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Colorado's MOST Advance Directive:

Are you ready?

iStock 000012566607Small“Advance medical directives” is a broad term used to describe any written statement documenting a person’s wishes with regard to medical treatment. Meant to be used in the event you can’t speak for yourself, advance directives can, theoretically, be scribbled on a napkin or prepared by your attorney, signed and notarized (with varying degrees of effectiveness, of course). There are many types of documents that fall into this category, including living wills, CPR directives, and The Five Wishes workbook, for example.


Since 2010 in the state of Colorado, the "Medical Orders for Scope of Treatment (MOST)" program has been in effect to guide individuals through the process of defining their wishes for medical treatment. The MOST form is a clear and comprehensive document designed to inform your loved ones and medical caretakers about the actions and treatments you would desire (and, maybe even more importantly, the things you would prefer not be done).

No one is required to have a MOST form and the program is primarily intended for elderly people and those who have chronic medical problems. However, based on my experience as a physician assistant, I believe that everyone can benefit from the process of having this discussion and completing the form. It certainly can't hurt to think through these important issues while you are healthy and can contemplate with a clear mind what you might want.

iStock_000008726558SmallThe heart of the MOST program and the key to its effectiveness is the conversation between you and your physician about your wishes and desires with regard to specific circumstances. You doctor, nurse practitioner or physician assistant can walk you through the form and help you understand what the questions might mean for you based on your current medical condition and the potential risks and benefits of treatment options. It is helpful to include your spouse, adult children, or other loved ones in the discussion so they are familiar with your thought process and the basis for your decisions. While these conversations can be uncomfortable, it is much better to get it all out in the open when things are calm and there is not a critical or emergency situation unfolding.

I can't stress this enough: it is crucially important that you fully comprehend the questions and the implications of your answers. In my experience, too many people do not pay adequate attention--they sign the form without understanding it and perhaps in ways that conflict with their actual wishes. And that results in confusion and unintended outcomes down the road. For heaven's sake, don't be bashful about this. These are, truly, matters of life and death. Speak your mind while you are able.

The end result of the conversation with your physician should be a completed MOST form which adequately documents your desires. The form must be signed by the patient (or the patient's authorized agent, if s/he is incapacitated) as well as the physician. Once it is signed, it serves as official standing medical orders which "travel" with you to any care setting (e.g., hospital, outpatient clinic or surgery, assisted living, rehab, long term care, hospice). The original form is a bright green color for easy identification, but you should also make photocopies and keep them where they can easily be found (in your wallet, purse, on your fridge, etc.). You can also email an electronic scan to your various medical providers and loved ones. Remember, people can only carry out your wishes when they know what they are! Documents sealed away in a fireproof filing cabinet won't do you any good in a medical emergency.

It is possible that your physician will bring up these important issues. If not, you should take the initiative to do so. When you call to make your next regulariStock_000019018088XSmallappointment, tell the scheduler that you would like to book sufficient time to discuss advance directives with your provider. That way, they will be sure to have enough time planned for this important conversation. If you mention it as an "oh, by the way," during a regular appointment, your physician will not be able to do it without inconveniencing other patients. And, of course, the MOST form can also be filled in with a physician at a hospital, nursing facility, or during hospice care.

You may already have other advance directive documents (e.g., living will, medical power of attorney) in place. The MOST form does not take the place of or override these documents unless there is a direct conflict (then the MOST form trumps). And the MOST form should be updated at least annually, as well as every time you are hospitalized. The most recent form will always take precedence over earlier versions.

So what, exactly, does the MOST form cover? (You may download a copy at www.ColoradoAdvanceDirectives.com if you wish.)

A.     Cardiopulmonary Resuscitation (CPR). This section addresses the topic from the "old" CPR Directive (Do Not Resuscitate) form: if your heart stops do you, or do you not, wish to receive cardiopulmonary resuscitation? If you choose "yes," then all possible interventions are taken to keep you alive. My patients generally imagine various scenarios here, e.g., "if there is a chance of...then I would want it," or "I don't want it if I would be a vegetable." Unfortunately, there is no way of guessing what the probable outcome may be when you begin the process of CPR. The truth is that the likelihood of a good outcome is low, even in the best of circumstances. You have to be willing to take that chance if you answer "yes" to CPR.

B.      Medical Interventions. This section is both more inclusive and more confusing. I will reiterate that you really need to have an in-depth discussion with your physician to clearly understand what is meant by each of these choices and how they might play out in your particular circumstances.

  • "Comfort Measures" means just that—only actions necessary to keep you comfortable (e.g., pain management) will be undertaken if you check this box. So it would not make sense to choose this option if, for example, you've stated above that you want CPR.
  • "Limited Additional Interventions" and "Full Treatment" options encompass a variety of different interventions that should be discussed with your provider to determine the best choices for you.

C.     Antibiotics. There are few situations wherein not using antibiotics would make sense (e.g., for a hospice patient at the very end of life). Most people would want antibiotics for things like pneumonia or a urinary tract infection. If you choose "no" in this section, you are electing not to address some of the most easily treatable infections.

D.     Artificially Administered Nutrition and Hydration. This is also a conversation to be had with your physician as there are countless variables to consider before making an educated choice in this matter. Implications related to feeding tubes should never be taken lightly. While it is relatively easy to have one placed, the decision to stop supplementing a patient who is not doing well is a daunting one. It becomes an ethical dilemma for everyone involved.

So, there you have it: the Colorado MOST program empowers your physician to guide you and your loved ones through a weighty and important conversation. Then, if and when the time comes that you are unable to express yourself, the MOST form will instruct your medical providers about how to proceed according to your wishes. Take advantage of this invaluable resource and complete your MOST form now.

MOST

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