NC MOST Form Guide: Medical Orders for End-of-Life Care
Honor Your Values in Your Final Chapter
A MOST form is not about giving up. It is about clarity. It is about ensuring that if your health becomes seriously compromised, your healthcare team knows exactly what matters to you and how to treat you in alignment with your deepest values.
Imagine this: You have advanced cancer. Your prognosis is measured in months. Your doctor sits with you and says, “Let’s talk about what matters most to you. Let’s translate those values into specific medical orders that will guide your care.”
That conversation, leading to a MOST form, gives both you and your healthcare team peace of mind. When emergencies arise, your team does not guess. They follow orders that reflect your values.
This guide walks you through everything you need to know about MOST forms in North Carolina, when they are appropriate, and how they complement your other healthcare planning documents.
What is a MOST Form?
MOST stands for Medical Orders for Scope of Treatment. It is an official North Carolina healthcare document that translates your end-of-life wishes into specific, actionable medical orders.
Purpose: Translating General Wishes into Medical Orders
Your advance directive might say “I want comfort care.” Your MOST form says “Do Not Attempt Resuscitation (DNAR), no mechanical ventilation, comfort care and pain management focus.”
An advance directive specifies what you want; a MOST form specifies what doctors will actually do. The MOST form is immediately actionable by emergency responders and hospital staff without interpretation needed.
Statutory Basis: NCGS 32A-25.1
North Carolina General Statutes Section 32A-25.1 authorizes MOST forms and establishes requirements for validity. The statute was added to address a gap: advance directives are important but require interpretation; MOST forms provide specific, binding medical orders.
Distinctive Appearance: Bright Pink or Orange
MOST forms are printed on bright pink or orange paper, making them immediately visible in medical records and emergency settings. The distinctive color ensures the form is not overlooked or missed.
Key Difference from Advance Directive
- Advance Directive: General statement of healthcare wishes; requires interpretation by healthcare team
- MOST Form: Specific actionable medical orders signed by physician; immediately binding on healthcare providers
Think of advance directive as the foundation; MOST form as the specific blueprint built on that foundation.
Who Should Have a MOST Form? Appropriateness Criteria
MOST forms are not appropriate for everyone. They are designed for specific situations.
Appropriate for Seriously Ill Adults
MOST forms are appropriate for people with serious, life-limiting illness including:
- Advanced cancer (especially metastatic disease)
- End-stage organ disease (advanced heart failure, COPD, kidney failure)
- Dementia or Alzheimer’s (especially advanced dementia with inability to communicate)
- ALS (amyotrophic lateral sclerosis) and other motor neuron diseases
- Stroke with severe disability and poor prognosis for recovery
Appropriate for Very Elderly in Declining Health
Very elderly people (85+) in declining health with multiple chronic conditions often benefit from MOST forms. Prognosis may be uncertain, but healthcare goals can be clarified.
Elderly in nursing home or assisted living with health decline are often appropriate candidates.
Anyone with Advance Directive Wanting More Specificity
Even if not terminally ill, if you have an advance directive and want specific medical orders, MOST form is appropriate. MOST translates your advance directive wishes into actionable orders.
Not Needed: Generally Healthy People
Healthy people without serious illness typically do not need MOST forms. Advance directive alone is sufficient. MOST becomes relevant when health changes significantly and serious illness develops.
Appropriateness Determined by Healthcare Provider
MOST forms are usually initiated by healthcare provider (doctor, hospice nurse). Doctor assesses whether you have serious illness appropriate for MOST form.
Patient input is critical; doctor and patient jointly decide if MOST form is appropriate. Timing is usually when prognosis becomes limited (months to couple years remaining).
MOST Form vs. Advance Directive vs. Healthcare POA: Complete Comparison
Understanding how these three documents relate helps you use each appropriately.
Advance Directive: Your Wishes
Advance directive documents general healthcare wishes. Examples: “I want comfort care over life extension” or “I do not want artificial nutrition.”
Advance directive requires interpretation by healthcare team. It is valid but not immediately actionable in emergency settings.
Healthcare POA: Who Decides
Healthcare POA names person who makes healthcare decisions if you are incapacitated. Does not specify medical wishes; designates “who decides.”
