Source: http://regulations.delaware.gov/register/january2016/final/19%20DE%20Reg%20637%2001-01-16.htm
Timestamp: 2018-08-16 12:52:46
Document Index: 729799834

Matched Legal Cases: ['§2506', '§2503', '§2517', '§2511', '§2511', '§2503', '§2505', '§2511', '§2504', '§2507', '§707']

Delaware Health and Social Services ("DHSS") initiated proceedings to adopt the State of Delaware Medical Orders for Scope of Treatment (4304). The DHSS proceedings to adopt regulations were initiated pursuant to 29 Delaware Code Chapter 101 and authority as prescribed by 16 Del.C. §2506A.
On November 1, 2015 (Volume 19, Issue 5), DHSS published in the Delaware Register of Regulations its notice of proposed regulations, pursuant to 29 Delaware Code Section 10115. It requested that written materials and suggestions from the public concerning the proposed regulations be delivered to DHSS by December, 2015, after which time the DHSS would review information, factual evidence and public comment to the said proposed regulations.
Minor comments regarding grammatical and formatting issues were received that addressed observations made throughout the document. These changes have been made in the final document presented here where the recommended change did not result in a substantive change to the meaning or intent of the section affected. Corrections to spelling, grammar and other technical aspects of the final regulations are not addressed individually here, but are highlighted in the final regulations published in the January edition of the Delaware Register.
Comments from State Council for Persons with Disabilities and the Governor's Advisory Council for Exceptional Citizens
Comments on the proposed revisions to the DMOST Regulations were received from the Governor's Advisory Council for Exceptional Citizen's and the State Council for Persons With Disabilities. As the comments from both agencies were similar in scope and nature, they are addressed concurrently in this summary of evidence.
First, in the definition of "Advance health care directive", the definition seeks to clarify that Advance Health Care Directives (AHCDs) that are valid where executed are to be honored in Delaware. However, the regulatory definition adds the phrase "valid under Delaware law" to the statutory definition. This language suggests that the only out of state AHCDs that are recognized in Delaware are ones that are valid where executed and in Delaware. This requirement would prove unworkable and is inconsistent with the statutory language in 16 Del. Code §2503A(a) and of 16 Del. Code §2517, which plainly states that AHCDs valid where executed are honored in Delaware, whether they strictly comport to Delaware law or not.
The definition of Advance Health Care Directive has been revised for clarification that an AHCD is recognized in Delaware if it is recognized in the jurisdiction where it was executed.
Second, Section 4.7 addresses situations where a person has decision-making capacity but is unable to communicate by speaking or writing. In those circumstances, the person is allowed to communicate through the method by which they usually communicate, so long as the person interpreting understands that method. This must be documented in the medical record.
There is always a concern in these circumstances that the person interpreting is actually doing so and not substituting their own words or wishes. The requirement that there be a notation in the chart is a limited safeguard. However, it would be appropriate to add a requirement that there be a witness to this communication and that a health care practitioner has noted some indication of reliability regarding the ability of the interpreter to understand what is being communicated.
Additional documentation of the communication in these instances has been added to 4.7.2 to address these concerns.
In addition, this section does not and cannot eliminate the requirement under the Americans with Disabilities Act (ADA) or state law that a health care facility provide effective communication for individuals with communication impairments. This should be clearly stated in the regulation. It would be unfortunate for this regulation to be used to deny qualified interpreters when they are required and sanction the use of lay interpreters or family members, which is often inappropriate.
The existing requirement for facilities to provide effective communication to people with communication impairments is now stated in the regulation in 4.7.
SCPD and GACEC Comments on DMOST Form and Directions:
First, in the DMOST form, an "s" is needed in bullet 4 at the end of "measure."
Second, in Section E, it is unclear who is signing on the line to the immediate right. You have to check the directions to be sure.
Third, the line regarding whether an appointed representative can alter a DMOST should be set off in some fashion, either by bolding or by line. It gets lost in the rest of the box which is unfortunate since this is a very significant designation. The Division might consider using a yes/no box format or adding it to Box F.
