34-12H-4. MOST form--Contents. The secretary shall develop a standardized form for a MOST and instructions for completion of the form. The secretary shall make the form available to the public on the department's website. A completed form includes:

(1) The name and date of birth of the patient;

(2) A statement that the patient either has or does not have an advance health care directive;

(3) Information regarding the patient's diagnosis of a terminal condition;

(4) Information indicating the preference of the patient or the patient's authorized representative regarding the use of cardiopulmonary resuscitation, specified medical interventions, and the intensity of treatment for each intervention, and if there is no such indication of the patient or authorized representative's preference, a directive to health care providers to use all necessary and appropriate medical interventions;

(5) A provision directing the administration of artificial nutrition and hydration unless it is determined that:

(a) Artificial nutrition and hydration cannot reasonably be expected to prolong the patient's life;

(b) The burden of providing artificial nutrition and hydration outweighs its benefit, if the determination of burden refers to the provision of artificial nutrition and hydration itself and not to the quality of the continued life of the patient;

(c) Administering artificial nutrition and hydration would cause the patient significant discomfort; or

(d) The patient has expressed a desire not to receive artificial nutrition and hydration by tube;

(6) A statement confirming that the medical provider and the patient or the patient's authorized representative had a discussion about the patient's medical condition, treatment goals, and use of medical intervention;

(7) A statement confirming that the execution of the MOST by the patient or the patient's authorized representative is based on informed consent;

(8) A statement advising the patient that if there is a conflict between the MOST and the patient's written directives in any previously executed and unrevoked durable power of attorney or living will, the health care provider will treat the patient in accordance with the instructions in the MOST;

(9) The signature and date of signing of the patient or the patient's authorized representative;

(10) The signature and date of signing of the medical provider; and

(11) A statement that the duty of medicine is to care for patients even when they cannot be cured, that health care providers and their patients must evaluate the use of technology at their disposal based on available information, that judgments about the use of technology to maintain life must reflect the inherent dignity of the patient and the purpose of medical care, and that everyone is to be treated with dignity and respect.Source: SL 2019, ch 146, § 4.