83R7903 JSC-D
By: Klick H.B. No. 1455
A BILL TO BE ENTITLED
AN ACT
relating to in-hospital and out-of-hospital do-not-resuscitate
orders and advance directives; providing a criminal penalty.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 166.002, Health and Safety Code, is
amended by adding Subdivision (16) to read as follows:
(16) "Reasonable medical judgment" means a medical
judgment that would be made by a reasonably prudent physician,
knowledgeable about the case and the treatment possibilities with
respect to the medical conditions involved.
SECTION 2. The heading to Subchapter C, Chapter 166, Health
and Safety Code, is amended to read as follows:
SUBCHAPTER C. OUT-OF-HOSPITAL AND IN-HOSPITAL
DO-NOT-RESUSCITATE ORDERS
SECTION 3. Section 166.081, Health and Safety Code, is
amended by adding Subdivision (5-a) and amending Subdivision (6) to
read as follows:
(5-a) "In-hospital DNR order":
(A) means an order placed in a patient's medical
file that complies with the requirements of Sections 166.0855 and
166.0856 and that directs health care professionals in a hospital
setting not to initiate or continue the following life-sustaining
treatment:
(i) cardiopulmonary resuscitation;
(ii) advanced airway management;
(iii) artificial ventilation;
(iv) defibrillation;
(v) transcutaneous cardiac pacing; and
(vi) other life-sustaining treatment
specified by the board under Section 166.101(a); and
(B) does not include authorization to withhold:
(i) medical interventions or therapies
necessary to provide comfort care or to alleviate pain; or
(ii) fluids or nutrition, including fluids
or nutrition by mouth or by nasogastric tube or artificial
nutrition and hydration.
(6) "Out-of-hospital DNR order":
(A) means a legally binding out-of-hospital
do-not-resuscitate order, in the form specified by the board under
Section 166.083, prepared and signed in accordance with Section
166.082, 166.084, or 166.085 [by the attending physician of a
person], that documents the instructions of a person or the
person's legally authorized representative and directs health care
professionals acting in an out-of-hospital setting not to initiate
or continue the following life-sustaining treatment:
(i) cardiopulmonary resuscitation;
(ii) advanced airway management;
(iii) artificial ventilation;
(iv) defibrillation;
(v) transcutaneous cardiac pacing; and
(vi) other life-sustaining treatment
specified by the board under Section 166.101(a); and
(B) does not include authorization to withhold:
(i) medical interventions or therapies
[considered] necessary to provide comfort care or to alleviate
pain; or
(ii) fluids [to provide water] or
nutrition, including fluids or nutrition by mouth or by nasogastric
tube or artificial nutrition and hydration.
SECTION 4. Subchapter C, Chapter 166, Health and Safety
Code, is amended by adding Sections 166.0855 and 166.0856 to read as
follows:
Sec. 166.0855. DNR ORDERS APPLICABLE IN-HOSPITAL. An
in-hospital DNR order is valid only if it is issued in compliance
with:
(1) the directions of the patient, if competent, given
orally or otherwise;
(2) the directions in an advance directive issued in
accordance with Section 166.005 or 166.032;
(3) the directions of the patient's legal guardian or
agent under a medical power of attorney;
(4) a treatment decision made in accordance with
Section 166.039; or
(5) a reasonable medical judgment that the patient's
death is imminent within minutes to hours even if cardiopulmonary
resuscitation is provided.
Sec. 166.0856. FORM OF IN-HOSPITAL DNR ORDER; PROCEDURE.
(a) A written in-hospital DNR order shall be in the standard form
specified by board rule as recommended by the department.
(b) A written in-hospital DNR order may be executed based on
the oral instructions of a person provided the order complies with
Section 166.0855.
(c) An in-hospital DNR order by a physician must be in
writing and comply with the requirements of Section 166.0855.
SECTION 5. Sections 166.086 and 166.087, Health and Safety
Code, are amended to read as follows:
Sec. 166.086. DESIRE OF PERSON SUPERSEDES OUT-OF-HOSPITAL
OR IN-HOSPITAL DNR ORDER. The desire of a competent person,
including a competent minor, supersedes the effect of an
out-of-hospital or in-hospital DNR order executed or issued by or
on behalf of the person when the desire is communicated to
responding health care professionals as provided by this
subchapter.
Sec. 166.087. PROCEDURE WHEN DECLARANT IS INCOMPETENT OR
INCAPABLE OF COMMUNICATION. (a) This section applies when a person
18 years of age or older has executed or issued an out-of-hospital
or in-hospital DNR order and subsequently becomes incompetent or
otherwise mentally or physically incapable of communication.
(b) If the adult person has designated a person to make a
treatment decision as authorized by Section 166.032(c), the
attending physician and the designated person shall comply with the
out-of-hospital or in-hospital DNR order.
(c) If the adult person has not designated a person to make a
treatment decision as authorized by Section 166.032(c), the
attending physician shall comply with the out-of-hospital or
in-hospital DNR order unless the physician believes that the order
does not reflect the person's present desire.
