On February 20, 2025, Delaware’s newly established DMOST Steering Committee held its first meeting to begin carrying out its statutory mandate to study and improve implementation of the DMOST Act and make recommendations for statutory and regulatory improvements to the Act. I am honored to represent the Elder Law Section of the Delaware State Bar Association on the DMOST Steering Committee. This article explains what DMOST and the DMOST Steering Committee are and provides report from the first meeting.  

What is DMOST? 

DMOST is the acronym for Delaware’s statute, 16 Del. C. Chapter 25A, “Delaware Medical Orders for Scope of Treatment Act.” 

Let’s start with what DMOST is not.  

DMOST is not a health care power of attorney or advance directive, which are governed by a different statute, 16 Del. C. Chapter 25 (a new version of which replaces the current statute on September 30, 2025). Attorneys prepare health care powers of attorney and advance directives, or the statutory form can be used (though we do not recommend it). These documents appoint an agent to make a health care decision for you if you lack capacity and, if desired, express instructions for the care you wish your agent to select for you if you lack capacity. Anyone with legal capacity can sign these documents. No physician signature or counseling is required.  

DMOST is not a do not resuscitate (DNR) order, which is an order written by a physician, prohibiting resuscitation of a patient by health care professionals in the event of cardiac or respiratory arrest that ordinarily would require resuscitation efforts. Because the "DNR" is a physician's order (and prerogative), it cannot be incorporated into an advance directive document by the patient. The patient can, however, express his or her preference regarding resuscitation in an advance directive. A patient’s agent under an advance directive can request that a physician enter a DNR order.  

Enter POLST and Delaware’s DMOST.  

In an effort to standardize the use and understanding of DNR and similar orders, a number of states implemented a different approach to the withholding of life-sustaining treatment. The "Physician Orders for Life-Sustaining Treatment" (POLST) movement attempts to engage physicians and patients in discussion, understanding and commitment of the patient and medical community to honoring patient wishes on end-of-life care. The format of these various programs typically includes a standardized form (often with a distinctive color) addressing DNR orders, feeding tube placement, and antibiotics, among other treatment options. Details about the national POLST movement are reported online at http://www.polst.org.  

Delaware’s version of the POLST paradigm is called DMOST – Delaware Medical Orders for Scope of Treatment. 16 Del. C. Ch. 25A. The statute enacting DMOST was passed in May, 2015, which became effective in 2016. DMOST provides a single document that functions as an actionable medical order and transitions with a patient through all health care settings in order to clearly indicate their wishes for life-sustaining treatment and CPR.  

The DMOST is a process and is executed after discussion with the patient or the patient’s authorized representative. 16 Del. C. § 2509A (3). 

Therefore, DMOST is not a document one gets at an attorney’s office. One gets a DMOST at the physician’s office. 

DMOST is a process where the patient (or his or her authorized representative) and the Physician, Advance Practice Registered Nurse, or Physician Assistant together review the patient’s medical condition and titrate the directions for end-of-life care to the patient’s medical condition.  

DMOST cannot be executed by just any patient (or authorized representative). The patient must be a “living with serious illness or frailty whose health care practitioner would not be surprised if the patient died within the next year.” 16 Del. C. § 2503A.  

One must use the standard form required by statute, unlike a health care power of attorney or advance directive which statutory form is optional. The DMOST form is promulgated by State regulation. 16 Del. C. § 2505A; 16 DE Admin. Code 4304, 4.5: “Only the DMOST form in these regulations, which contains a watermark, can be recognized as a DMOST form.” 

The DMOST is revocable by the patient (and even by his or her authorized representative if the patient lacks capacity) because under constitutional law one has a right of self-determination.  

DMOST is to be posted in a person’s home in a prominent place and travel with the patient from home through all health-care settings. DMOST is also to be saved to central repository that any health-care setting can access.  

What is the DMOST Steering Committee? 

The DMOST Steering Committee was created as part of Senate Bill No. 195, which became effective September 26, 2034. The new legislation amended the DMOST Act to establish a DMOST Program at the at the Department of Health and Social Services (“DHSS”) and a DMOST Steering Committee to address shortcomings in DMOST and its implementation.  

The Bill Synopsis noted the DMOST is being underutilized, despite efforts by advocates and the creation of a statewide, electronic registry for DMOST forms hosted by the Delaware Health Information Network (DHIN).  

In the original 2016 DMOST Act, there was no fiscal note for a DMOST Coordinator employment position or for education programs.  

To remedy this, with Senate Bill No. 195 came a Fiscal Note authorizing a full-time DMOST Coordinator position within DHSS and establishing a $50,000 annual contractual funding for education programs.  

As part of program coordination, the DMOST Coordinator will oversee the maintenance of a new website and will be responsible for working with DHIN to maintain an electronic registry.  

