6.3 Colorado MOST Form, Advance Directives, and End-of-Life Orders
Key Takeaways
- Colorado MOST (Medical Orders for Scope of Treatment) is a POLST-style medical order under C.R.S. 15-18.7, hosted by the CU Anschutz Center for Bioethics and Humanities.
- MOST is for people with serious life-limiting illness or advanced frailty — not for healthy people — and is voluntary; C.R.S. 15-18.7-108 forbids requiring it for admission or treatment.
- A valid MOST must be signed by the patient or legal decision-maker AND a physician, advanced practice nurse, or physician assistant. CNAs follow posted orders; they do not complete or sign as the authorizing provider.
- Copies, scans, and faxes are valid; the form is often copied on neon green paper and posted where staff and EMS can see it. Colorado has no electronic MOST registry yet.
- A living will, CPR directive, and medical durable power of attorney are not the same as MOST. Report a missing or conflicting MOST to the licensed nurse — do not guess.
6.3 Colorado MOST Form, Advance Directives, and End-of-Life Orders
Quick Answer: The Colorado Medical Orders for Scope of Treatment (MOST) form is a POLST-style medical order under C.R.S. 15-18.7. The program is hosted by the University of Colorado Anschutz Medical Campus Center for Bioethics and Humanities. MOST is for people with serious, life-limiting illness or advanced frailty, not for healthy people. It is voluntary. C.R.S. 15-18.7-108 says a facility may not require a MOST as a condition of admission or treatment. A valid form is signed by the patient or legal decision-maker and a physician, advanced practice nurse (APN), or physician assistant (PA). The CNA follows posted orders and does not complete or sign as the authorizing provider.
Why the CNA must know this form
NNAAP items on legal behavior and on dying clients ask who decides, what you follow, and what you never invent. In Colorado the answer is often a piece of paper that looks like a bright-green order set: CPR versus do-not-resuscitate (DNR), hospitalize versus comfort-in-place, and how much treatment to give. If that paper is posted, it is an order. If it is missing, conflicting, unsigned, or written for a healthy roommate “because admissions wants one on every chart,” you report to the licensed nurse. You do not guess. You do not start a MOST conversation as if you were the provider.
What MOST is — and who it is for
MOST is Colorado’s version of POLST (Physician / Portable Orders for Life-Sustaining Treatment). It turns a goals-of-care conversation into medical orders that travel across settings. Emergency medical services (EMS), emergency departments, and nursing-facility staff are expected to follow a valid MOST.
The official program is clear about the audience. MOST is intended for patients with serious, life-limiting conditions, including advanced frailty, who are at risk for a life-threatening event. It is a medical order based on the current condition of a declining person. Healthy people should not have a MOST. A provider should not help a healthy adult fill one out “just in case,” and a facility should not hand every new admit a blank MOST as if it were an intake form.
Completing a MOST is entirely voluntary. C.R.S. 15-18.7-108 states that a health-care facility shall not require a person to have executed a MOST form as a condition of being admitted or of receiving medical treatment. If admissions staff tell a family “we cannot take Mom until this is signed,” that statement is wrong. Report it to the licensed nurse. Do not pressure the family to sign so the bed can be filled.
Who signs — and who does not
A MOST is valid when both of these signatures are present:
- The patient, or the legal decision-maker if the patient no longer makes medical decisions.
- A physician, advanced practice nurse, or physician assistant.
The CNA is not the authorizing provider. You do not complete the checkboxes as if you were writing orders. You do not sign the provider line because “the doctor is off the unit and the family is waiting.” You do not witness your way into making the form valid. If someone asks you to “just finish this green sheet,” take the form to the licensed nurse.
The patient’s signature date and the provider’s signature date do not have to match, but a long unexplained gap is a reason for the provider to review the form — not a reason for the CNA to decide the form still “counts.” The original belongs to the patient. Providers should keep a copy. Copies, scans, and faxes are as valid as the original. The program recommends copying on distinctive neon green paper (the form names Astrobrights “Vulcan Green” or “Terra Green”); any color or white is still acceptable. Post the form where it can be seen — a residence refrigerator, the designated place in the chart or on the door — not in a safe-deposit box. Carry a copy when the person leaves home.
Colorado does not have an electronic MOST registry yet. EMS cannot look the form up in a statewide database. If the form is hidden, first responders will not know the orders exist. That is why posting and telling the family where the copy lives is part of making the order usable.
On admission to a new facility the existing MOST should be reviewed, not automatically replaced. Review dates go on the back of the form or on the supplemental review template. The CNA does not run that review. The CNA does report that a form arrived with the person, that staff cannot find it, or that two versions disagree.
