Texas 2013 - 83rd Regular

Texas Senate Bill SB303 Compare Versions

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1	1	By: Deuell, Lucio S.B. No. 303
2	2	(In the Senate - Filed January 31, 2013; February 5, 2013,
3	3	read first time and referred to Committee on Health and Human
4	4	Services; April 15, 2013, reported adversely, with favorable
5	5	Committee Substitute by the following vote: Yeas 7, Nays 0;
6	6	April 15, 2013, sent to printer.)
7	7	COMMITTEE SUBSTITUTE FOR S.B. No. 303 By: Deuell
8	8
9	9
10	10	A BILL TO BE ENTITLED
11	11	AN ACT
12	12	relating to advance directives and health care and treatment
13	13	decisions.
14	14	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
15	15	SECTION 1. Section 166.002, Health and Safety Code, is
16	16	amended by amending Subdivisions (2) and (10) and adding
17	17	Subdivision (16) to read as follows:
18	18	(2) "Artificially administered [Artificial] nutrition
19	19	and hydration" means the provision of nutrients or fluids by a tube
20	20	inserted in a vein, under the skin in the subcutaneous tissues, or
21	21	in the stomach (gastrointestinal tract).
22	22	(10) "Life-sustaining treatment" means treatment
23	23	that, based on reasonable medical judgment, sustains the life of a
24	24	patient and without which the patient will die. The term includes
25	25	both life-sustaining medications and artificial life support, such
26	26	as mechanical breathing machines, kidney dialysis treatment, and
27	27	artificially administered [artificial] nutrition and hydration.
28	28	The term does not include the administration of pain management
29	29	medication or the performance of a medical procedure considered to
30	30	be necessary to provide comfort care, or any other medical care
31	31	provided to alleviate a patient's pain.
32	32	(16) "Surrogate" means a legal guardian, an agent
33	33	under a medical power of attorney, or a person authorized under
34	34	Section 166.039(b) to make a health care or treatment decision for
35	35	an incompetent patient under this chapter.
36	36	SECTION 2. Subchapter A, Chapter 166, Health and Safety
37	37	Code, is amended by adding Section 166.012 to read as follows:
38	38	Sec. 166.012. STATEMENT RELATING TO
39	39	DO-NOT-ATTEMPT-RESUSCITATION ORDERS. (a) In this section,
40	40	"do-not-attempt-resuscitation order" or "DNAR order" means an
41	41	order instructing health care professionals not to attempt
42	42	cardiopulmonary resuscitation of the patient if circulatory or
43	43	respiratory function ceases.
44	44	(b) Upon admission, a health care facility shall provide a
45	45	patient or surrogate written notice of the facility's policies
46	46	regarding the rights of the patient or surrogate under this
47	47	section.
48	48	(c) Before placing a do-not-attempt-resuscitation (DNAR)
49	49	order in a patient's medical record, the physician or the facility's
50	50	personnel shall inform the patient or, if the patient is
51	51	incompetent, make a reasonably diligent effort to contact or cause
52	52	to be contacted the surrogate. The facility shall establish a
53	53	policy regarding the notification required under this section. The
54	54	policy must authorize the notification to be given verbally by a
55	55	physician or facility personnel.
56	56	(d) The DNAR order takes effect at the time it is written in
57	57	the patient's chart or otherwise placed in the patient's medical
58	58	record.
59	59	(e) If the patient or surrogate disagrees with the DNAR
60	60	order being placed in or removed from the medical record, the
61	61	patient or surrogate may request in writing and is entitled to a
62	62	consultation or a review of the disagreement by the ethics or
63	63	medical committee in the manner described by Section 166.046, with
64	64	the patient or surrogate afforded all rights provided to the
65	65	surrogate under that section, and with the physician afforded all
66	66	protections from liability provided under Section 166.045(d). The
67	67	patient or surrogate may discontinue the process initiated under
68	68	Section 166.046 by providing written notice to the ethics or
69	69	medical committee.
70	70	(f) A DNAR order in the patient's medical record at the time
71	71	a consultation or review is requested under Subsection (e) must be
72	72	removed from the patient's medical record at that time. A DNAR
73	73	order may not be placed in the patient's medical record until the
74	74	process initiated under Section 166.046 is concluded or
75	75	discontinued at the request of the patient or surrogate.
76	76	(g) Subsection (c) does not apply to a DNAR order placed in
77	77	the medical record of a patient:
78	78	(1) whose death, based on reasonable medical judgment,
79	79	is imminent despite attempted resuscitation;
80	80	(2) for whom, based on reasonable medical judgment,
81	81	resuscitation would be medically ineffective and there is
82	82	insufficient time to contact the surrogate; or
83	83	(3) for whom the DNAR order is consistent with a
84	84	patient's or surrogate's request or a patient's advance directive to
85	85	not attempt resuscitation.
86	86	(h) Subsection (e) does not apply to a DNAR order placed in
87	87	the medical record of a patient with respect to whom, based on
88	88	reasonable medical judgment, death is imminent and resuscitation
89	89	would be medically ineffective.
90	90	(i) This section does not create a cause of action or
91	91	liability against a physician, health professional acting under the
92	92	direction of a physician, or health care facility.
93	93	(j) A physician, health professional acting under the
94	94	direction of a physician, or health care facility is not civilly or
95	95	criminally liable or subject to review or disciplinary action by
96	96	the appropriate licensing authority if the actor has complied with
97	97	the procedures under this section and Section 166.046.
98	98	(k) This section does not affect the immunity from liability
99	99	under Section 74.151, Civil Practice and Remedies Code.
100	100	(l) This section does not apply to an assisted living
101	101	facility licensed under Chapter 247.