Agent uses healthcare POA authority to make decisions based on your advance directive or known preferences. It is decision-making authority, not medical orders.
MOST Form: Specific Medical Orders
MOST form contains specific physician orders about interventions. Examples: “Do Not Attempt Resuscitation (DNAR)” or “No mechanical ventilation.”
MOST form is signed by physician; becomes binding medical order. Immediately actionable by EMTs and hospital staff without interpretation.
Example: All Three Documents in Action
Scenario: Elderly person with advanced cancer.
Advance Directive: “I want comfort care and no life-extending interventions.”
Healthcare POA: “I designate my daughter as my healthcare agent to implement these wishes.”
MOST Form: Physician order reads “DNAR, no mechanical ventilation, comfort care, pain management focus.”
All three working together ensure consistent implementation of your values.
MOST Form Sections: What Each Option Means
A MOST form addresses four main medical decisions. Understanding each is crucial for making informed choices.
Section 1: Resuscitation (CPR)
The Decision: If your heart stops, should doctors attempt CPR?
Option A: Attempt Resuscitation
- CPR involves chest compressions, electrical shock (defibrillation), medication
- In elderly or seriously ill, CPR often causes broken ribs and may not restore meaningful function
- Select this if you want aggressive resuscitation if heart stops
Option B: Do Not Attempt Resuscitation (DNAR)
- Natural death occurs if heart stops without CPR intervention
- Select this if you prefer natural death over CPR intervention
- DNAR is most common choice for terminally ill patients
Your choice should reflect: Do you value life extension above all? Or do you value natural death and quality of life?
Section 2: Antibiotics for Infection
The Decision: If you develop serious infection, should doctors use antibiotics?
Option A: Use Antibiotics
- Antibiotics can cure infections and may extend life temporarily
- For recovering patients, antibiotics enable healing
- Select this if you want infection treatment
Option B: Do Not Use Antibiotics; Comfort Care Only
- Untreated infections may cause death within days to weeks
- Comfort care without antibiotics allows natural death while keeping you comfortable
- Common choice for end-stage dementia or advanced cancer
This choice is complex; depends on your prognosis and goals of care.
Section 3: Artificial Nutrition and Hydration (Feeding Tube)
The Decision: If you cannot eat or swallow, should doctors place feeding tube?
Option A: Long-Term Feeding Tube
- Tube placed in stomach or small intestine; provides permanent nutrition
- Sustains life but doesn’t cure underlying condition
- Appropriate for temporary swallowing problems expected to improve
Option B: Time-Limited Trial
- Feeding tube placed temporarily to see if function returns
- Trial period (weeks to months); if function returns, tube can be removed
- If function doesn’t return, tube is removed per plan; natural death ensues
- Compromise option allowing trial while respecting risk of permanent dependence
Option C: No Artificial Nutrition/Hydration; Comfort Care
- No feeding tube; natural death from inability to eat
- Allows death from inability to sustain nutrition
- Most difficult choice emotionally; requires accepting death from inability to eat
This is often the most emotionally difficult choice. Discuss thoroughly with your doctor.
Section 4: Hospital Admission and Transfer
The Decision: If you become very ill, should doctors admit you to hospital?
Option A: Request Hospital Transfer
- If seriously ill, transfer to hospital for intensive care
- Hospital provides access to advanced technology and specialists
- Select if you want aggressive treatment and hope for recovery
Option B: Avoid Hospital Transfer; Provide Care at Current Location
- Keep at home or current care facility
- Allows natural death without hospital admission
- Avoids hospital environment; allows death at home with family
- Common choice for hospice patients or terminally ill
Your choice depends on: Do you want hospital intervention if possible? Or do you prefer dying at home?
When MOST Form Becomes Necessary: Timing
MOST forms are typically initiated at specific points in illness trajectory.
Usually Initiated by Healthcare Provider
Your doctor, nurse, or hospice provider typically suggests MOST form. Provider assesses your condition and determines if MOST is appropriate.
You can also request MOST form; you do not have to wait for provider to initiate.
Timing: When Prognosis Becomes Limited
MOST form is typically completed when prognosis becomes limited (months to couple years remaining):
- Advanced cancer: Usually when metastatic disease confirmed or curative treatment fails
- Dementia: Usually when patient no longer recognizes family or needs total care assistance
- COPD/Heart failure: Usually when multiple hospitalizations occur or oxygen/medications fail
- Stroke: Usually when prognosis for recovery becomes clear and limited
Timing is variable; depends on individual trajectory and condition.
