Understand Medical Orders for Scope of Treatment (MOST) in BC, Canada
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Medical Orders for Scope of Treatment is known by its acronym, MOST (known as ‘Code Status’ in Providence Health) and are medical orders for the level of resuscitation and treatment in hospital, residential care, or palliative care and hospice.
In Canadian provinces other than BC, these orders are called ‘Goals of Care’ (a more logical term), and in the U.S., they are called MOLST or POLST. They are all basically the same: five or six levels of treatment defining if the patient wants or is an appropriate candidate for CPR, being put on a ventilator, and admission to ICU, or they frail and in a health decline and admission to ICU is no longer appropriate.
Ultimately, MOST orders are to reduce unwanted, unwarranted, or futile treatment.
A quick but important note… There is a difference between treatment and care:
“Care” is generally ‘nursing care’ and is a part of every Level:
• Pain management
• Turning and skin care
• Nutrition
“Treatments” are generally ‘physician orders’ to improve, maintain and prolong life. Treatments become less intensive as we move down the Levels of Care.
A little history about the advent of MOST
Up until a few years ago, when a doctor came into the hospital and saw one of their patients who had expressed the wish not to have CPR, the doctor would scribble across an order sheet, “DNR!” Those of us on the healthcare team wouldn’t know what that meant for our patient: do we keep providing treatment up until the point of cardiac arrest, or do we stop treatment now? (I vividly remember chasing doctors down the hall to clarify this.) MOST has made these conversations and decisions more intentional.
Because the public doesn’t understand (or have never heard of) MOST orders, there is a great deal of misunderstanding about resuscitation and levels of care, and that affects the decisions they make about the care they would – and would not – want to receive.
Mary is 78 years old and had developed life-threatening blood clots after a hip replacement. She was in the ICU for almost a month. She received exemplary care and is now leading a fully functional life. In our discussion about her current Letter of Wishes, she said, “If I had asked for No CPR last time, I’d be dead now.” I asked her if she had gone into cardiac arrest, and she said, “No, but if I’d said I didn’t want it, they would have thrown in the towel, and I wouldn’t have been admitted to ICU at all.”
Mary’s confusion and misunderstanding are common. Even if you don’t want to have CPR or to be put on a ventilator, you can consent to be transferred to critical care or intensive care for more advanced treatments and care… if your condition warrants it. And that is precisely what Mary had received.
If you have an Advance Directive (or Letter of Medical Wishes or Living Will), it will be used in conjunction with MOST to facilitate conversations and decisions. Your Advance Directive or Letter of Wishes will likely include your values and beliefs and other instructions, so it is meant to be paired with MOST orders. MOST orders do not replace an Advance Directive or Letter of Wishes.
A note of clarification from Providence Health
We discourage suggesting an Advance Directive unless the adult is offering the caveat that the instructions are ‘enduring’ and would not change. For example: never a blood transfusion for religious reasons; never CPR or ICU because I am ready to die a natural death; or never an antibiotic because I do not believe in them.
MOST orders are generally used in the hospital setting, residential care, palliative and hospice care (in the home or a facility). (Except for Island Health), they are not meant for the public, living in the community and not receiving ongoing community health services.
Special notes regarding MOST in acute care
· If you do not want CPR, be proactive and start the conversation. Often, the best person to speak with is the unit Social Worker.
· Too often, MOST is not discussed with the patient or Substitute Decision Maker until a time of crisis, and compassionate conversation is no longer a priority.
Special notes about MOST in Residential Care
· Assigning a MOST level is mandatory upon admission to Assisted Living or Long-Term Care. However, this decision is often made with a Substitute Decision Maker and a Nurse rather than the adult (as they often have cognitive issues), and rarely with a doctor. If you do not understand the information, ask to speak with the facility doctor before deciding and signing.
· Do not feel pressured to decide on Level M1 or M2 (see below). Your loved one may benefit from going to the hospital for testing, IV antibiotics, or blood products.
Special notes about MOST in Palliative Care and Hospice (home or facility)
· Palliative Care = Pain & Symptom Management. It does mean that the adult has a life-limiting or life-ending illness, but it does not necessarily mean that the adult is nearing end-of-life (even though the term is often misused). It is appropriate to be at an M2 or M3 level (see below) while receiving palliative care.
· Hospice Care means end-of-life, comfort care only. To qualify for hospice at home or in a facility, you (or your substitute decision maker) should consent to withdrawal of treatment (M1).
