Medical Directive - DNR - Preparation Worksheet

DELAWARE DMOST / DNR REQUEST AND CLINICAL WORKSHEET

Not a DMOST Form or Medical Order

CRITICAL NOTICE: Signing this worksheet does not create an EMS-recognized DNR or other medical order. Under 16 Del. C. ch. 25A and 16 Del. Admin. C. 4304, the operative document is the standardized Delaware Medical Orders for Scope of Treatment (DMOST) form completed through shared decision-making and signed by the patient or authorized representative and a qualified health-care practitioner.

The current Delaware BLS protocol states that a living will does not control whether out-of-hospital EMS initiates or continues resuscitation. EMS personnel contact Medical Control about a standalone DNR order or prehospital advance care directive. Use the official DMOST process for portable medical orders.

1. PATIENT INFORMATION

2. ELIGIBILITY AND VOLUNTARY CHOICE

DMOST is intended for a patient living with serious illness or frailty whose health-care practitioner would not be surprised if the patient died within the next year. Completion is voluntary and cannot be required as a condition of insurance, care, admission, or services.

Serious illness or frailty: [________________________________]

Clinical basis for the one-year surprise question: [________________________________]

☐ Eligibility assessed under 16 Del. C. § 2503A and 16 Del. Admin. C. 4304

☐ Patient told that DMOST is voluntary

☐ Patient received the required plain-language explanation

☐ Benefits, risks, alternatives, prognosis, and likely course discussed

3. CAPACITY AND AUTHORIZED REPRESENTATIVE

An adult is presumed to have decision-making capacity. A physician must determine lack of capacity before an authorized representative executes DMOST for an adult, and the determination must be documented in the medical record.

Signer: ☐ Patient with capacity ☐ Authorized representative ☐ Parent or authorized representative of minor

Representative name: [________________________________]

Relationship and authority: [________________________________]

Supporting document, court order, or statutory basis: [________________________________]

Medical-record location: [________________________________]

☐ Capacity assessed

☐ Physician determination of incapacity documented, if applicable

☐ Highest-priority representative and scope of authority verified

☐ Patient's known instructions and wishes reviewed

☐ If wishes are unknown, substituted decision documented under 16 Del. C. § 2504A

Possible authority sources include a court-appointed guardian with appropriate authority, the most recently appointed agent under an advance health-care directive or health-care power of attorney, a Delaware statutory surrogate, or another person authorized by law. Special rules apply to minors.

4. QUALIFIED HEALTH-CARE PRACTITIONER

Practitioner name: [________________________________]

Profession: ☐ M.D. ☐ D.O. ☐ APRN ☐ PA

Delaware license number: [________________________________]

Telephone: [________________________________]

☐ Providing or overseeing care for this patient

☐ Authorized to write the selected medical orders

☐ Required Department DMOST training completed

☐ DMOST discussed directly with the patient or authorized representative

☐ Current standardized DMOST form used without alteration

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

This worksheet signature documents preparation only. The practitioner must sign and date the official DMOST for portable medical orders to exist.

5. OFFICIAL DMOST ORDER CHECKLIST

Make treatment selections only on the current official DMOST.

Section A — goals of care

Goals and desired outcomes: [________________________________]

Section A supports the treatment plan but is not itself a medical order.

Section B — no pulse and not breathing

☐ Attempt resuscitation / CPR

☐ Do not attempt resuscitation / DNAR

Section C — pulse or breathing present

☐ Full Treatment

☐ Limited Treatment

☐ Treatment of Symptoms Only / Comfort Measures

☐ Other Orders completed

If Limited Treatment is selected:

☐ Transfer for medical interventions

☐ Transfer only if comfort needs cannot be met in the current setting

Section D — fluids and nutrition

☐ Long-term artificial nutrition

☐ Defined trial period and goal

☐ No artificial nutrition

☐ Hydration selection completed

Food and fluids by mouth remain offered when feasible and desired.

