Medical Directive - DNR

DISTRICT OF COLUMBIA MOST / DNR REQUEST AND CLINICAL WORKSHEET

Not a MOST, eMOST, or Provider Order

CRITICAL NOTICE: Signing this worksheet does not create a D.C. medical order. DC Health states that the Medical Orders for Scope of Treatment (MOST) program replaces the former EMS Comfort Care Order/Do Not Resuscitate program. A valid MOST requires an authorized DC-licensed physician or advanced practice registered nurse and the patient or authorized representative.

Use this worksheet to prepare for completion of the current paper MOST or eMOST.

1. PATIENT INFORMATION

2. ELIGIBILITY AND VOLUNTARY CHOICE

D.C. Code § 21-2221.01 defines a MOST patient as a person whom an authorized health care professional has determined to be approaching the end stage of a serious, life-limiting illness or frailty with a life expectancy of 12 months or less. Completion is voluntary.

Medical condition or frailty: [________________________________]

Estimated prognosis and basis: [________________________________]

☐ Eligibility under the statutory definition assessed

☐ Patient offered the option to complete MOST

☐ Patient not pressured or required to complete MOST

3. PATIENT OR AUTHORIZED REPRESENTATIVE

Signer: ☐ Patient age 18 or older ☐ Authorized representative

Authorized representative name: [________________________________]

Relationship or legal authority: [________________________________]

Supporting document and date: [________________________________]

Medical-record location: [________________________________]

☐ Patient capacity assessed

☐ Representative authority confirmed under D.C. Code §§ 21-2205 and 21-2210

☐ Any separate power-of-attorney execution or substituted-consent witness requirements satisfied and documented

☐ Patient's choices, goals, preferences, or known wishes reviewed

A MOST is executed by the patient or authorized representative's signature. The MOST form itself does not require two witnesses or a notary. Separate authority documents and consent rules remain controlling: D.C. Code § 21-2205 requires two adult witnesses for a health-care power of attorney, and § 21-2210(c) requires one witness for substituted consent by specified priority-class representatives.

4. AUTHORIZED HEALTH CARE PROFESSIONAL

Provider name: [________________________________]

Profession: ☐ M.D. ☐ D.O. ☐ APRN

DC license number: [________________________________]

Telephone: [________________________________]

Review date: [__/__/____]

☐ I am treating the patient and qualify as an authorized health care professional under D.C. Code § 21-2221.01(4).

☐ I discussed prognosis, likely course of illness, goals, benefits, risks, and treatment choices with the patient or authorized representative.

☐ Paper MOST completed separately. Required orders, signatures, dates, and initial location were entered.

☐ eMOST completed separately through the District-designated health information exchange.

☐ No MOST completed. Further evaluation, discussion, authority, or documentation is required.

Reason or follow-up plan:

[____________________________________________________________]

Provider signature on this worksheet: [________________________________] Date: [__/__/____]

Physician assistants are “health care professionals” under the broader definition, but the current statute defines the professional authorized to issue MOST orders as a licensed physician or advanced practice nurse. Do not use a PA signature as the issuing-provider signature on the current DC MOST.

5. MOST ORDER CHECKLIST

Complete selections only on the current DC Health form or eMOST.

Section A — no pulse and not breathing

☐ Attempt Resuscitation/CPR

☐ Do Not Attempt Resuscitation (DNAR) / Allow Natural Death

Choosing DNAR includes appropriate comfort measures.

Medical interventions and treatment preferences

☐ Full Treatment

☐ Selective Treatment

☐ Comfort-Focused Treatment

☐ Medical nutrition preferences completed

☐ Antibiotic preferences completed

☐ Additional orders completed

Any incomplete treatment section implies full treatment for that section.

Required execution information

☐ Authorized provider signed and dated

☐ Patient or authorized representative signed and dated

☐ Initial authorization date and location recorded

☐ Representative status identified

6. RECORDS, COPIES, AND TRANSFER

D.C. Code §§ 21-2221.04 and 21-2221.05 provide that:

• a hard copy of the operative MOST must be given to the patient or authorized representative;
• an executed MOST must be kept prominently in printed and electronic medical records;
• a copy must transfer with the patient to another institution, practice, or residence;
• a copy is as effective as the original;
• the transferring institution must notify the receiving institution before transfer; and
• the form must be reviewed within 72 hours after transfer with the patient, if not incapacitated, or the authorized representative, if present.