102	102	SECTION 3. Section 166.033, Health and Safety Code, is
103	103	amended to read as follows:
104	104	Sec. 166.033. FORM OF WRITTEN DIRECTIVE. A written
105	105	directive may be in the following form:
106	106	DIRECTIVE TO PHYSICIANS AND FAMILY OR SURROGATES
107	107	Instructions for completing this document:
108	108	This is an important legal document known as an Advance
109	109	Directive. It is designed to help you communicate your wishes about
110	110	medical treatment at some time in the future when you are unable to
111	111	make your wishes known because of illness or injury. These wishes
112	112	are usually based on personal values. In particular, you may want
113	113	to consider what burdens or hardships of treatment you would be
114	114	willing to accept for a particular amount of benefit obtained if you
115	115	were seriously ill.
116	116	You are encouraged to discuss your values and wishes with
117	117	your family or chosen spokesperson, as well as your physician. Your
118	118	physician, other health care provider, or medical institution may
119	119	provide you with various resources to assist you in completing your
120	120	advance directive. Brief definitions are listed below and may aid
121	121	you in your discussions and advance planning. Initial the
122	122	treatment choices that best reflect your personal preferences.
123	123	Provide a copy of your directive to your physician, usual hospital,
124	124	and family or spokesperson. Consider a periodic review of this
125	125	document. By periodic review, you can best assure that the
126	126	directive reflects your preferences.
127	127	In addition to this advance directive, Texas law provides for
128	128	two other types of directives that can be important during a serious
129	129	illness. These are the Medical Power of Attorney and the
130	130	Out-of-Hospital Do-Not-Resuscitate Order. You may wish to discuss
131	131	these with your physician, family, hospital representative, or
132	132	other advisers. You may also wish to complete a directive related
133	133	to the donation of organs and tissues.
134	134	DIRECTIVE
135	135	I, __________, recognize that the best health care is based
136	136	upon a partnership of trust and communication with my physician. My
137	137	physician and I will make health care or treatment decisions
138	138	together as long as I am of sound mind and able to make my wishes
139	139	known. If there comes a time that I am unable to make medical
140	140	decisions about myself because of illness or injury, I direct that
141	141	the following treatment preferences be honored:
142	142	If, in the judgment of my physician, I am suffering with a
143	143	terminal condition from which I am expected to die within six
144	144	months, even with available life-sustaining treatment provided in
145	145	accordance with prevailing standards of medical care:
146	146	__________ I request that all treatments other than those needed to keep me comfortable be discontinued or withheld and my physician allow me to die as gently as possible; __________ I request that all treatments other than those needed to keep me comfortable be discontinued or withheld and my physician allow me to die as gently as possible;
147	147	__________ I request that all treatments other than those needed to keep me comfortable be discontinued or withheld and my physician allow me to die as gently as possible;
148	148	OR OR
149	149	OR
150	150	__________ I request that I be kept alive in this terminal condition using available life-sustaining treatment. (THIS SELECTION DOES NOT APPLY TO HOSPICE CARE.) __________ I request that I be kept alive in this terminal condition using available life-sustaining treatment. (THIS SELECTION DOES NOT APPLY TO HOSPICE CARE.)
151	151	__________ I request that I be kept alive in this terminal condition using available life-sustaining treatment. (THIS SELECTION DOES NOT APPLY TO HOSPICE CARE.)
152	152	If, in the judgment of my physician, I am suffering with an
153	153	irreversible condition so that I cannot care for myself or make
154	154	decisions for myself and am expected to die without life-sustaining
155	155	treatment provided in accordance with prevailing standards of care:
156	156	__________ I request that all treatments other than those needed to keep me comfortable be discontinued or withheld and my physician allow me to die as gently as possible; __________ I request that all treatments other than those needed to keep me comfortable be discontinued or withheld and my physician allow me to die as gently as possible;
157	157	__________ I request that all treatments other than those needed to keep me comfortable be discontinued or withheld and my physician allow me to die as gently as possible;
158	158	OR OR
159	159	OR
160	160	__________ I request that I be kept alive in this irreversible condition using available life-sustaining treatment. (THIS SELECTION DOES NOT APPLY TO HOSPICE CARE.) __________ I request that I be kept alive in this irreversible condition using available life-sustaining treatment. (THIS SELECTION DOES NOT APPLY TO HOSPICE CARE.)
161	161	__________ I request that I be kept alive in this irreversible condition using available life-sustaining treatment. (THIS SELECTION DOES NOT APPLY TO HOSPICE CARE.)
162	162	Additional requests: (After discussion with your physician,
163	163	you may wish to consider listing particular treatments in this
164	164	space that you do or do not want in specific circumstances, such as
165	165	artificially administered [artificial] nutrition and hydration
166	166	[fluids], intravenous antibiotics, etc. Be sure to state whether
167	167	you do or do not want the particular treatment.)
168	168	After signing this directive, if my representative or I elect
169	169	hospice care, I understand and agree that only those treatments
170	170	needed to keep me comfortable would be provided and I would not be
171	171	given available life-sustaining treatments.
172	172	If I do not have a Medical Power of Attorney, and I am unable
173	173	to make my wishes known, I designate the following person(s) to make
174	174	health care or treatment decisions with my physician compatible
175	175	with my personal values:
176	176	1. __________
177	177	2. __________
178	178	(If a Medical Power of Attorney has been executed, then an
179	179	agent already has been named and you should not list additional
180	180	names in this document.)
181	181	If the above persons are not available, or if I have not
182	182	designated a spokesperson, I understand that a spokesperson will be
183	183	chosen for me following standards specified in the laws of Texas.