MOST is not a living will
Families and exam stems mix four documents. Only one is an actionable medical order that EMS follows in the moment.
| Document | What it is | What the CNA does |
|---|---|---|
| MOST | POLST-style medical orders for a person who is already seriously ill or frail: CPR vs DNR, hospital vs comfort-in-place, treatment intensity, including avoiding ICU when that is the order | Follow the posted, valid orders. Do not complete or sign as the provider. Report missing or conflicting forms. |
| Living will | An advance directive about future treatment if the person is terminally ill or in a persistent vegetative state. It is not, by itself, an EMS order set. | Do not interpret a living will as a DNR order. Tell the nurse the document is present. |
| CPR directive | A Colorado document (and sometimes a bracelet or necklace) that directs whether to start CPR | Follow facility policy and the posted directive. If it conflicts with a MOST, get the nurse — do not pick a favorite. |
| Medical durable power of attorney (MDPOA) | Names an agent to make decisions when the person cannot | The agent may be the legal decision-maker who signs a MOST. The CNA still does not take verbal treatment orders from a family member who is not that agent. |
A blank section on a MOST is treated as maximum treatment in that section. That is a provider-and-patient problem to fix, not a CNA guess. If the family says “she would never want this” while a posted MOST says Attempt CPR, you follow the order you have and get the nurse. You do not withhold CPR because a daughter is crying, and you do not start extra treatment a DNR MOST forbids because a son just arrived from out of town.
If the person’s wishes change, the old form is marked VOID, signed and dated, and a new MOST is completed by the patient or decision-maker and the authorized provider. The CNA does not void a form. The CNA reports that the family is asking for a change.
What the CNA follows at the bedside
Posted MOST choices the exam cares about:
- Yes, attempt resuscitation (CPR) versus No, do not attempt resuscitation (CPR / DNR).
- Take me to the hospital versus I want to stay here if I can be comfortable (comfort-in-place).
- How much medical treatment to give, including limits such as avoid ICU.
If the person is in cardiac arrest and a valid, posted MOST says do not attempt CPR, you do not start compressions. If the form says attempt CPR, you call for help and begin the facility’s CPR process. If you cannot find the form, the form is unsigned, or two forms disagree, treat this as an emergency communication problem for the licensed nurse — do not flip a coin. Facility policy for an unwitnessed arrest when no valid order is available is a nurse-and-code-team decision. Your job is to summon help and say, clearly, that the MOST is missing or conflicting.
Dying clients, feelings, and clergy
Legal orders sit next to ordinary psychosocial care. A dying client may be angry, afraid, joking, silent, or suddenly spiritual. Allow the person to express feelings. Sit, listen, and report pain, new distress, or a request to see someone. Do not force clergy, a prayer, or a “you should make peace” speech. Do not change the subject because death makes you uncomfortable. Do not promise a cure. If the person asks for a chaplain, priest, rabbi, imam, or no visitor at all, report that request and honor it. Culture and religion belong to the client, not to the CNA’s preferences.
The same honesty rules from section 6.1 still apply. Do not chart that the resident was “resting comfortably” if the resident was grimacing. Do not post a bedside photo. Do not accept a deathbed cash gift.
Colorado scenario
You admit Mr. Padilla to a Denver skilled-nursing unit. He has advanced heart failure and marked frailty. Admissions tells the daughter, “Every new resident has to have a MOST before we can put him in the bed — just have the aide check the boxes.” In the suitcase you find two green forms. One, signed last year by Mr. Padilla and a physician, says Attempt CPR and hospitalize. A second, dated last month, signed only by the daughter, says Do Not Attempt CPR and comfort-in-place. The daughter asks you to “sign the new one so it’s official” and to hide the old one. Mr. Padilla is tired and says he does not want to talk about dying, then starts to cry.
Four rules fire at once. C.R.S. 15-18.7-108 forbids requiring a MOST for admission — you do not complete one to satisfy the clerk. You are not the authorizing provider, so you do not sign. Two versions in conflict means you report to the licensed nurse and leave both forms in the open; you do not guess and you do not hide the older order. While you wait for the nurse, you sit with Mr. Padilla, let him cry, and do not force a chaplain or a goals-of-care lecture. That is Colorado MOST plus ordinary end-of-life ethics in one admission.
Exam traps
- Treating MOST as a form every healthy adult should sign on admission.
- Believing a facility may require MOST under 15-18.7-108.
- Signing the provider line, or completing checkboxes, because the physician is busy.
- Assuming a living will or an MDPOA is the same as a DNR order.
- Guessing which of two MOST forms is “the real one.”
- Hiding the form, or forgetting that Colorado has no electronic registry yet, so a form no one can see cannot guide EMS.
- Forcing clergy or shutting down a dying client’s feelings.
Which statement about the Colorado MOST form is correct?
To be valid, a Colorado MOST form must be signed by whom?
You find two MOST forms in a resident’s drawer — one says Attempt CPR and one says Do Not Attempt CPR. What should the CNA do?