Important note about the wording on MOST forms
Definitions vary slightly from one health authority to another. The following definitions are a general version. It is important to read the actual MOST form you are being asked to sign… and ask questions!
The terms used in the following levels of care can be daunting, and to put them entirely in lay language would make the definitions cumbersome. For a more thorough understanding, See Understand Resuscitation & No Cardiopulmonary Resuscitation (No CPR) and Understanding Terms Used in Resuscitation.
MOST/Code Status – two divisions
‘Critical Care’ = ‘C’; and
“Medical Care’ = ‘M’.
Each has three levels.
Critical Care does not necessarily mean you will be transferred to a critical care or intensive care unit in an acute care hospital. Still, it does mean the option is open should you need more intensive treatment and observation. It means that should you need it, you will be given treatments such as blood products, tube feeding, dialysis, and oxygen therapy. Often, the patients who need this increased care and observation the most are the elderly and frail.
If you do not want any or all of these ‘heroic’ measures, even in the short term, you must take the initiative, discuss with your healthcare team, and strongly consider writing an Advance Directive.
If you are willing to have any or all these advanced treatments but would want them stopped if you were not going to recover to the extent that is acceptable to you, it is also important that you write this in an Advance Directive or Letter of Wishes for Medical Care and present it at every point of healthcare.
A Detailed Look Medical Orders for Scope of Treatment Levels
MOST: Critical Care
Highest Level: Attempt Resuscitation (CPR), including ventilation, maximal therapeutic support, treatment, and transfer to critical care. All patients are presumed to be at the highest level of care, including CPR, unless they have discussed it with a medical practitioner, and either a No CPR or a MOST order (with No CPR selected) has been signed.
This level is for those who are relatively healthy and want full resuscitation. Everything will be done to save your life. You will be transferred to the ICU, and you will most likely need to be put on a ventilator. You will probably have multiple intravenous (IV) lines and receive multiple medications, including antibiotics, and artificial nutrition might be essential to your recovery.
C1/Option 5: Do not perform CPR, but allow mechanical ventilation – transfer to critical care.
Everything will be done to save your life except CPR. You will be transferred to the ICU, and you may be put on a ventilator. You will likely have multiple intravenous (IV) lines and receive multiple medications, including antibiotics, and artificial nutrition might be essential to your recovery. You may require tube feeding (because nutrition is essential for healing), and you may need kidney dialysis during your recovery (but kidneys often bounce back).
C2/Option 4: Do not perform CPR, do not perform mechanical ventilation, but allow supportive respiratory therapies* and allow transfer to critical care.
These levels are for those who may want the option of admission to ICU or CCU and want or need all medical care – but who do not wish to do CPR and may not want mechanical ventilation but who would accept other forms of advanced treatment.
Even if you don't want CPR or to be on a ventilator, it’s important to consider the need for transfer to critical care in a case where extra vigilance and care are required after a serious injury, illness, or surgery, even for those of advancing age and frailty.
*Supportive respiratory therapies include regular oxygen (by mask or nasal prongs), high-flow oxygen, CPAP and BiPAP (see definitions). Note that oxygen is considered ‘comfort care,’ even for those at end-of-life. It does not prolong life for those who are actively dying but reduces the uncomfortable feeling of air hunger.
MOST: Medical Care
(M3)/Option 3: Medical Care without transfer to critical care: Do not perform CPR or any resuscitation: Symptom Management & Transport to Hospital (if you’re not already there) for a higher level of care.
This level is for those with significant health issues or frailty where admission to the ER or hospital for treatments and medications will maintain their current level of health. These patients may be living at home, may be receiving palliative care, or in residential care.
Admission to the hospital might be considered for those who need a more rigorous evaluation than they can receive in the community (x-rays and bloodwork), blood transfusions for low hemoglobin, or IV antibiotics for infections such as urinary tract infections or pneumonia.
(M2)/Option 2: Approaching End-of-Life: Do not perform CPR or any resuscitation: Symptom Management and Supportive Care only. Do not transfer to a higher level of care (hospital/critical care).
This level is for those with increasing health issues or frailty nearing the end of life. This is often appropriate for those in residential care or receiving palliative care. The goal is conservative management of medical conditions with specific short-term, symptom-directed treatment. It will allow medications, such as oral antibiotics, to be given.
(M1)/Option 1: End-of-Life: Do not perform CPR or resuscitation: Symptom Management and Supportive Care Only.
This Level is for those who are at the natural end of life or who have a life-ending disease and no longer want treatment but to maximize comfort care and symptom control at the end of life.