184	184	If, in the judgment of my physician, my death is imminent within
185	185	minutes to hours, even with the use of all available medical
186	186	treatment provided within the prevailing standard of care, I
187	187	acknowledge that all treatments may be withheld or removed except
188	188	those needed to maintain my comfort. I understand that under Texas
189	189	law this directive has no effect if I have been diagnosed as
190	190	pregnant. This directive will remain in effect until I revoke it.
191	191	No other person may do so.
192	192	Signed__________ Date__________ City, County, State of
193	193	Residence __________
194	194	Two competent adult witnesses must sign below, acknowledging
195	195	the signature of the declarant. The witness designated as Witness 1
196	196	may not be a person designated to make a health care or treatment
197	197	decision for the patient and may not be related to the patient by
198	198	blood or marriage. This witness may not be entitled to any part of
199	199	the estate and may not have a claim against the estate of the
200	200	patient. This witness may not be the attending physician or an
201	201	employee of the attending physician. If this witness is an employee
202	202	of a health care facility in which the patient is being cared for,
203	203	this witness may not be involved in providing direct patient care to
204	204	the patient. This witness may not be an officer, director, partner,
205	205	or business office employee of a health care facility in which the
206	206	patient is being cared for or of any parent organization of the
207	207	health care facility.
208	208	Witness 1 __________ Witness 2 __________
209	209	Definitions:
210	210	"Artificially administered [Artificial] nutrition and
211	211	hydration" means the provision of nutrients or fluids by a tube
212	212	inserted in a vein, under the skin in the subcutaneous tissues, or
213	213	in the stomach (gastrointestinal tract).
214	214	"Irreversible condition" means a condition, injury, or
215	215	illness:
216	216	(1) that may be treated, but is never cured or
217	217	eliminated;
218	218	(2) that leaves a person unable to care for or make
219	219	decisions for the person's own self; and
220	220	(3) that, without life-sustaining treatment provided
221	221	in accordance with the prevailing standard of medical care, is
222	222	fatal.
223	223	Explanation: Many serious illnesses such as cancer, failure
224	224	of major organs (kidney, heart, liver, or lung), and serious brain
225	225	disease such as Alzheimer's dementia may be considered irreversible
226	226	early on. There is no cure, but the patient may be kept alive for
227	227	prolonged periods of time if the patient receives life-sustaining
228	228	treatments. Late in the course of the same illness, the disease may
229	229	be considered terminal when, even with treatment, the patient is
230	230	expected to die. You may wish to consider which burdens of
231	231	treatment you would be willing to accept in an effort to achieve a
232	232	particular outcome. This is a very personal decision that you may
233	233	wish to discuss with your physician, family, or other important
234	234	persons in your life.
235	235	"Life-sustaining treatment" means treatment that, based on
236	236	reasonable medical judgment, sustains the life of a patient and
237	237	without which the patient will die. The term includes both
238	238	life-sustaining medications and artificial life support such as
239	239	mechanical breathing machines, kidney dialysis treatment, and
240	240	artificially administered nutrition and [artificial] hydration
241	241	[and nutrition]. The term does not include the administration of
242	242	pain management medication, the performance of a medical procedure
243	243	necessary to provide comfort care, or any other medical care
244	244	provided to alleviate a patient's pain.
245	245	"Terminal condition" means an incurable condition caused by
246	246	injury, disease, or illness that according to reasonable medical
247	247	judgment will produce death within six months, even with available
248	248	life-sustaining treatment provided in accordance with the
249	249	prevailing standard of medical care.
250	250	Explanation: Many serious illnesses may be considered
251	251	irreversible early in the course of the illness, but they may not be
252	252	considered terminal until the disease is fairly advanced. In
253	253	thinking about terminal illness and its treatment, you again may
254	254	wish to consider the relative benefits and burdens of treatment and
255	255	discuss your wishes with your physician, family, or other important
256	256	persons in your life.
257	257	SECTION 4. Section 166.039, Health and Safety Code, is
258	258	amended by adding Subsections (a-1) and (b-1) and amending
259	259	Subsections (e) and (f) to read as follows:
260	260	(a-1) In making the decision described by Subsection (a),
261	261	the attending physician may consult with a physician who previously
262	262	treated the patient if the previous physician:
263	263	(1) is known and available, regardless of whether the
264	264	previous physician has discontinued providing care for the patient
265	265	or does not have privileges at the treating facility;
266	266	(2) had a conversation with the patient on end-of-life
267	267	issues at a time when the patient was competent and capable of
268	268	communication; and
269	269	(3) documented the conversation described by
270	270	Subdivision (2) in the patient's medical record.
271	271	(b-1) The attending physician and the health care
272	272	facility's personnel shall make a reasonably diligent effort to
273	273	contact or cause to be contacted the persons listed in Subsection
274	274	(b) in the order of priority under Subsection (b) until one of the
275	275	persons is contacted or the list is exhausted regarding making a
276	276	health care or treatment decision for the patient.
277	277	(e) If the patient does not have a legal guardian or agent
278	278	under a medical power of attorney and a person listed in Subsection
279	279	(b) is not available, a health care or treatment decision made under
280	280	Subsection (b) must be concurred with [in] by another physician who
281	281	is not involved in the treatment of the patient or who is a
282	282	representative of an ethics or medical committee of the health care
283	283	facility in which the person is a patient.
284	284	(f) The fact that an adult [qualified] patient has not
285	285	executed or issued a directive does not create a presumption
286	286	regarding the provision, withholding, or withdrawal of [that the
287	287	patient does not want a treatment decision to be made to withhold or
288	288	withdraw] life-sustaining treatment.