Sections E and F — discussion, authority, and signatures

☐ Person with whom orders were discussed identified

☐ Representative authority documented, if applicable

☐ Patient selected whether a future representative may change or void DMOST after loss of capacity

☐ Patient, authorized representative, or parent signed and dated

☐ Qualified practitioner signed, dated, and completed required identifying information

☐ If the practitioner did not sign in the patient's presence, the individual in whose presence the patient or representative signed also signed as required by 16 Del. C. § 2509A(5)

Delaware does not impose a blanket two-witness or notary requirement on DMOST. The conditional additional signature above applies when the practitioner did not sign in the patient's presence. The current statute says “individual”; 16 Del. Admin. C. 4304 § 3.1.5 describes that signer as the health-care provider in whose presence the patient or representative signed. Confirm the current official workflow before execution. Separate advance-directive or authority documents have their own execution rules.

Any incomplete treatment section requires full treatment for that section. Comfort measures are always provided.

6. PORTABILITY, COPIES, AND REGISTRY

☐ Operative DMOST placed in the medical record

☐ DMOST accompanies the patient whenever moved to a new setting

☐ Patient, representative, caregivers, and receiving team know where it is located

☐ Faxed, copied, or electronic version available as needed

☐ Electronic-registry workflow checked with the Delaware Health Information Network

Under 16 Del. C. § 2520A and 16 Del. Admin. C. 4304, copies have the same effect as the original. Section 2507A directs the Delaware Health Information Network to maintain the electronic DMOST registry.

7. REVIEW, MODIFICATION, AND VOIDING

Review is recommended when the patient transfers between settings or care levels, the patient's health status changes substantially, or treatment preferences change.

Last review: [__/__/____]

Outcome: ☐ No change ☐ Prior form voided ☐ New DMOST completed ☐ Alternative treatment requested

Any change or alteration to a completed DMOST voids it. To change orders, void the prior form and complete a new DMOST with a qualified practitioner.

A patient with capacity may void DMOST at any time in any manner indicating intent to void, or request different treatment. After the patient loses capacity, an authorized representative may request modification or voiding in consultation with the practitioner only if the representative has authority and the patient did not prohibit that action on the form.

The patient's latest expressed oral or written directive controls when directives conflict. Inform the practitioner promptly so DMOST can be voided or replaced.

Date and manner voided: [________________________________]

Practitioner and others notified: [________________________________]

Medical-record update: [________________________________]

8. DELAWARE EMS USE

The current Delaware BLS protocol instructs EMS personnel to:

• treat a living will as inapplicable to the out-of-hospital resuscitation decision;
• contact Medical Control immediately about a standalone DNR order or prehospital advance care directive;
• review DMOST treatment sections and confirm the patient or representative and health-care-practitioner signatures;
• provide full treatment for any incomplete section;
• provide comfort measures regardless of the treatment level selected;
• honor a similar valid out-of-state MOLST, POLST, or other form; and
• contact Medical Control whenever a question arises about a living will, DNR, PACD, or DMOST.

Do not represent this worksheet as the official form or instruct EMS to rely on it.

9. LIABILITY AND PRIVATE TERMS

16 Del. C. § 2515A provides defined protections for specified good-faith conduct that also complies with generally accepted health-care standards. It does not authorize a patient-written indemnity, release, liability cap, default clause, prevailing-party fee clause, forum-selection term, or private enforcement covenant in the medical order.

Section 2517A separately provides professional discipline, civil penalties, and criminal penalties for specified misconduct. Do not replace those statutory standards with private remedies.

10. OFFICIAL SOURCES

• Delaware Code, 16 Del. C. ch. 25A — https://delcode.delaware.gov/title16/c025a/index.html
• Delaware Administrative Code, 16 Del. Admin. C. 4304 authenticated PDF — https://regulations.delaware.gov/api/AdminCode/title16/4304/7000d2be-7778-4863-b73d-4f658f385e3f
• Delaware DHSS DMOST Program — https://dhss.delaware.gov/dhcc/dmost/
• 2024 Delaware BLS Protocols, DNR protocol and Appendix H — https://statefirecommission.delaware.gov/wp-content/uploads/sites/103/2024/09/2024-BLS-Protocols-Revised-September-2024-min.pdf

Verify the current statute, regulation, standardized form, registry workflow, practitioner credentials, and EMS protocol before relying on any medical order.