Not Rushed Decision
You should not feel pressured to complete MOST form immediately. You are not making an irreversible decision about life or death. You are clarifying your values and healthcare preferences.
Take time to understand options. Ask questions. Involve family if you want. Complete form only when you feel ready and informed.
How MOST Form is Created: The Conversation
A MOST form is never completed in isolation. It results from meaningful conversation between you and your healthcare provider.
Step 1: Provider Initiates Conversation
Your doctor discusses your current health status: What is your diagnosis? What is your realistic prognosis? What interventions are still appropriate given your condition?
Provider asks: What matters most to you? What is your goal of care? What are you hoping for?
Step 2: Mutual Discussion of Options
Provider explains each MOST option in plain language. Ensures you understand what each choice means:
“If you choose DNAR, this means if your heart stops, we will not attempt CPR. You will have a natural death.”
“If you choose comfort care with antibiotics, this means we will treat infections that cause you discomfort, but we are not trying to cure infections.”
Provider recommends specific options based on your condition and values. But final choice is yours.
Step 3: Honest Conversation About Goals
This conversation is not clinical; it is deeply personal. You and your doctor discuss:
- What outcome are you hoping for?
- What does quality of life mean to you?
- What would be worse than death for you?
- What would you want if you could no longer communicate?
These conversations clarify values and help translate values into specific orders.
Step 4: Mutual Decision-Making
MOST form is not doctor’s decision alone. Doctor offers guidance; you decide.
You have right to refuse recommended orders. You should never feel pressured. Decision should reflect your values and goals, not just medical recommendations.
If you feel pressured or uncomfortable, request time to think. Get second opinion. Have family help you think through options.
Creating and Completing MOST Form: Practical Steps
Once you have decided MOST form is appropriate, here is how to complete it.
Step 1: Obtain MOST Form
MOST form is available from:
- Your healthcare provider (doctor often has forms available)
- Hospice (hospice agencies always have MOST forms)
- Hospital (hospitals provide upon admission if appropriate)
- NC Board of Health and Human Services (online)
Forms are typically free or minimal cost.
Step 2: Have Detailed Conversation First
Before completing MOST form, have thorough conversation with your doctor about your health, prognosis, and goals. Understanding your condition helps you make informed decisions.
Doctor should explain what each option means for your specific condition. Do not rush into completing form; take time to understand implications.
Step 3: Discuss Each Section
For each section (resuscitation, antibiotics, nutrition, hospital transfer), discuss what each option means:
“If you choose this option, here is what would happen in this situation…”
Doctor should explain realistic outcomes: “This option gives best chance of recovery, but may prolong dying if recovery doesn’t occur.”
Ensure you understand before committing to order.
Step 4: Be Honest About Your Values
Be honest with doctor about what you want. Doctor wants to respect your wishes. If uncertain, say so; take time to think.
Clarify your values: What is most important to you? Quality of life? Avoiding machines? Spending time with family? Doctor’s role is translating your values into medical orders.
Step 5: Ask Questions
Ask about anything you do not understand. No such thing as “stupid question”; all questions are legitimate. Doctor should encourage questions and not rush through form.
Take notes if helpful. Bring family member if want support or another perspective.
Step 6: Sign the Form
You (patient) must sign MOST form. If unable to sign (paralyzed, too weak), healthcare agent can sign on your behalf. Sign after understanding each option.
Sign voluntarily; not under pressure or coercion.
Physician Signature: Making MOST Orders Valid
A critical step that many people do not understand: physician signature is required.
Why Physician Signature is Essential
Patient signature alone is not enough. Physician must sign to make MOST orders binding medical orders. Physician’s signature transforms MOST from wishes to binding orders.
Physician ensures that you understand options and made informed decision.
Without physician signature, MOST is just a statement; not a medical order.
Timing of Signature
Physician signature typically happens at conclusion of conversation after you have made your decisions. Physician reviews form to ensure your choices are clearly documented.
Both you and physician sign and date the form.