An additional space has been added to help separate this line and make it clearer to the user of the form.
Comments from Stephen Kleiner, Esq., Kleiner & Kleiner, LLC
Ambiguities regarding revocation of Authorized Representative's authority to change or void the DMOST. Section E of the proposed DMOST form as shown in the proposed regulations, includes a line to provide the "Name of Authorized Representative," "Relation to Patient," "Address" and "Phone Number." Below that is a line stating, "[i]f lose capacity, my Authorized Representative may not change or void this DMOST," followed by a blank signature line identified as "Patient Signature."
From this form, it appears that the Division intends, pursuant to 16 Del.C. §2511A (c), that a patient may revoke a named authorized representative 's authority to void or create a new DMOST only by expressly limiting such authority as evidenced by the patient's signature.
However, the proposed regulations at 2.1.2.5 state that "Section E contains ... a signature block for the patient to authorize an authorized representative the ability to void the DMOST form and execute a new DMOST form that changes the treatment choices if the patient loses decision-making capacity." (emphasis added) Contrary to the aforesaid form and 16 Del.C. §2511A (c), this language implies that such authority is, by default revoked, and the patient's signature is required to authorize such powers of an authorized representative.
To avoid this ambiguity, I suggest that section 2.1.2.5 be changed to read as follows:
2.1.2.5 Section E contains information as to whom the DMOST form was discussed with and it contains a signature block allowing the patient to revoke an authorized representative's authority to void the DMOST form and execute a new DMOST form that changes the treatment choices if the patient loses decision-making capacity.
The section in question has been revised to address the concerns raised by this comment. The section has been revised for clarity to ensure the proper intent of the regulation is more evident.
Authority to sign the DMOST under existing Advance Health-Care Directives ("AHCD") for an agent under 16 Del. Code Ch. 25. The proposed regulations at 4.9.1 state "[t]he health-care practitioner shall determine if there is an individual who is the patient's authorized representative. This is determined by referencing the documentation giving such individual the required authority under law. The documentation should establish both that the authorized representative is the person named in this role and that the authorized representative has the authority to sign the DMOST form on behalf of the patient." (emphasis added) Similar language appears at section 4.9.2.2 of the proposed regulations.
While 16 Del.C. §2503A (1) requires only that the authorized representative "has the authority to make decisions with respect to the patient's health-care preferences being made on the DMOST form," the proposed regulations may be construed so as to require an express grant of authority to actually sign the DMOST form.
Many individuals have previously executed a statutory AHCD as provided at 16 Del.C. §2505, or by using the form provided by the Delaware Department of Health and Social Services at http://www .dhss.delaware.gov /dsaapd / files/ad vancedirective.pdf (last visited November 11, 2015). Without modification, neither of these forms expressly grant the agent the "authority to sign the DMOST form on behalf of a patient."
I suggest the language of the code be echoed in the proposed regulations, i.e. that the authorized representative have "the authority to make decisions with respect to the patient's health-care preferences being made on the DMOST form."
Clarifying language has been included in the final regulations.
Comments from Beverly Wik, Esq.
Some of the edits of the attached forms are grammatical errors, others make sure that the same word is used consistently for the same thing in the same sentence or section of the proposed Regulations (as in patient, person, and individual in the same section or sentence), cap and not cap words that used repeatedly in the proposed Regulations are consistent, and inserting "articles" (such as an, a, the, etc.) in a sentence. Articles should be included but are often omitted in this day of texting and email-speak. I realize these are minor in nature, but I feel that the regulations should be grammatically correct.
Thank you for the thorough review of the proposed document. While we do not individually respond to these all the suggested edits, we have considered the recommendations and made the necessary edits in the final regulations. Responses to individual edits:
AHCD Definition - Comments here were addressed by language revisions made in response to Mr. Kleiner's comments.
