Medical Orders For Scope Of Treatment


• FIRST, follow the orders below. THEN contact physician or other health care practitioner for further orders, if indicated.
• T he DMOST form is voluntary and is to be used by a patient with serious illness or frailty whose health care practitioner
would not be surprised if the patient died within next year.
• Any section not completed requires providing the patient with the full treatment described in that section.
• Always provide comfort measures, regardless of the level of treatment chosen.
• The Patient or the Authorized Representative has been given a plain-language explanation of the DMOST form.
• The DMOST form must accompany the patient at all times. It is valid in every health care setting in Delaware.
Print Patient’s Name (last, first, middle)
Date of Birth
last four digits of SSN
(see reverse for instructions. This section does not constitute a medical order.)
Goals of Care
Cardiopulmonary Resuscitation (CPR)
Patient has no pulse and/or is not breathing
o Attempt resuscitation/CPR. o Do not attempt resuscitation/DNAR.
Medical Interventions: Patient is breathing and/or has a pulse.
o Full Treatment: Use all appropriate medical and surgical interventions, including intubation and mechanical
ventilation in an intensive care setting, if indicated to support life. Transfer to a hospital, if necessary.
o Limited Treatment: Use appropriate medical treatment, such as antibiotics and IV fluids, as indicated. May use
oxygen and noninvasive positive airway pressure. Generally avoid intensive care.
o Transfer to hospital for medical interventions.
o Transfer to hospital only if comfort needs cannot be met in current setting.
o Treatment of Symptoms Only/Comfort Measures: Use any medications, including pain medication,
by any route, positioning, wound care, and other measures to keep clean, warm, dry, and comfortable.
Use oxygen, suctioning, and manual treatment of airway obstruction as needed for comfort.
Use antibiotics only to promote comfort. Transfer only if comfort needs cannot be met in current location.
o Other Orders: ____________________________________________________________________________________
Artificially Administered Fluids and Nutrition: Always offer food/fluids by mouth if feasible and desired.
o Long-term artificial nutrition
o Defined trial period of artificial nutrition: Length of trial: ______________________ Goal:_________________________
o No artificial nutrition o hydration only o none (check one box)
Orders Discussed With: o Patient ______________________ ph.#________________________
o Guardian o Surrogate (per DE Surrogacy Statute) Printed Name & phone number
o Other o Agent under healthcare POA/or AHCD _________________________________________________
o Parent of a minor Signature
Print Name of Authorized Representative Relation to Patient Address Phone #
If I lose capacity, my Authorized Representative may not change or void this DMOST ________________________________
Patient Signature
SIGNATURES: Patient/Authorized Representative/
Physician / APRN / PA (mandatory)
Parent (mandatory) I have discussed this information
with my Physician / APRN / PA
Signature Date Time
Signature Date
Print Name
If Authorized Representative signs, the medical record
Print Address
must document that a physician has determined the
patient’s incapacity & the Authorized Representative’s
License Number Phone #
authority, in accordance with DE law.


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