Distribution of Signed Form
Once signed by you and physician:
- Request multiple copies
- Provide to: your physician, hospital (if anticipating admission), healthcare agent, emergency contact
- Multiple copies ensure form is available when needed
- Keep original in safe location; copies can be distributed widely
How Healthcare Providers Use MOST Form
Once signed, your MOST form becomes operational. Here is how different healthcare settings use it.
Emergency Responders (EMTs)
If MOST form is found at scene of emergency (at home, in public), EMTs follow the orders. Example: If MOST says DNAR, EMTs will not attempt CPR even if family asks.
Example: If MOST says no mechanical ventilation, EMTs will provide oxygen but not intubate.
MOST form carries legal weight; responders must honor it.
Hospital Providers
Upon hospital admission, MOST form becomes part of medical record. Hospital doctors follow MOST orders when making treatment decisions. If MOST says no mechanical ventilation, doctors will not place patient on ventilator.
MOST orders guide hospital care; doctors plan treatment consistent with orders.
Hospice Providers
Hospice patients typically have MOST forms. MOST form aligns with hospice philosophy of comfort care.
Hospice uses MOST orders to guide symptom management and end-of-life care. MOST for hospice patient typically emphasizes comfort and pain control.
Home Care Providers
If receiving home care services, MOST form should be provided to home care team. Home care workers follow MOST orders when providing care.
Example: If MOST says comfort care only, home care focuses on hygiene, comfort, pain management (not curative treatment).
Visibility Ensures Implementation
MOST form should be easily visible in patient’s medical record. Form should be given to all providers involved in care. Visibility ensures providers don’t miss form; know what orders exist.
Example: Keep MOST on refrigerator at home so EMTs find it quickly if emergency.
Real-Life MOST Decisions: Four Scenarios
Understanding how different people make MOST decisions in different situations helps clarify your own values.
Scenario A: Cancer Patient Responding to Treatment
Situation: 65-year-old with newly diagnosed cancer undergoing chemotherapy; responding well.
MOST Orders: “Attempt resuscitation, use antibiotics for infections, time-limited trial of feeding tube if needed, transfer to hospital if needed.”
Reasoning: Active intervention approach; patient hopes for cure or long-term survival.
Goals: Aggressive treatment with goal of recovery or extended life.
Treatment Approach: All interventions available; maximize chance of recovery.
Scenario B: Metastatic Cancer with Limited Prognosis
Situation: 70-year-old with stage 4 cancer, metastatic to liver and lungs; prognosis 6 months.
MOST Orders: “Do Not Attempt Resuscitation, comfort care with antibiotics for symptoms (not infections), no feeding tube, avoid hospital transfer.”
Reasoning: Comfort care approach; goal is quality of life in final months.
Goals: Comfort, pain management, time with family.
Treatment Approach: Focus on comfort; avoid aggressive interventions that prolong dying.
Scenario C: Advanced Dementia in Care Facility
Situation: 85-year-old with advanced Alzheimer’s; no longer recognizes family; total care dependence.
MOST Orders: “DNAR, no antibiotics for infections (comfort care for symptoms), no artificial nutrition, no hospital transfer; provide comfort care.”
Reasoning: Natural death approach; acceptance of inevitable decline.
Goals: Dignity, comfort, peaceful death in familiar setting.
Treatment Approach: Comfort focus; allow natural death from infections or inability to sustain nutrition.
Scenario D: COPD with Advanced Disease
Situation: 75-year-old with severe COPD; multiple hospitalizations; inadequate oxygen despite maximum therapy.
MOST Orders: “DNAR, no mechanical ventilation (oxygen okay for comfort), limited antibiotics for infections, avoid hospital transfer unless specifically requested, comfort focus.”
Reasoning: Limited intervention approach; balance between treatment and comfort.
Goals: Maintain independence at home; avoid hospitalization; comfort if condition worsens.
Treatment Approach: Support current function; comfort if decline accelerates.
Updating or Changing MOST Form
MOST forms are not permanent. Your healthcare wishes may change as your condition changes.
When Conditions Change
If your health status improves, MOST orders can be made more aggressive. If condition worsens, MOST orders can be made more comfort-focused.
Example: Initially treated for CPR; later changed to DNAR as condition deteriorates.