•	DMOST definition - This definition is taken largely from statutory language and only minor changes were made to existing text with one exception. The final statement was revised to read, The DMOST form is applicable across health-care settings, is reviewable, and [the patient controls if it] can be voided". The revised language was used to clarify the patient has control over voiding the form.
•	DMOST Form definition was revised to specify authorized representative in a case where a patient lacks decision making capacity.
•	Patient's Authorized Representative - comments on this section did not result in changes as the language used has been well-vetted with stakeholders and reviewers felt the existing statement was clear.
•	Serious Illness or Frailty - comments on this section did not result in changes as the language used has been well-vetted with stakeholders and reviewers felt the existing statement was clear.
•	2.1 - Comments suggesting "a form" be used did not result in revision. DHSS feels that adding the article would indicate that it is permissible to use any form, rather than the DHSS form that is required.
•	2.1.2.3.2 - Location is used as this language was carefully vetted and it refers to where the patient is. Setting could mean a different location but the same level of care.
•	3.1.6 - The proposed language was retained because it covers a broader scope of possible scenarios.
•	4.6 - comments on this section did not result in changes as the language used has been well-vetted with stakeholders and reviewers felt the existing statement was clear.
•	4.9 - comments on this section did not result in changes as the language used has been well-vetted with stakeholders and reviewers felt the existing statement was clear and the comment is further addressed by language added in 4.9.1
•	4.9.2 - comments on this section were addressed by changes to 4.9.1.
•	4.9.2.1 - comment on this section did not result in revisions as the language was well-vetted with stake holders and provides flexibility of language in considering an order from another jurisdiction.
•	4.10 - Language revised to address comment.
•	5.4 - Language revised to address comment.
•	8.3 - Comments on this section did not result in revisions as the language is well-vetted with stakeholders and DHSS feels it is adequate.
One pervasive problem is not using the hyphen in health care when "health care" is used as an adjective. When "health care" is used as an adjective it includes a hyphen and the DE Code for Advance Health-Care Directives consistently uses health-care when followed by Directive or "institution." When "health care" is used as a noun, then there is no hyphen, as in "the nurse provides health care to patients in the hospital."
After discussion within the Division of Public Health and review of the spelling and format of health care in statutes and other references, changes were made throughout these regulations. The final document consistently uses the accepted form, "health care" except when referring to "Advance Health-Care Directive" because that is the name of the legal document as stated in the statute.
Lastly, I am concerned about Reg subsection 4.9.2 on page 5 of the attached. That subsection repeatedly uses the phrase "only with the appropriate authority." I strongly feel that this phrase should be given some explanation and tied to the documentation giving a patient's authorized representative the required authority under law. Health-care practitioners may not understand what is required and what the committee intended in its lengthy discussions about the authority of authorized representatives. I fear that health-care providers may assume that all that needs to be evaluated is whether a person is the appointed representative having the highest priority.
Because such evaluation is only the first step in the evaluation of the authority of a patient's authorized representative, I suggest adding a subsection 4.9.3 that explains the second step of such evaluation, i.e., understanding what is meant by "with the appropriate authority." Below is a suggested additional subsection to follow subsection 4.9.2.
4.9.3 If an authorized representative is executing a DMOST form for a patient without decision-making capacity that directs that life-sustaining treatment be withheld or withdrawn from such patient, the documentation relied upon by the health-care practitioner to determine the authorized representatives authority should indicate that the authorized representative has the authority to make the specific decisions that such authorized representative is indicating on a DMOST form, specifically decisions that direct that life-sustaining treatment be withheld or withdrawn. This is required because an order appointing a guardian of the person may not authorized that life-sustaining treatment be withdrawn or withheld (this is authority that is not part of a guardian of the person's general authority unless indicated in the court order appointing the guardian or a further order addressing the administration of life-sustaining authority), a medical power of attorney may not authorize withholding or withdrawing life-sustaining treatments, or only authorize withdrawing or withholding of life-sustaining treatment, until there has been a determination that the patient has certain conditions that physicians must certify (that a patient is in a permanently unconscious state or is in a terminal state), and a surrogate under the Delaware Surrogate Statute does not have the authority to authorize withholding or withdrawing life-sustaining treatments unless again the patient has certain conditions that physicians must certify (is in a permanently unconscious state or is in a terminal state). In such instances, even if a DMOST form is signed by an authorized representative, the authorized representative will not have the "appropriate authority." Then action taken by health-care providers that rely upon a DMOST form signed by an authorized representative of a patient who does not have the appropriate authority could expose the authorized representative and the health-care providers to liability for improperly withholding or withdrawing life-sustaining treatment from a patient. In the event that a health-care practitioner is unsure as to whether an authorized representative has the appropriate authority, he or she should confirm the authority with the legal authorities of the patient and/or the authorized representative.