289	289	SECTION 5. Subsection (c), Section 166.045, Health and
290	290	Safety Code, is amended to read as follows:
291	291	(c) If an attending physician disagrees with and refuses to
292	292	comply with a patient's directive or a health care or treatment
293	293	decision of a patient or of a surrogate made on behalf of an
294	294	incompetent patient, and the attending physician does not wish to
295	295	follow the procedure established under Section 166.046,
296	296	life-sustaining treatment shall be provided to the patient, but
297	297	only until a reasonable opportunity has been afforded for the
298	298	transfer of the patient to another physician or health care
299	299	facility willing to comply with the health care [directive] or
300	300	treatment decision.
301	301	SECTION 6. The heading to Section 166.046, Health and
302	302	Safety Code, is amended to read as follows:
303	303	Sec. 166.046. PROCEDURE IF PHYSICIAN DISAGREES WITH AND
304	304	REFUSES TO COMPLY WITH HEALTH CARE [NOT EFFECTUATING A DIRECTIVE]
305	305	OR TREATMENT DECISION.
306	306	SECTION 7. Section 166.046, Health and Safety Code, is
307	307	amended by amending Subsections (a), (b), (c), (d), (e), (e-1),
308	308	(g), and (h) and adding Subsections (a-1), (a-2), (a-3), (a-4),
309	309	(a-5), (a-6), (a-7), (a-8), and (b-1) to read as follows:
310	310	(a) If an attending physician disagrees with and refuses to
311	311	comply with [honor] a patient's advance directive or a health care
312	312	or treatment decision [made by or on behalf] of a patient or of a
313	313	surrogate made on behalf of an incompetent patient, the
314	314	disagreement and the physician's refusal shall be reviewed by an
315	315	ethics or medical committee under this section. The ethics or
316	316	medical committee of a facility other than a nursing home licensed
317	317	under Chapter 242 may not include any health care provider involved
318	318	in the direct care of a patient whose treatment the committee
319	319	reviews or a subcommittee of such an ethics or medical committee.
320	320	(a-1) If the patient has been diagnosed with a terminal
321	321	condition, the ethics or medical committee shall determine if,
322	322	based on reasonable medical judgment, the treatment requested by
323	323	the patient or, if the patient is incompetent, by the surrogate
324	324	would:
325	325	(1) hasten the patient's death;
326	326	(2) seriously exacerbate other major medical problems
327	327	not outweighed by the benefit of the provision of the treatment;
328	328	(3) result in substantial irremediable physical pain
329	329	or discomfort not outweighed by the benefit of the provision of the
330	330	treatment; or
331	331	(4) be medically ineffective in prolonging the
332	332	patient's life.
333	333	(a-2) If the patient has been diagnosed with an irreversible
334	334	nonterminal condition, the ethics or medical committee may sustain
335	335	the decision to withdraw life-sustaining treatment requested by the
336	336	patient or, if the patient is incompetent, by the surrogate only if,
337	337	based on reasonable medical judgment, the treatment would:
338	338	(1) threaten the patient's life;
339	339	(2) seriously exacerbate other major medical problems
340	340	not outweighed by the benefit of the provision of the treatment;
341	341	(3) result in substantial irremediable physical pain
342	342	or discomfort not outweighed by the benefit of the provision of the
343	343	treatment; or
344	344	(4) be medically ineffective in prolonging the
345	345	patient's life.
346	346	(a-3) In all deliberations under this section, the ethics or
347	347	medical committee should strive to honor the values of each unique
348	348	patient. All patients will be treated equally without regard to
349	349	permanent physical or mental disabilities, age, gender, religion,
350	350	ethnic background, or financial or insurance status. The committee
351	351	should make the same decision about whether or not a requested
352	352	treatment is medically appropriate for individuals with or without
353	353	a permanent disability, advanced age, gender, religious or cultural
354	354	differences, or financial circumstances.
355	355	(a-4) The fact that life-sustaining treatment is delivered
356	356	in an intensive care unit is not itself sufficient to justify the
357	357	refusal to provide that treatment. This section does not authorize
358	358	withholding or withdrawing pain management medication, medical
359	359	procedures considered necessary to provide comfort care, or any
360	360	other medical care provided to alleviate a patient's pain.
361	361	(a-5) [The attending physician may not be a member of that
362	362	committee.] The patient shall be given life-sustaining treatment
363	363	pending [during] the ethics or medical committee's review.
364	364	(a-6) When an ethics or medical committee review has been
365	365	initiated under this chapter, the ethics or medical committee
366	366	shall:
367	367	(1) inform the patient or surrogate that the patient
368	368	or surrogate may discontinue the process under this section by
369	369	providing written notice to the ethics or medical committee;
370	370	(2) appoint a patient liaison familiar with
371	371	end-of-life issues and hospice care options to assist the patient
372	372	or surrogate throughout the process described by this section; and
373	373	(3) appoint one or more representatives of the ethics
374	374	or medical committee to conduct an advisory ethics consultation
375	375	with the patient or surrogate, the outcome of which must be
376	376	documented in the patient's medical record by a representative of
377	377	the committee.
378	378	(a-7) If a disagreement over a health care or treatment
379	379	decision persists following the consultation described in
380	380	Subsection (a-6)(3), the ethics or medical committee shall hold a
381	381	meeting to review the disagreement.
382	382	(a-8) The ethics or medical committee in holding a review
383	383	required under this section, including a review following a
384	384	consultation described by Subsection (a-6)(3), shall advise the
385	385	patient or surrogate that the patient's attending physician may
386	386	present medical facts at the meeting. The patient's attending
387	387	physician may attend and present facts but may not participate as a
388	388	member of the committee in the case being evaluated.
