Survey Code__________
Documenting Patient Goals and Preferences:
Understanding the Experiences of Physicians and Nursing Home Staff
NC MOST Health Care Provider Survey
__________________________________________________________________________________________
University of North Carolina-Chapel Hill
IRB Study #
Principal Investigator: Anthony J. Caprio, MD
Co-Investigators: Tori Rollins, BS; Laura Hanson, MD, MPH; Ellen Roberts, MPH, PhD
Study Contact telephone number: 919-966-5945 ext. 281
Study Contact email: acaprio@med.unc.edu
__________________________________________________________________________________________
The purpose of this research study is to learn about your experience using standardized forms to document and
communicate patient goals and preferences for medical care if a patient becomes seriously ill or is dying. We
are also interested in learning different ways in which physicians, nurses, and other health care professionals
can communicate more effectively with families about making medical decisions for a loved one in a long-term
care facility (nursing home). You are being asked to be in the study because you regularly care for older adults
in a long-term care facility (nursing home).
Please review the enclosed study information fact sheet. If you agree to participate in this research study,
please complete the following survey by checking the appropriate box or boxes. You should complete this
survey before your interview.
1.) Please describe your role as a health care professional:
 Physician
 Nurse Practitioner
 Nurse
 Social Worker
 Nursing Home Administrator
 Other_______________________________________________________________________
2.) How do you describe your racial or ethnic identity? (Check all that apply)
 Hispanic or Latino
 American Indian or Alaska Native
 Asian
 Native Hawaiian or Other Pacific Islander
 Black or African American
 White or Caucasian
3.) Are you familiar with the Medical Orders for Scope of Treatment (MOST) form?
 NO
 YES
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Survey Code__________
Please read the following brief description of the MOST form and see the enclosed sample form:
Medical Orders for Scope of Treatment (MOST) form is an optional, bright pink, portable medical
order used in North Carolina to document patient preferences for end-of-life care. Section A of the
MOST form elicits instructions for cardiopulmonary resuscitation. Section B of the MOST outlines the
scope of medical treatment for a patient who is not experiencing cardiopulmonary arrest. This section of
the MOST form outlines 3 types of care: Full Scope of Treatment, Limited Interventions, and Comfort
Measures. The MOST form also allows patients to specify their wishes for other medical treatments if
they are seriously ill or dying, including orders to provide or withhold antibiotics, and medicallyadministered fluids or nutrition.
4.) Have you used the MOST form in clinical practice? [Check all that apply]
 NO, I have never used the MOST form in my clinical practice
 YES, I have completed a MOST form with a patient/family
 YES, I cared for a patient who had a completed MOST form, but I did not personally complete the form
5.) When would you consider using the MOST form? [Check all that apply]
 At the time of nursing home admission
 During routine care planning meetings
 After change in health status
 After a hospitalization
 With Hospice enrollment
 When asked by the patient or family
 When asked by other staff
 Other_______________________________________________________________________
6.) When do you believe is the most important time to complete the MOST form?
[Select one]
 At the time of nursing home admission
 During routine care planning meetings
 After change in health status
 After a hospitalization
 With Hospice enrollment
 When asked by the patient or family
 When asked by other staff
 Other_______________________________________________________________________
7.) When do you believe it is appropriate to complete a MOST form? [Check all that apply]
 Only after a physician has a specific discussion about goals of care and medical treatments with
the patient/family
 After a nurse practitioner has a discussion about goals of care and medical treatments with the
patient/family
 After a social worker has a discussion about goals of care and medical treatments with the
patient/family
 Based on a patient’s living will or other prior written directives, but in the absence of a
discussion with the patient or family
 Based on medical judgment about prognosis and appropriate treatment, but in the absence of a
discussion with the patient or family
 Other_______________________________________________________________________
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Survey Code__________
8.) How often do you have to review and renew (sign) a MOST form? [Check all that apply]
 Annually
 Whenever the patient is admitted or discharged from a health care facility
 Whenever there is a substantial change in clinical status
 Whenever treatment preference change
 Other_______________________________________________________________________
9.) What is the best way to use the MOST form during discussions with patients or their families?
[Check one]
 I would ask the patient or family to review the form before our discussion
 I would use the form during our meeting to discuss goals and treatments
 I would use the form after our discussion to document treatment decisions
 I would give the form to someone else to review with the family
 Other_______________________________________________________________________
10.) What are some of the barriers that might prevent you from using the MOST form?
[Check all that apply]
 Time-consuming
 Redundant (duplicate paperwork)
 Too vague
 Difficult to match resident goals with a particular scope of treatment
 Concerned about liability or responsibility
 Other_______________________________________________________________________
11.) Please use the following scale to rate how the MOST form might change communication about a
patient’s goals and treatment preferences:
Improve a lot ----- Improve Somewhat ----- Worsen Somewhat ----- Worsen a lot ----- No Effect
Communication
Between physicians and/or nurse practitioners
Improve
a lot
Improve
Worsen
somewhat somewhat
Worsen
a lot
No effect
Between physicians and nursing staff
With an on-call or covering physician
Between hospital and nursing home
Between physicians and patients/families
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Survey Code__________
12.) What is your greatest concern about the use of the Medical Orders for Scope of Treatment (MOST)
form in clinical practice? [Select one]
 Takes too long to complete
 Undermines patient autonomy
 Forms will get lost
 Forms will not be filled-out properly
 Patients/families will not understand the forms
 Physicians will not follow the instructions on the forms
 No concerns
 Other_______________________________________________________________________
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