Process for Updating
Discuss with doctor: “My health has changed; I want to reconsider my MOST orders.”
Doctor explains how changed health affects previous choices. Together, decide on new orders reflecting current status and wishes.
Sign new MOST form with updated orders and physician signature. Distribute copies of new form to relevant providers.
Managing Multiple Forms
When new MOST form is created, old form should be destroyed or marked “VOID.” Notification to providers that old form is superseded prevents confusion.
Old form should be removed from medical records if possible. Clear indication that new form is current prevents accidental implementation of old orders.
Communication About Changes
Inform all healthcare providers of change to MOST orders. Call hospital, hospice, primary care doctor; ensure they have new form. Notify emergency contacts and family members of changes.
Changes take effect when new form is signed and distributed.
MOST Form and Hospice: Natural Partnership
MOST forms and hospice care are perfectly aligned.
Why They Work Together
Hospice care emphasizes comfort and quality of life; aligns perfectly with MOST philosophy. Most hospice patients have MOST forms.
MOST form is often initiated by hospice as part of admission process. MOST orders operationalize hospice’s comfort care philosophy.
Typical Hospice MOST Orders
Most hospice patients have MOST forms emphasizing comfort care:
- DNAR
- Limited antibiotics (for comfort, not infection cure)
- No artificial nutrition
- No hospital transfer
- Pain management and symptom control focus
Orders reflect acceptance of dying process; focus on comfort.
Transition from Curative to Palliative
If patient transitions from curative care to hospice, MOST form can be updated to reflect transition. MOST update from aggressive to comfort-focused orders signals shift to hospice care model.
Physician sign-off on comfort-focused MOST validates and supports hospice approach. MOST form provides legal/medical foundation for comfort care approach.
Integration with Hospice Services
Hospice team uses MOST orders to guide symptom management. If MOST emphasizes pain control, hospice prioritizes adequate pain medication.
If MOST limits interventions, hospice avoids unnecessary tests or medications. MOST form and hospice services work together toward comfort goals.
Common Misconceptions About MOST Forms
Myths about MOST forms often prevent people from creating them. Let us address these misconceptions directly.
Misconception A: “MOST Means I’m Giving Up”
Reality: MOST clarifies your goals and values; does not represent giving up. MOST may emphasize comfort, but you are not abandoning the possibility of feeling better.
MOST is active choice to pursue goals that matter to you (whether aggressive treatment or comfort care). Many people with MOST forms continue treatments aligned with their goals.
Misconception B: “Once I Sign MOST, I Can’t Change My Mind”
Reality: MOST can be revoked or updated anytime. You maintain right to change your mind about medical decisions.
If wishes change, new MOST form can be created. Flexibility is built into MOST process.
Misconception C: “MOST Will Make Me Die Sooner”
Reality: MOST doesn’t directly affect lifespan; specifies how death will be managed. MOST ordering comfort care doesn’t hasten death; specifies how death process will be managed.
MOST ordering aggressive treatment doesn’t guarantee survival. Lifespan is determined by underlying disease; MOST determines how disease progression is treated.
Misconception D: “Only Dying People Need MOST”
Reality: MOST is useful for anyone with serious illness, not just immediately dying. People with serious illness prognosis of months to years benefit from MOST.
MOST helps clarify goals even when exact timing of death is uncertain. MOST is appropriate for anyone with life-limiting condition.
Misconception E: “MOST is Same as Do-Not-Resuscitate”
Reality: MOST is much broader; addresses resuscitation, antibiotics, nutrition, hospital transfer. DNR (Do Not Resuscitate) addresses only CPR; MOST addresses multiple interventions.
MOST provides comprehensive guidance; DNR provides single-intervention guidance. If you want comprehensive orders, MOST is more useful than DNR alone.
Healthcare Equity and MOST Forms
Healthcare disparities can affect MOST decision-making. Ensuring MOST forms are approached equitably is important.
Potential Disparity Concerns
Healthcare disparities may affect MOST decision-making. Risk: MOST form could unfairly limit treatment for certain populations if not carefully discussed.
Concern: Language barriers, cultural differences may affect understanding of MOST options. MOST should ensure equity; not become tool for limiting care based on bias.
Importance of Clear Communication
Healthcare providers must ensure patient understands MOST options. Communication should not be rushed; adequate time for questions.
