DELAWARE MEDICAL ORDERS FOR SCOPE OF TREATMENT (DMOST)
FIRST, follow the orders below. THEN contact physician or other health[-]care practitioner for further orders, if indicated.
The 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 [they the patient] died [by within] next year.
Any section not completed requires providing the patient with the full treatment described in that section.
Always provide comfort measure[s], 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
Goals of Care
(see reverse for instructions. This section does not constitute a medical order.)
Cardiopulmonary Resuscitation (CPR)
Patient has no pulse and/or is not breathing
Do not attempt resuscitation/DNAR.
Medical Interventions: Patient is breathing and/or has a pulse.
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.
Use appropriate medical treatment, such as antibiotics and IV fluids, as indicated.
May use oxygen and noninvasive positive airway pressure. Generally avoid intensive care.
Transfer to hospital for medical interventions
Transfer to hospital only if comfort needs cannot be met in current setting.
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 [setting
Artificially Administered Fluids and Nutrition:
Always offer food/fluids by mouth if feasible and desired.
Long-term artificial nutrition
Defined trial period of artificial nutrition: Length of trial: ________________Goal:__________________
No artificial nutrition
(check one box)
Orders Discussed With:
Surrogate (per DE Surrogacy Statute)
Printed Name & phone number
Agent under healthcare POA/or AHCD __________________________________________
Parent of a minor
Print Name of Authorized Representative
Relation to Patient
If I lose capacity, my Authorized Representative may not change or void this DMOST _____________________
Physician / APRN / PA
Representative/Parent (mandatory) I have discussed
this information with my Physician / APRN / PA
If [aA]uthorized [rR]epresentative signs, the medical record
must document that a physician has determined the patient’s
incapacity & the [aA]uthorized [rR]epresentative’s authority, in
accordance with DE law.