389	389	(b) When a meeting of the ethics or medical committee is
390	390	required under this section [The patient or the person responsible
391	391	for the health care decisions of the individual who has made the
392	392	decision regarding the directive or treatment decision]:
393	393	(1) not later than the seventh calendar day before the
394	394	scheduled date of the meeting required under this section, unless
395	395	the time period is waived by mutual agreement, the committee shall
396	396	provide to the patient or surrogate:
397	397	(A) [may be given] a written description of the
398	398	ethics or medical committee review process and any other policies
399	399	and procedures related to this section adopted by the health care
400	400	facility;
401	401	(B) notice that the patient or surrogate is
402	402	entitled to receive the continued assistance of a patient liaison
403	403	to assist the patient or surrogate throughout the process described
404	404	in this section;
405	405	(C) notice that the patient or surrogate may seek
406	406	a second opinion at the patient's or surrogate's expense from other
407	407	medical professionals regarding the patient's medical status and
408	408	treatment requirements and communicate the resulting information
409	409	to the members of the committee for consideration before the
410	410	meeting;
411	411	(D) [(2) shall be informed of the committee
412	412	review process not less than 48 hours before the meeting called to
413	413	discuss the patient's directive, unless the time period is waived
414	414	by mutual agreement;
415	415	[(3) at the time of being so informed, shall be
416	416	provided:
417	417	[(A)] a copy of the appropriate statement set
418	418	forth in Section 166.052; and
419	419	(E) [(B)] a copy of the registry list of health
420	420	care providers, health care facilities, and referral groups that,
421	421	in compliance with any state laws prohibiting barratry, have
422	422	volunteered their readiness to consider accepting transfer or to
423	423	assist in locating a provider willing to accept transfer that is
424	424	posted on the website maintained by the department [Texas Health
425	425	Care Information Council] under Section 166.053; and
426	426	(2) if requested in writing, the patient or surrogate
427	427	is entitled to receive from the facility:
428	428	(A) not later than 72 hours after the request is
429	429	made, a free copy of the portion of the patient's medical record
430	430	related to the current admission to the facility or the treatment
431	431	received by the patient during the preceding 30 calendar days in the
432	432	facility, whichever is shorter, together with any reasonably
433	433	available diagnostic results and reports; and
434	434	(B) not later than the fifth calendar day after
435	435	the date of the request or at another time specified by mutual
436	436	agreement, a free copy of the remainder of the patient's medical
437	437	record, if any, related to the current admission to the facility.
438	438	(b-1) The patient or surrogate[; and
439	439	[(4)] is entitled to:
440	440	(1) [(A)] attend and participate in the meeting of the
441	441	ethics or medical committee, excluding the committee's
442	442	deliberations;
443	443	(2) be accompanied at the meeting by up to five
444	444	persons, or more persons at the committee's discretion, for
445	445	support, subject to the facility's reasonable written attendance
446	446	policy as necessary to:
447	447	(A) facilitate information sharing and
448	448	discussion of the patient's medical status and treatment
449	449	requirements; and
450	450	(B) preserve the order and decorum of the
451	451	meeting; and
452	452	(3) [(B)] receive a written explanation of the
453	453	decision reached during the review process.
454	454	(c) The written explanation required by Subsection (b-1)(3)
455	455	[(b)(2)(B)] must be included in the patient's medical record.
456	456	(d) If the attending physician, the patient, or the
457	457	surrogate [person responsible for the health care decisions of the
458	458	individual] does not agree with the decision reached during the
459	459	review process [under Subsection (b)], the physician and the
460	460	facility shall make a reasonably diligent [reasonable] effort to
461	461	transfer the patient to a physician of the patient's or surrogate's
462	462	choice who is willing to accept the patient [comply with the
463	463	directive]. The [If the patient is a patient in a health care
464	464	facility, the] facility's personnel shall assist the physician in
465	465	arranging the patient's transfer to:
466	466	(1) another physician;
467	467	(2) an alternative care setting within that facility;
468	468	or
469	469	(3) another facility.
470	470	(e) If the patient or surrogate [the person responsible for
471	471	the health care decisions of the patient] is requesting
472	472	life-sustaining treatment that the attending physician has decided
473	473	and the ethics or medical committee [review process] has affirmed
474	474	is medically inappropriate treatment, the patient shall be given
475	475	available life-sustaining treatment pending transfer under
476	476	Subsection (d). This subsection does not authorize withholding or
477	477	withdrawing pain management medication, medical procedures
478	478	considered necessary to provide comfort care, or any other medical
479	479	care provided to alleviate a patient's pain. The patient is
480	480	responsible for any costs incurred in transferring the patient to
481	481	another facility. The attending physician, any other physician
482	482	responsible for the care of the patient, and the health care
483	483	facility are not obligated to provide life-sustaining treatment
484	484	after the 21st calendar [10th] day after the written decision
485	485	required under Subsection (b-1) [(b)] is provided to the patient or
486	486	the surrogate [person responsible for the health care decisions of
487	487	the patient] unless ordered to do so under Subsection (g), except
488	488	that artificially administered nutrition and hydration must be
489	489	provided unless, based on reasonable medical judgment, providing
490	490	artificially administered nutrition and hydration would:
491	491	(1) hasten the patient's death;
492	492	(2) seriously exacerbate other major medical problems
493	493	not outweighed by the benefit of the provision of the treatment;
494	494	(3) result in substantial irremediable physical pain
495	495	or discomfort not outweighed by the benefit of the provision of the
496	496	treatment; or
497	497	(4) be medically ineffective in prolonging the
498	498	patient's life.