All materials should be in patient’s primary language. Interpreter services should be provided if needed.
Cultural and Spiritual Considerations
MOST decisions should respect patient’s cultural and spiritual beliefs. Some cultures value family decision-making; some value individual choice.
Some religions have specific preferences about end-of-life care. Provider should inquire: What are your cultural or religious beliefs about this decision?
Education and Advocacy
Patient education about MOST should address common misconceptions. MOST materials should be culturally appropriate.
MOST should not be presented as only option; patient should understand full range of choices. Provider should ensure patient feels free to choose any option; no subtle pressure.
Conversation Starters: How to Talk About MOST
If you think MOST form might be appropriate for your situation, here are ways to start the conversation with your healthcare provider.
Conversation Starter 1
“I want to discuss what matters most to me if my health gets worse. Can we talk about my goals of care?”
This invites discussion without presupposing what goals should be.
Conversation Starter 2
“If I can’t communicate, what would be my goals of care? What interventions align with those goals?”
This questions assumes doctor can help you think through your values.
Conversation Starter 3
“What are realistic outcomes if I choose aggressive treatment vs. comfort care? Can you help me understand the differences?”
This asks doctor for factual information to inform your decision.
Conversation Starter 4
“Can you explain each option in plain language? I want to make sure I understand what each choice means.”
This empowers you to ask for understandable explanations.
Conversation Starter 5
“I appreciate the information. I’d like time to think about this before I make a decision. When can we talk again?”
This signals you take decision seriously; do not want to rush.
Integration: MOST With Your Other Documents
MOST form works best as part of comprehensive healthcare planning.
Advance Directive and MOST: Foundation and Specification
Advance directive provides general wishes and values. MOST form specifies concrete orders implementing those wishes.
Both documents should align; MOST should be consistent with advance directive. Example: Advance directive says “comfort care”; MOST specifies “DNAR, no feeding tube, comfort focus.”
Healthcare POA and MOST: Agent and Orders
Healthcare agent should understand MOST orders. Agent’s role is to support and implement MOST orders.
Agent should have copy of MOST form; know what orders you have authorized. Agent can explain MOST orders to doctors; helps ensure compliance.
Will and MOST: Separate Purposes
MOST addresses medical care during serious illness. Will addresses property distribution after death.
MOST is about dying process; will is about what happens after death. Both important but serve different purposes.
Complete Planning Approach
- Advance Directive: Documents general healthcare wishes
- Healthcare POA: Designates person to implement wishes
- MOST Form: Specifies concrete medical orders aligned with wishes
- Will: Addresses property distribution after death
All documents together provide comprehensive end-of-life and post-death planning.
How Afterpath Helps
Creating a MOST form is often the turning point in healthcare planning when serious illness becomes a reality. Afterpath helps families manage the entire journey from healthcare planning through estate settlement.
Your MOST form, combined with your advance directive and healthcare power of attorney, ensures your values are honored in your most vulnerable moments. When you eventually need estate settlement, having these healthcare documents in place demonstrates thoughtful planning that protects your family.
Key Takeaways
- MOST form translates your general healthcare wishes into specific medical orders
- MOST form is most appropriate for people with serious illness with limited prognosis (months to years)
- MOST form should be created through meaningful conversation between you and your healthcare provider
- MOST form addresses four main decisions: resuscitation, antibiotics, nutrition, hospital transfer
- Physician signature is required to make MOST orders binding and legally valid
- MOST form can be updated or changed anytime; it is not a permanent irreversible decision
- MOST form is not about giving up; it is about clarifying values and ensuring care aligns with those values
- MOST form should be distributed to all healthcare providers involved in your care
- MOST form works best as part of comprehensive healthcare planning with advance directive and healthcare POA
What’s Next?
If you are facing serious illness and considering a MOST form, work with your healthcare provider to have this important conversation. Bring family members or trusted friends if you want support.
Ensure your advance directive and healthcare power of attorney are also in place. Our guides on NC Living Wills & Advance Directives and Healthcare Power of Attorney provide detailed guidance on these complementary documents.
Your MOST form, along with your other healthcare planning documents, gives your healthcare team clear direction and gives you peace of mind. That clarity is invaluable, both for you and for your family.
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