

Delaware Medical Orders for Scope of Treatment (DMOST)

• Who has one? People with less than 1 year to live

• Where is it stored? In a pink envelope, kept with the patient at all times

• What is it for? Current care

• Form is: Medical orders, honoredin all medical institutions, clinics, ambulances, etc. in the satte of Delaware

• Can it be changed? Yes - with a physician

• Authorized representative: may make changes if the patient has lost capacity

{Content modified from polst.org}

What are the parts of the DMOST form?

A DMOST form has six sections, A–F. Each of these sections tells your health care provider something different about your goals, values, and decisions.

• This form, and your Authorized Representative, will NOT be consulted unless you cannot communicate with the health care team.

• You must keep this form with you, at all times. Talk to your family about your decisions and let them read the form.

• You may revoke or change your DMOST at any time – just call your health care team. They will assist you in filling out a new DMOST with your new wishes, or revoking an old form.