Checklist:

☐ Operative form placed prominently in printed and electronic records

☐ Patient or representative received a hard copy

☐ Patient keeps a copy on the person or in the immediate visible vicinity

☐ Receiving institution notified before transfer

☐ Copy accompanied patient

☐ Post-transfer review scheduled or completed within 72 hours

7. REVIEW AND REVISION

An authorized health care professional must review the MOST with the patient or authorized representative at least annually and whenever the patient's condition changes significantly or review is requested.

Any incomplete section implies full treatment. To make substantive changes, void the prior form and complete a new one rather than amending a private worksheet.

Last annual or event-based review: [__/__/____]

Outcome: ☐ No change ☐ Prior form voided and replaced ☐ MOST revoked

8. REVOCATION

Under D.C. Code § 21-2221.06, a patient or authorized representative may revoke MOST at any time by:

• directing the authorized professional who issued it to cancel it; or
• communicating intent to revoke to treating EMS personnel or another health care professional.

Treating personnel who receive the communication must record the circumstances. DC Health also instructs users to draw a line through “Medical Orders,” write “VOID” in large letters, and complete a new form for changed orders.

Date and time revoked: [________________________________]

Person notified: [________________________________]

Circumstances and record location:

[____________________________________________________________]

9. EMS USE, UNCERTAINTY, AND COMFORT CARE

EMS personnel and health care professionals must verify that the person is the subject of the MOST and determine whether it has been revoked. If revocation is uncertain or the form is unreadable in an emergency, personnel act as if there is no MOST and resuscitate.

When EMS withholds resuscitation based on MOST, the response must be recorded in the run report and reported to DC Health within five business days.

The statute separately permits comfort and pain-relief interventions regardless of the MOST treatment orders. Do not use a private document to withhold all care.

10. LIABILITY AND PRIVATE TERMS

D.C. Code § 21-2221.11 states that the MOST subchapter does not create a private right of action. Do not add indemnity, release, liability-cap, default, attorneys' fees, forum-selection, identification-card, bracelet, necklace, or private-remedies provisions to the medical order.

11. OFFICIAL SOURCES

• D.C. Code, MOST subchapter — https://code.dccouncil.gov/us/dc/council/code/titles/21/chapters/22/subchapters/II
• D.C. Code § 21-2221.01 — https://code.dccouncil.gov/us/dc/council/code/sections/21-2221.01
• D.C. Code § 21-2221.02 — https://code.dccouncil.gov/us/dc/council/code/sections/21-2221.02
• D.C. Code § 21-2221.04 — https://code.dccouncil.gov/us/dc/council/code/sections/21-2221.04
• D.C. Code § 21-2221.05 — https://code.dccouncil.gov/us/dc/council/code/sections/21-2221.05
• D.C. Code § 21-2221.06 — https://code.dccouncil.gov/us/dc/council/code/sections/21-2221.06
• D.C. Code § 21-2221.07 — https://code.dccouncil.gov/us/dc/council/code/sections/21-2221.07
• D.C. Code § 21-2221.08 — https://code.dccouncil.gov/us/dc/council/code/sections/21-2221.08
• D.C. Code § 21-2221.11 — https://code.dccouncil.gov/us/dc/council/code/sections/21-2221.11
• D.C. Code § 21-2221.14a — https://code.dccouncil.gov/us/dc/council/code/sections/21-2221.14a
• D.C. Code § 21-2205 — https://code.dccouncil.gov/us/dc/council/code/sections/21-2205
• D.C. Code § 21-2210 — https://code.dccouncil.gov/us/dc/council/code/sections/21-2210
• D.C. Health MOST Program — https://dchealth.dc.gov/most
• DC MOST Form — https://dchealth.dc.gov/sites/default/files/dc/sites/doh/FINAL%20MOST%20Fillable%20Form%20V2%2008182021.pdf
• DC Fire and EMS Protocols — https://fems.dc.gov/sites/default/files/dc/sites/fems/page_content/attachments/DC_Fire_%26_EMS_Protocols_August_2024.pdf

Verify the current code, MOST form, eMOST registry, provider credentials, and EMS or facility protocol before relying on any order.