This comment is addressed by the change made to 4.9.1 in response to a similar comment from Mr. Kleiner.
Minor changes were made to the proposed regulations based on the comments received. The Department finds that the proposed regulations, as set forth in the attached copy should be adopted in the best interest of the general public of the State of Delaware.
THEREFORE, IT IS ORDERED, that the proposed State of Delaware Medical Orders for Scope of Treatment (4304) is adopted and shall become effective April 1, 2016, after publication of the final regulation in the Delaware Register of Regulations.
These DMOST regulations implement 16 Del.C. Ch. 25A which authorizes the Division of Public Health/Office of Emergency Medical Services, in conjunction with the Board of Medical Licensure and Discipline, the Delaware EMS Oversight Council, the Delaware State Fire Prevention Commission, and other key groups within the State to develop and implement DMOST regulations and protocol. These regulations, protocol, and form standardize documentation so that Emergency Medical Service (EMS) personnel and all health[-]care providers have a readily recognizable form which sets forth a patient’s preferences regarding the provision of and the scope of treatment. The DMOST form allows EMS personnel and other health[-]care providers both to identify and to honor an individual’s wishes to the greatest extent possible and to grant individuals the dignity, humanity, and compassion they deserve.
In order for EMS personnel to honor an individual’s request related to end-of-life decisions, the EMS provider must have a medical order. The DMOST form serves both as the summary of the individual’s advance health[-]care planning decisions and as the medical order.
"Advance [hH]ealth-[cC]are [dD]irective (AHCD)” means an [aA]dvance [hH]ealth-[cC]are [dD]irective under 16 Del.C. Ch. 25, a durable power of attorney for health[-]care decisions, or any individual instruction or power of attorney for health care valid under Delaware law [because it is valid] in the state where such document was executed or where the individual executing such document was a resident at the time that such document appointing an agent was executed. Said document must have been executed by the individual authorizing the appointed agent to make decisions about the individual's health care when such individual no longer has decision-making capacity.
“Decision-making capacity” means a patient's ability to understand and appreciate the nature and consequences of a particular health[-]care decision, including the benefits and risks of that decision and alternatives to any proposed health care treatment, and to reach an informed health[-]care decision.
“Delaware Medical Orders for Scope of Treatment (DMOST)” means a clinical process to facilitate communication between health[-]care professionals and a patient living with serious illness or frailty whose health[-]care practitioner would not be surprised if the patient died within the next year or, if the patient lacks decision-making capacity, the patient’s authorized representative. The process encourages shared, informed medical decision-making.The decisions are memorialized [in on] a completed DMOST form, which contains portable medical orders that respect the patient’s goals for care with respect to the use of CPR and other life-sustaining treatments and medical interventions. The DMOST form is applicable across health[-]care settings, is reviewable, and [the patient controls if it] can be voided.
Is used on a voluntary basis by a patient living with serious illness or frailty whose health[-]care practitioner would not be surprised if the patient died within the next year;
Is intended to provide direction to emergency care personnel regarding the use of emergency care and to health[-]care providers regarding the use of life-sustaining treatment by indicating the patient’s preference[s] concerning the scope of treatment, the use of specified interventions, and the intensity of treatment for each intervention;
Is intended to accompany the patient, and to be honored by all personnel attending the patient, across the full range of possible health[-]care settings, including but not limited to the patient’s home, a health[-]care institution, at the scene of a medical emergency, or during transport;
May be reviewed or voided at any time by a patient with decision-making capacity or, if the patient lacks decision-making capacity, the patient’s [authorized] representative in accordance with the provisions of 16 Del.C. §2511A; and
Must be signed by a health[-]care practitioner as defined below.