499	499	(e-1) If during a previous admission to a facility the [a
500	500	patient's] attending physician and the ethics or medical committee
501	501	[review process under Subsection (b) have] determined that
502	502	life-sustaining treatment is inappropriate, a subsequent committee
503	503	review is not required if [and] the patient is readmitted to the
504	504	same facility for the same condition within six months from the date
505	505	of the previous decision, provided that the [reached during the
506	506	review process conducted upon the previous admission, Subsections
507	507	(b) through (e) need not be followed if the patient's] attending
508	508	physician and a consulting physician who is a member of the ethics
509	509	or medical committee of the facility document on the patient's
510	510	readmission that the patient's condition [either has not improved
511	511	or] has deteriorated since the previous review [process] was
512	512	conducted.
513	513	(g) On motion [At the request] of the patient or surrogate
514	514	[the person responsible for the health care decisions of the
515	515	patient], the appropriate district or county court shall extend the
516	516	time period provided under Subsection (e) [only] if the court
517	517	finds, by a preponderance of the evidence, that there is a
518	518	reasonable expectation that the patient or surrogate may find a
519	519	physician or health care facility that will honor the patient's or
520	520	surrogate's health care or treatment decision [directive will be
521	521	found] if the time extension is granted.
522	522	(h) This section may not be construed to impose an
523	523	obligation on a facility or a home and community support services
524	524	agency licensed under Chapter 142, an assisted living facility
525	525	licensed under Chapter 247, or a similar organization that is
526	526	beyond the scope of the services or resources of the facility, [or]
527	527	agency, or organization. This section does not apply to hospice
528	528	services provided by a home and community support services agency
529	529	licensed under Chapter 142 or services provided by an assisted
530	530	living facility licensed under Chapter 247.
531	531	SECTION 8. Subsections (a) and (b), Section 166.052, Health
532	532	and Safety Code, are amended to read as follows:
533	533	(a) In cases in which the attending physician disagrees with
534	534	and refuses to comply with a health care [honor an advance
535	535	directive] or treatment decision requesting the provision of
536	536	life-sustaining treatment, the statement required by Section
537	537	166.046(b)(1)(D) [166.046(b)(2)(A)] shall be in substantially the
538	538	following form:
539	539	When There Is A Disagreement About Medical Treatment: The
540	540	Physician Recommends Against Certain Life-Sustaining Treatment
541	541	That You Wish To Continue
542	542	You have been given this information because you have
543	543	requested life-sustaining treatment[,]* for yourself as the
544	544	patient or on behalf of the patient, as applicable, which the
545	545	attending physician believes is not medically appropriate. This
546	546	information is being provided to help you understand state law,
547	547	your rights, and the resources available to you in such
548	548	circumstances. It outlines the process for resolving disagreements
549	549	about treatment among patients, families, and physicians. It is
550	550	based upon Section 166.046 of the Texas Advance Directives Act,
551	551	codified in Chapter 166 of the Texas Health and Safety Code.
552	552	When an attending physician disagrees with and refuses to
553	553	comply with a [an advance directive or other] request for
554	554	life-sustaining treatment because of the physician's medical
555	555	judgment that the treatment would be medically inappropriate, the
556	556	case will be reviewed by an ethics or medical committee.
557	557	Life-sustaining treatment will be provided through the review.
558	558	As the patient or the patient's decision-maker, you [You]
559	559	will receive notification of this review at least seven calendar
560	560	days [48 hours] before a meeting of the committee related to your
561	561	case. [You are entitled to attend the meeting.] With your
562	562	agreement, the meeting may be held sooner than seven calendar days
563	563	[48 hours], if possible.
564	564	The committee will appoint a patient liaison to assist you
565	565	through this process. You are entitled to attend the meeting,
566	566	address the committee, and be accompanied by up to five persons, or
567	567	more persons at the committee's discretion, to support you, subject
568	568	to the facility's reasonable written attendance policy to
569	569	facilitate information sharing and discussion of the patient's
570	570	medical status and treatment requirements and preserve the order
571	571	and decorum of the meeting. On written request, you are also
572	572	entitled to receive:
573	573	(1) not later than 72 hours after the request is made,
574	574	a free copy of the portion of the patient's medical record related
575	575	to the current admission to the facility or the treatment received
576	576	during the preceding 30 calendar days in the facility, whichever is
577	577	shorter, together with any reasonably available diagnostic results
578	578	and reports; and
579	579	(2) not later than the fifth calendar day following
580	580	the request or at another time specified by mutual agreement, a free
581	581	copy of the remainder of the medical record, if any, related to the
582	582	current admission to the facility.
583	583	As the patient or the patient's decision-maker, you are free
584	584	to seek a second opinion at the patient's or your expense from other
585	585	medical professionals regarding the patient's medical status and
586	586	treatment requirements and communicate the resulting information
587	587	to the members of the ethics or medical committee for consideration
588	588	before the meeting.
589	589	You are entitled to receive a written explanation of the
590	590	decision reached during the review process.
591	591	If after this review process both the attending physician and
592	592	the ethics or medical committee conclude that life-sustaining
593	593	treatment is medically inappropriate and yet you continue to
594	594	request such treatment, then the following procedure will occur:
595	595	1. The physician, with the help of the health care facility,
596	596	will assist you in trying to find a physician and facility willing
597	597	to provide the requested treatment.
598	598	2. You are being given a list of health care providers,
599	599	health care facilities, and referral groups that have volunteered
600	600	their readiness to consider accepting transfer, or to assist in
601	601	locating a provider willing to accept transfer, maintained by the
602	602	Department of State [Texas] Health Services [Care Information
603	603	Council]. You may wish to contact providers, facilities, or
604	604	referral groups on the list or others of your choice to get help in
605	605	arranging a transfer.