As provided in the Bill Synopsis, the new legislation expands on DHSS’s current DMOST responsibilities to include: 

1. Providing ongoing education and training for health-care practitioners and providers, emergency care providers, patients, and their families. 
2. Maintaining a website for information and education about DMOST. 
3. Working with the DHIN to maintain the electronic registry. 
4. Coordinating with the National POLST Collaborative regarding current best practices and research.  
5. Creating an 11-member DMOST Steering Committee, consisting of a broad group of stakeholders, to evaluate and improve the DMOST Program and use of DMOST forms. The DMOST Steering Committee must produce an annual report containing data about: a) the use of DMOST forms, b) trainings, c) public education and outreach, and d) current challenges and recommendations to improve the DMOST Program.  

New Section 2521A of the DMOST Act creates the DMOST Steering Committee to support implementation of the DMOST program and make recommendations to improve implementation.  

The Committee is comprised of the following 11 members, or a designee selected by the member serving by virtue of position, and shall meet not less than once every 4 months:   

(1) The President, Delaware Quality of Life Coalition, who serves as chair. 

(2) The Secretary of DHSS. 

(3) Chief Executive Officer, Delaware Health Information Network. 

(4) The Delaware representative to the National Physician Orders for Life-Sustaining Treatment Coalition. 

(5) The Long-Term Care Ombudsperson under subchapter VI of Chapter 11 of Title 16. 

(6) The Executive Director, Delaware State Fire Prevention Commission. 

(7) The Chief Executive Officer, Delaware Healthcare Association. 

(8) The Executive Director, Delaware Health Care Facilities Association. 

(9) The Chair, Elder Law Section, Delaware State Bar Association. 

(10) One member representing a health-care insurance provider, appointed by the Secretary. 

(11) One member of the public, appointed by the Secretary of DHSS. 

What are the DMOST Steering Committee Goals? 

The Committee’s goals are articulated in new Section 2521A(d). The Committee shall produce an annual report, published on the DMOST Program website, that includes all of the following:  

(1) Data regarding all of the following: 

a. The number of DMOST forms in the electronic registry. 

b. How often the electronic registry is consulted by health-care providers. 

c. Use of DMOST forms by emergency-care providers. 

(2) Information about trainings provided to health-care practitioners, health-care providers, and emergency-care providers. 

(3) Public education and outreach efforts. 

(4) Current challenges and recommendations to improve the DMOST Program and the use of DMOST forms.

Report from First Meeting of the DMOST Steering Committee 

The first meeting of the DMOST Steering Committee was held in hybrid format in person at the Herman M. Holloway Sr. Health and Social Services Campus and virtually. Led by Dr. Sarah Matthews, M.D., at the meeting the following topics were covered: 

1. Overview of the DMOST program and SB 195. 
2. Vendor Support. Vendor contracts will be needed for education and awareness.  
3. DMOST Coordinator. The DHSS internal approval process for creation of the new position is underway, and until completed, two individuals working within DHSS will perform the DMOST Coordinator position.  
4. DHIN and Electronic Registry. DHIN maintains the registry but few health care providers use it. This is a serious hurdle to DMOST’s purposes and a core mission of the Steering Committee to resolve. DHIN seeks connection to the larger health care system. 
5. DMOST Form:  
6. Updates to form. The Committee will study forms that are successful in other states to consider changes to our form. One issue is non-English translations. A broader, deeper issuer is readability and understandability for all involved. A specific issue relates to Part E of the DMOST form which permits an Authorized Representative (a term undefined in the DMOST form itself) to complete and sign the DMOST form on behalf of the patient. There is confusion over this provision. For these and other reasons, the Committee is considering aligning the form more to the national POLST form which has been updated in the last few years. The Committee will review, and considering shifting to, the more modern national POLST form. Changing the form requires not a statutory change but a regulation change, as in the original 2016 legislation the drafters took the form out of the statute and put it in the regulations just for this purpose – ease of updating.  
7. Coordination with Emergency Medical Service Personnel. The DMOST form is to be in a pink envelope posted on the patient’s refrigerator or bed so the EMS professionals can see it. However, when EMS responds to a call away from someone’s home – such as a car accident – that envelope is back at the home. This is why the registry is needed with EMS access to it. 
8. Interoperability with acute care systems. This is a major obstacle to DMOST implementation. Each acute care system in Delaware has its own DMOST registry. This means when one travels to a different health system, that DMOST is trapped back in the former system’s registry. Likewise, DMOST forms often do not travel out of the health care system back to the patient’s home post-discharge. Importantly, this issue is not limited to acute care settings. A process and registry are needed for Long-Term Care Facilities and In-Home providers to use and access.  
9. Education and Awareness. These are necessary for DMOST implementation as lack of awareness and misinformation abound not only among consumers but in the health care industry.  
10. Data Collection. This is necessary to track and report progress in the Committee’s efforts.  

What Comes Next? 

At least for now, the DMOST Steering Committee is meeting monthly to get a good start on the substantial work to be done. The next meeting is scheduled for March 20, 2025 at 3:00 p.m., which is public, and posted with information to attend in-person or virtually (should you wish to attend), at the State of Delaware Public Meeting Calendar: https://publicmeetings.delaware.gov/#/meeting/81703.  

At the first meeting, the Committee noted the significant changes in the new Uniform Health-care Decisions Act (2023), which goes into effect September 30, 2025, and asked its effect on the DMOST Act, particularly as to the capacity to make a DMOST. I will be presenting on this important topic at the March 20 meeting.