“Health[-]care institution” means an institution, facility, or agency licensed, certified or otherwise authorized or permitted by law to provide health care in the ordinary course of business.
“Health[-]care practitioner” means a physician or an individual licensed and authorized to write medical orders pursuant to 24 Del.C. Ch. 17 and Ch. 19 who is providing care for the patient or overseeing the health care provided to the patient and has completed all training required by the Department for individuals participating in the completion of a DMOST form. Over time, a patient’s health[-]care practitioner may change.
“Health[-]care provider” means an individual licensed, certified, or otherwise authorized or permitted by law to provide health care in the ordinary course of business or practice of a profession. A health[-]care practitioner is also a health[-]care provider.
“Patient” means an individual who is under the care of the health[-]care practitioner or health[-]care provider.
“Patient’s authorized representative” or “authorized representative” means the individual signing a DMOST form on behalf of a patient without decision-making capacity, who has the highest priority to act for the patient under law, and who has the authority to make decisions with respect to the patient’s health[-]care preferences being made on the DMOST form. The health[-]care practitioner shall determine the individual who is the patient’s authorized representative by referencing the documentation giving such individual the required authority under law. Based on the documentation provided by such individual as evidence of his or her authority, the patient’s authorized representative could be an individual designated by a patient under an advance health-care directive, an agent under a medical durable power of attorney for health[-]care decisions, a guardian of the person appointed pursuant to 12 Del.C. Ch. 39 or Ch. 39A, in accordance with the authority granted by the appointing court, a surrogate appointed under 16 Del.C. Ch. 25, or an individual who is otherwise authorized under applicable law to make the health[-]care decisions being made by execution of the DMOST form on the patient’s behalf, if the patient lacks decision-making capacity.
“Scope of treatment” means those medical interventions, procedures, medications, and treatments that a patient, in consultation with a health[-]care practitioner, has determined are appropriate, necessary, and desired by and for the patient and will always include the provision of comfort measures. A patient may decline life-sustaining treatment.
“Serious illness or frailty” means a condition for which a health[-]care practitioner would not be surprised if a patient died within the next year.
2.1	The DMOST [Ff]orm, including instructions for completion and plain language explanation, is published in these regulations. The DHSS documents in these regulations may not be altered.
2.1.2	The Scope of Treatment sections are Blocks A to [ED].
2.1.2.3.3	Full Treatment. Includes care described above, and use all appropriate medical and surgical interventions, including intubation, advanced airway interventions, mechanical ventilation, and cardioversion, in an intensive care setting if indicated to support life. Transfer to [a] hospital, if indicated, including intensive care.
2.1.2.5	Section E contains information as to whom the DMOST form was discussed with and it contains a signature block [for where] the patient [to authorize, if they have decision-making capacity, can prohibit] an authorized representative [from voiding] the [ability to void the] DMOST form and [execute executing] a new DMOST form that changes the treatment choices if the patient loses decision-making capacity.
2.1.3	The Signature [blocks]. Section F contains the signature areas for the patient/authorized representative/parent and the health[-]care practitioner. To be valid the form must have [all both] required signatures [in this block].
3.1.1	Contains information indicating the patient’s health[-]care preferences;
3.1.3	Contains a statement that the DMOST form is being signed after discussion with the patient, or if the patient lacks decision-making capacity, [with] the patient’s authorized representative;
3.1.4	Includes the signature of the patient’s health[-]care practitioner and the date and time of the health[-]care practitioner’s signature;
3.1.5	If the DMOST form is not signed by the heath-care practitioner in the presence of the patient, the DMOST form will also be signed by the health[-]care provider in whose presence the patient or, [if the patient does not have decision-making capacity,] the patient’s authorized representative [if the patient does not have decision-making capacity,] signed the DMOST form;
3.1.6	The DMOST form shall include a statement that the patient or, if the patient does not have decision-making capacity, the patient’s authorized representative, has been provided with the plain language [statement explanation] explaining the DMOST form, and the consequences of executing the DMOST form, including whether or not the DMOST form may be changed if the patient lacks decision-making capacity.
