Alaska Most Form Medical Orders For Scope Of Treatment Page 2
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4HIPAA permits disclosure of ‘MOST form’ to other Healthcare Professionals as necessary
Last Name
MOST
Alaska
form
Medical Orders for Scope
First Name
Middle Name
of Treatment
This is a Medical Order Sheet. Any section not completed
indicates full treatment for that section. When need
Date of Birth
occurs, first follow these orders, then contact provider.
Treatment options when the person is not breathing and has no pulse.
A
Do Not Attempt Resuscitation (DNAR/DNR/Allow Natural Death)
Attempt Resuscitation/CPR
Check
One
When not in cardiopulmonary arrest, follow orders in B, C, and D
Treatment options when the person has pulse and/or is breathing.
B
Comfort measures only. Use medication, positioning, and other measures to relieve pain and suffering. Use
Check
oxygen, suction and manual treatment of airway obstruction as needed for comfort. Do not transfer to hospital
One
for life-sustaining treatment. Transfer only if comfort needs cannot be met in current location.
Limited Interventions. Includes care described above as necessary. Use medical treatment, IV fluids and
cardiac monitor as appropriate. Transfer to hospital if necessary. Avoid intensive care.
Trial of Intensive Therapy. Includes care described above. Time-limited trial of intubation, mechanical
ventilation and/or intensive care if medically indicated. Transfer to hospital and intensive care if necessary.
Full Treatment. Includes care described above. ACLS, intubation, mechanical ventilation or other advanced
airway interventions, and cardioversion as indicated. Transfer to hospital and intensive care if necessary.
Additional Orders:
Antibiotics
C
No antibiotics. Use other measures to relieve symptoms.
Check
Determine use or limitation of antibiotics when infection occurs, with comfort as goal.
One
Use antibiotics if medically indicated.
Additional Orders:
Artificial Nutrition (Always offer food by mouth first if feasible and medically appropriate).
D
No artificial nutrition.
Check
Time-limited trial of artificial nutrition.
One
Long-term artificial nutrition if medically indicated.
Additional Orders:
June 2011
Page 2 of 2
This MOST form must accompany person when transferred or discharged.
Alaska MOST Task Force
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