SECTION 6. Section 166.092, Health and Safety Code, is
amended by amending Subsections (a) and (b) and adding Subsections
(b-1) and (d) to read as follows:
(a) A declarant or another person may revoke an
out-of-hospital DNR order at any time without regard to the
declarant's mental state or competency. A patient or another person
may revoke an in-hospital DNR order at any time without regard to
the patient's mental state or competency. An order may be revoked
by:
(1) the declarant or patient or someone in the
declarant's or patient's presence and at the declarant's or
patient's direction destroying the order form and removing the DNR
identification device, if any;
(2) a person who identifies himself or herself as the
legal guardian, as a qualified relative, or as the agent of the
declarant or patient having a medical power of attorney [who
executed the out-of-hospital DNR order] or another person in the
person's presence and at the person's direction destroying the
order form and removing the DNR identification device, if any;
(3) the declarant or patient communicating, orally or
in another manner, the declarant's or patient's intent to revoke the
order; or
(4) a person who identifies himself or herself as the
legal guardian, a qualified relative, or the agent of the declarant
or patient having a medical power of attorney [who executed the
out-of-hospital DNR order] orally stating the person's intent to
revoke the order.
(b) An oral revocation under Subsection (a)(3) or (a)(4) of
an out-of-hospital DNR order takes effect only when the declarant
or patient or a person who identifies himself or herself as the
legal guardian, a qualified relative, or the agent of the declarant
or patient having a medical power of attorney [who executed the
out-of-hospital DNR order] communicates the intent to revoke the
order to the responding health care professionals or the attending
physician at the scene. The responding health care professionals
shall record the time, date, and place of the revocation in
accordance with the statewide out-of-hospital DNR protocol and
rules adopted by the board and any applicable local out-of-hospital
DNR protocol. The attending physician or the physician's designee
shall record in the person's medical record the time, date, and
place of the revocation and, if different, the time, date, and place
that the physician received notice of the revocation. The
attending physician or the physician's designee shall also enter
the word "VOID" on each page of the copy of the order in the person's
medical record and enter and note the revocation in all relevant
electronic medical records of the patient.
(b-1) An oral revocation under Subsection (a)(3) or (a)(4)
of an in-hospital DNR order takes effect only when the patient or a
person who identifies himself or herself as the legal guardian, a
qualified relative, or the agent of the patient having a medical
power of attorney communicates the intent to revoke the order to a
health care professional at the hospital. The health care
professional shall record the time and date of the revocation. The
attending physician or the physician's designee shall record in the
person's medical record the time and date of the revocation and, if
different, the time, date, and place that the physician received
notice of the revocation. The attending physician or the
physician's designee shall also remove the order from the person's
physical and electronic medical record.
(d) If a health care professional fails to comply with a
revocation under Subsection (a), the declarant or patient, the
legal guardian, a qualified relative, or an agent of the declarant
or patient having medical power of attorney may obtain an
injunction to enforce the revocation.
SECTION 7. The heading to Section 166.096, Health and
Safety Code, is amended to read as follows:
Sec. 166.096. HONORING OUT-OF-HOSPITAL OR IN-HOSPITAL DNR
ORDER DOES NOT CONSTITUTE OFFENSE OF AIDING SUICIDE.
SECTION 8. Section 166.097, Health and Safety Code, is
amended by adding Subsection (c) to read as follows:
(c) A person other than the declarant or patient commits an
offense if the person knowingly executes an out-of-hospital or
in-hospital DNR order that is not in compliance with the provisions
of this subchapter. An offense under this subsection is a Class A
misdemeanor.
SECTION 9. Section 166.101(a), Health and Safety Code, is
amended to read as follows:
(a) The board shall, on the recommendation of the
department, adopt all reasonable and necessary rules to carry out
the purposes of this subchapter, including rules:
(1) adopting a statewide out-of-hospital DNR order
protocol that sets out standard procedures for the withholding of
cardiopulmonary resuscitation and certain other life-sustaining
treatment by health care professionals acting in out-of-hospital
settings that addresses each of the methods for executing the order
described in Section 166.082, subject to Sections 166.084 and
166.085;
(2) designating life-sustaining treatment that may be
included in an out-of-hospital or in-hospital DNR order, including
all procedures listed in Sections 166.081(6)(A)(i) through (v) or
Sections 166.081(5-a)(A)(i) through (v), as applicable; [and]
(3) governing recordkeeping in circumstances in
which:
(A) an out-of-hospital DNR order or DNR
identification device is encountered by responding health care
professionals; or
(B) an in-hospital DNR order is encountered by
health care professionals in a hospital setting; and
(4) explicitly specifying that:
(A) an out-of-hospital DNR order may be issued by
a physician only in compliance with the methods for executing the
order described in Section 166.082, subject to Sections 166.084 and
166.085; and
(B) an in-hospital DNR order may be issued only
in compliance with Section 166.0855.
SECTION 10. Not later than December 1, 2013, the executive
commissioner of the Health and Human Services Commission shall
adopt the rules required by Section 166.101(a), Health and Safety
Code, as amended by this Act.
SECTION 11. (a) Except as otherwise provided by Subsection
(b) of this section, the changes in law made by this Act apply to an
in-hospital order withholding life-sustaining treatment in a
patient's medical file on or after the effective date of this Act,
regardless of whether the order was issued before, on, or after the
effective date of this Act.
(b) Sections 166.0855 and 166.0856, Health and Safety Code,
as added by this Act, apply only to an in-hospital DNR order that is
issued on or after the effective date of this Act.
SECTION 12. This Act takes effect September 1, 2013.