606	606	3. The patient will continue to be given life-sustaining
607	607	treatment and treatment to enhance pain management and reduce
608	608	suffering, including artificially administered nutrition and
609	609	hydration, until the patient [he or she] can be transferred to a
610	610	willing provider for up to 21 calendar [10] days from the time you
611	611	were given the committee's written decision that life-sustaining
612	612	treatment is not medically appropriate.
613	613	4. If a transfer can be arranged, the patient will be
614	614	responsible for the costs of the transfer.
615	615	5. If a provider cannot be found willing to give the
616	616	requested treatment within 14 calendar [10] days, life-sustaining
617	617	treatment may be withdrawn unless a court of law has granted an
618	618	extension.
619	619	6. You may ask the appropriate district or county court to
620	620	extend the 21-day [10-day] period if the court finds that there is a
621	621	reasonable expectation that you may find a physician or health care
622	622	facility willing to provide life-sustaining treatment [will be
623	623	found] if the extension is granted.
624	624	*"Life-sustaining treatment" means treatment that, based on
625	625	reasonable medical judgment, sustains the life of a patient and
626	626	without which the patient will die. The term includes both
627	627	life-sustaining medications and artificial life support, such as
628	628	mechanical breathing machines, kidney dialysis treatment, and
629	629	artificially administered [artificial] nutrition and hydration.
630	630	The term does not include the administration of pain management
631	631	medication or the performance of a medical procedure considered to
632	632	be necessary to provide comfort care, or any other medical care
633	633	provided to alleviate a patient's pain.
634	634	(b) In cases in which the attending physician disagrees with
635	635	and refuses to comply with a health care [an advance directive] or
636	636	treatment decision requesting the withholding or withdrawal of
637	637	life-sustaining treatment, the statement required by Section
638	638	166.046(b)(1)(D) [166.046(b)(3)(A)] shall be in substantially the
639	639	following form:
640	640	When There Is A Disagreement About Medical Treatment: The
641	641	Physician Recommends Life-Sustaining Treatment That You Wish To
642	642	Stop
643	643	You have been given this information because you have
644	644	requested the withdrawal or withholding of life-sustaining
645	645	treatment* for yourself as the patient or on behalf of the patient,
646	646	as applicable, and the attending physician disagrees with and
647	647	refuses to comply with that request. The information is being
648	648	provided to help you understand state law, your rights, and the
649	649	resources available to you in such circumstances. It outlines the
650	650	process for resolving disagreements about treatment among
651	651	patients, families, and physicians. It is based upon Section
652	652	166.046 of the Texas Advance Directives Act, codified in Chapter
653	653	166 of the Texas Health and Safety Code.
654	654	When an attending physician disagrees with and refuses to
655	655	comply with a [an advance directive or other] request for
656	656	withdrawal or withholding of life-sustaining treatment for any
657	657	reason, the case will be reviewed by an ethics or medical committee.
658	658	Life-sustaining treatment will be provided through the review.
659	659	As the patient or the patient's decision-maker, you [You]
660	660	will receive notification of this review at least seven calendar
661	661	days [48 hours] before a meeting of the committee related to your
662	662	case. You are entitled to attend the meeting. With your agreement,
663	663	the meeting may be held sooner than seven calendar days [48 hours],
664	664	if possible.
665	665	You will be appointed a patient liaison familiar with
666	666	end-of-life issues and hospice care options to assist you
667	667	throughout this process. A representative of the ethics or medical
668	668	committee will also conduct an advisory consultation with you.
669	669	On written request you are entitled to receive:
670	670	(1) not later than 72 hours after the request is made,
671	671	a free copy of the portion of the patient's medical record related
672	672	to the current admission to the facility or the treatment received
673	673	by the patient during the preceding 30 calendar days in the
674	674	facility, whichever is shorter, together with any reasonably
675	675	available diagnostic results and reports; and
676	676	(2) not later than the fifth calendar day following
677	677	the date of the request or at another time specified by mutual
678	678	agreement, a free copy of the remainder of the medical record, if
679	679	any, related to the current admission to the facility.
680	680	As the patient or the patient's decision-maker, you are free
681	681	to seek a second opinion at the patient's or your expense from other
682	682	medical professionals regarding the patient's medical status and
683	683	treatment requests and communicate the resulting information to the
684	684	members of the ethics or medical committee for consideration before
685	685	the meeting.
686	686	You are entitled to receive a written explanation of the
687	687	decision reached during the review process.
688	688	If you or the attending physician do not agree with the
689	689	decision reached during the review process, and the attending
690	690	physician still disagrees with and refuses to comply with your
691	691	request to withhold or withdraw life-sustaining treatment, then the
692	692	following procedure will occur:
693	693	1. The physician, with the help of the health care facility,
694	694	will assist you in trying to find a physician and facility willing
695	695	to accept the patient [withdraw or withhold the life-sustaining
696	696	treatment].
697	697	2. You are being given a list of health care providers,
698	698	health care facilities, and referral groups that have volunteered
699	699	their readiness to consider accepting transfer, or to assist in
700	700	locating a provider willing to accept transfer, maintained by the
701	701	Department of State [Texas] Health Services [Care Information
702	702	Council]. You may wish to contact providers, facilities, or
703	703	referral groups on the list or others of your choice to get help in
704	704	arranging a transfer.
705	705	*"Life-sustaining treatment" means treatment that, based on
706	706	reasonable medical judgment, sustains the life of a patient and
707	707	without which the patient will die. The term includes both
708	708	life-sustaining medications and artificial life support, such as
709	709	mechanical breathing machines, kidney dialysis treatment, and
710	710	artificially administered [artificial] nutrition and hydration.