4.2	A DMOST form can only be used by a patient who is living with a serious illness or frailty whose health[-]care practitioner would not be surprised if the patient died within the next year.
4.3	The health[-]care practitioner must discuss the DMOST form directly with the patient, or if the patient lacks decision-making [capacity], [with] the patient’s authorized representative, prior to completion.
4.4	A DMOST form must be signed by a health[-]care practitioner.
4.7	The patient may have decision-making capacity but be unable to communicate by speaking or writing. [Federal and State laws require that a health care facility provide effective communication for people with communication impairments.] In such situations:
4.7.1	The patient can make his or her health[-]care treatment decisions known through any method by which the patient usually communicates so long as the person interpreting the communication understands the method by which the patient is communicating and the substance of the communication; and
4.7.2	The communication [and how it occurred must be witnessed by the health care practitioner. How the communication occurred and why it is considered reliable] must be documented in the patient’s medical record; and
4.7.3	If a patient cannot physically sign a DMOST form but has communicated that [they want he or she wants] to sign the DMOST form, someone other than the patient can sign the DMOST form on behalf of the patient.
4.9	If a physician determines a patient does not have decision-making capacity, this must be documented in the patient’s medical record. If an adult patient does not have decision-making capacity, an authorized representative may sign a DMOST form on behalf of the patient if the authorized representative has [the] legal authority to do so.
4.9.1	The health[-]care practitioner shall determine if there is an individual who is the patient’s authorized representative. This is determined by referencing the documentation giving such individual the required authority under law. The documentation should establish both that the authorized representative is the person named in this role and that the authorized representative has the authority to [sign make decisions with respect to the patient's health care preferences being made on] the DMOST form on behalf of the patient.
4.9.2	The hierarchy under Delaware [Ll]aw to act as the authorized[-]representative for [a person an individual] without decision-making capacity is as follows:
4.9.2.2	The patient’s most recently appointed Agent in an Advance Health[-]Care Directive or Health Care Power of Attorney, only with the appropriate authority;
4.9.2.3	If the there is no Guardian or Agent or if the designated Guardian or Agent is unavailable, or if the patient revoked an Advance Health[-]Care Directive pursuant to 16 Del.C. §2504, the Surrogate Statute applies and will allow either the individual named by the patient prior to losing decision-making capacity or if none, the individual recognized by the Surrogate Statute, 16 Del.C. §2507, to [act make decisions with respect to the patient's health care preferences being made on the DMOST form on behalf of the patient].
[4.10.1	In the absence of any legal activity to the contrary, biological parents and court-appointed guardians;
4.10.4	A caregiver acting under an Affidavit of Relative Caregiver under 13 Del.C. §§707 and 708.]
5.3	A patient with decision-making capacity[,] may, at any time, void his or her completed DMOST form or otherwise request alternative treatment to the treatment that was ordered on the DMOST form in any manner that indicates the patient’s intent to void the DMOST form.
5.4	If a patient does not have decision-making capacity, an authorized representative may void and/or request a new DMOST form, based on the known wishes of the [person patient], or if unknown, the [person’s patient's] best interest, if the authorized representative has the legal authority to do so and is [permitted to do not prohibited from doing] so on the existing DMOST form completed by the patient.