711	711	The term does not include the administration of pain management
712	712	medication or the performance of a medical procedure considered to
713	713	be necessary to provide comfort care, or any other medical care
714	714	provided to alleviate a patient's pain.
715	715	SECTION 9. Subchapter B, Chapter 166, Health and Safety
716	716	Code, is amended by adding Section 166.054 to read as follows:
717	717	Sec. 166.054. REPORTING REQUIREMENTS REGARDING ETHICS OR
718	718	MEDICAL COMMITTEE PROCESSES. (a) On submission of a health care
719	719	facility's application to renew its license, a facility in which
720	720	one or more meetings of an ethics or medical committee are held
721	721	under this chapter shall file a report with the department that
722	722	contains aggregate information regarding the number of cases
723	723	initiated by an ethics or medical committee under Section 166.046
724	724	and the disposition of those cases by the facility.
725	725	(b) Aggregate data submitted to the department under this
726	726	section may include only the following:
727	727	(1) the total number of patients for whom a review by
728	728	the ethics or medical committee was initiated under Section
729	729	166.046(b);
730	730	(2) the number of patients under Subdivision (1) who
731	731	were transferred to:
732	732	(A) another physician within the same facility;
733	733	or
734	734	(B) a different facility;
735	735	(3) the number of patients under Subdivision (1) who
736	736	were discharged to home;
737	737	(4) the number of patients under Subdivision (1) for
738	738	whom treatment was withheld or withdrawn pursuant to surrogate
739	739	consent:
740	740	(A) before the decision was rendered following a
741	741	review under Section 166.046(b);
742	742	(B) after the decision was rendered following a
743	743	review under Section 166.046(b); or
744	744	(C) during or after the 21-day period described
745	745	by Section 166.046(e);
746	746	(5) the average length of stay before a review meeting
747	747	is held under Section 166.046(b); and
748	748	(6) the number of patients under Subdivision (1) who
749	749	died while still receiving life-sustaining treatment:
750	750	(A) before the review meeting under Section
751	751	166.046(b);
752	752	(B) during the 21-day period; or
753	753	(C) during extension of the 21-day period, if
754	754	any.
755	755	(c) The report required by this section may not contain any
756	756	data specific to an individual patient or physician.
757	757	(d) The department shall adopt rules to:
758	758	(1) establish a standard form for the reporting
759	759	requirements of this section; and
760	760	(2) post on the department's Internet website the data
761	761	submitted under Subsection (b) in the format provided by rule.
762	762	(e) Data collected as required by, or submitted to the
763	763	department under, this section:
764	764	(1) is not admissible in a civil or criminal
765	765	proceeding in which a physician, health care professional acting
766	766	under the direction of a physician, or health care facility is a
767	767	defendant; and
768	768	(2) may not be used in relation to any disciplinary
769	769	action by a licensing board or other body with professional or
770	770	administrative oversight over a physician, health care
771	771	professional acting under the direction of a physician, or health
772	772	care facility.
773	773	SECTION 10. Subsections (a) and (c), Section 166.082,
774	774	Health and Safety Code, are amended to read as follows:
775	775	(a) A competent adult [person] may at any time execute a
776	776	written out-of-hospital DNR order directing health care
777	777	professionals acting in an out-of-hospital setting to withhold
778	778	cardiopulmonary resuscitation and certain other life-sustaining
779	779	treatment designated by the board.
780	780	(c) If the person is incompetent but previously executed or
781	781	issued a directive to physicians in accordance with Subchapter B
782	782	requesting that all treatment, other than treatment necessary for
783	783	keeping the person comfortable, be discontinued or withheld, the
784	784	physician may rely on the directive as the person's instructions to
785	785	issue an out-of-hospital DNR order and shall place a copy of the
786	786	directive in the person's medical record. The physician shall sign
787	787	the order in lieu of the person signing under Subsection (b) and may
788	788	use a digital or electronic signature authorized under Section
789	789	166.011.
790	790	SECTION 11. Subsection (d), Section 166.152, Health and
791	791	Safety Code, is amended to read as follows:
792	792	(d) The principal's attending physician shall make
793	793	reasonable efforts to inform the principal of any proposed
794	794	treatment or of any proposal to withdraw or withhold treatment
795	795	before implementing an agent's health care or treatment decision
796	796	[advance directive].
797	797	SECTION 12. Not later than March 1, 2014, the executive
798	798	commissioner of the Health and Human Services Commission shall
799	799	adopt the rules necessary to implement the changes in law made by
800	800	this Act to Chapter 166, Health and Safety Code.
801	801	SECTION 13. The change in law made by this Act applies only
802	802	to a review, consultation, disagreement, or other action relating
803	803	to a health care or treatment decision made on or after April 1,
804	804	2014. A review, consultation, disagreement, or other action
805	805	relating to a health care or treatment decision made before April 1,
806	806	2014, is governed by the law in effect immediately before the
807	807	effective date of this Act, and the former law is continued in
808	808	effect for that purpose.
809	809	SECTION 14. This Act takes effect September 1, 2013.
810	810	* * * * *
811	811
812	812	__________ I request that all treatments other than those needed to keep me comfortable be discontinued or withheld and my physician allow me to die as gently as possible;
813	813
814	814	OR
815	815
816	816	__________ I request that I be kept alive in this terminal condition using available life-sustaining treatment. (THIS SELECTION DOES NOT APPLY TO HOSPICE CARE.)
817	817
818	818	__________ I request that all treatments other than those needed to keep me comfortable be discontinued or withheld and my physician allow me to die as gently as possible;
819	819
820	820	OR
821	821
822	822	__________ I request that I be kept alive in this irreversible condition using available life-sustaining treatment. (THIS SELECTION DOES NOT APPLY TO HOSPICE CARE.)