8.1	In the event of a disagreement between the patient’s authorized representative and the patient’s health[-]care practitioner concerning the patient's decision-making capacity or the appropriate interpretation and application of the terms of a completed DMOST form regarding the patient's course of treatment, the parties:
8.1.1	May seek to resolve the disagreement by means of procedures and practices established by the health[-]care institution, including, but not limited to, consultation with an institutional ethics committee, or with an individual designated by the health[-]care institution for this purpose; or
8.2	A health[-]care provider involved in the patient's care or an administrator of a health[-]care institution may seek to resolve a disagreement concerning the appropriate interpretation and application of the terms of a completed DMOST form to the patient's course of treatment in the same manner as set forth in 8.1.
8.3.1	If the treatment directives of a later Advance Health[-]Care Directive conflict with the patient's directives on a DMOST form, a health[-]care practitioner shall be informed so that the DMOST form can be modified or voided in order to reflect that patient’s later directive.
8.4.1	Is contrary to the most [recent recently] expressed wishes of a patient;
8.5	A health[-]care institution, health[-]care practitioner, or health[-]care provider acting in good faith and in accordance with generally accepted health[-]care standards applicable to the health[-]care institution, health[-]care practitioner, or health[-]care provider is not subject to civil or criminal liability or to discipline for unprofessional conduct for:
8.5.1	Complying with a DMOST form signed by a health[-]care practitioner apparently having authority to make a DMOST for a patient, including a decision to withhold or withdraw health care;
8.5.2	Declining to comply with a DMOST form based on a belief that the health[-]care practitioner then lacked authority to sign a DMOST;
8.5.5	Declining to comply with a DMOST form because the DMOST form is contrary to the conscience or good faith medical judgment of the health[-]care practitioner or the written policies of the health[-]care institution.
9.1	The Division of Public Health shall provide appropriate information, education and training on the DMOST [Program regulations] to EMS personnel.
9.3	The Division of Public Health shall take such measures as [are] necessary to assure individual confidentiality.
10.1	A DMOST [Ff]orm transfers with a patient and the medical orders indicated on a DMOST form are valid in every health[-]care setting in Delaware. Copies of a valid DMOST form are valid to the same extent as the original.
A. A DMOST form can be used by a person with a serious illness or frailty, whose health[-]care practitioner would not be surprised if [they the person] died within the next year.
A. These orders will be followed by health care providers in any setting (ambulance, long-term care facility, emergency room, hospital, hospice, home, assisted living facility, etc.). It travels with you and is honored when you move to a new [setting location].
A. You make health[-]care decisions for yourself as long as you have decision-making capacity. You have the right to change your authorized representative at any time while you have decision-making capacity.
If a physician determines that a person lacks decision-making capacity, an authorized representative can sign a DMOST form on behalf of that person. A DMOST form does not change the decision-maker designated by an Advance Health Care Directive, a Health Care Power of Attorney document, a guardian of [the] person appointed by a Court, or Delaware law on health care surrogates.
A. If your condition or your choices change, you or your authorized representative should void (cancel) your DMOST form and request a new DMOST be completed with your new choices. You can void a DMOST form if you change your mind but do not want to create a new one. You may not make any changes to the content of the DMOST form. If you want to change your DMOST form you must void your previous form and complete a new one with your health[-]care practitioner. If your DMOST form does not agree with your advance directive, the most recent document will be followed.
A. The DMOST form is always voluntary and can be voided at any time. A [Hh]ealth care organization is prohibited from requiring you to complete a DMOST form for any reason, including as part of a person’s admission to a health care facility.
It is important to understand that this [DMOST] form contains medical orders. It will be followed by health care providers. For example, if you choose “Do Not Attempt Resuscitation[,]”[,] and your heart stops, no attempt will be made to restart your heart. If you choose “Intubate/Use Artificial ventilation[,]”[,] then you may be placed on a breathing machine with a tube in your throat and transferred to an intensive care setting in a hospital.
A.	Many states, including all the states in our region, currently use a form similar to the DMOST form. Forms from those states which are valid under the Delaware [Ll]aw will be honored in Delaware. DMOST forms will be honored in other states which have reciprocity.
19 DE Reg. 637 (01/01/16) (Final)
http://regulations.delaware.gov/register/january2016/final/4304 DMOST Form.pdf