By: Deuell, Lucio S.B. No. 303
(In the Senate - Filed January 31, 2013; February 5, 2013,
read first time and referred to Committee on Health and Human
Services; April 15, 2013, reported adversely, with favorable
Committee Substitute by the following vote: Yeas 7, Nays 0;
April 15, 2013, sent to printer.)
COMMITTEE SUBSTITUTE FOR S.B. No. 303 By: Deuell
A BILL TO BE ENTITLED
AN ACT
relating to advance directives and health care and treatment
decisions.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 166.002, Health and Safety Code, is
amended by amending Subdivisions (2) and (10) and adding
Subdivision (16) to read as follows:
(2) "Artificially administered [Artificial] nutrition
and hydration" means the provision of nutrients or fluids by a tube
inserted in a vein, under the skin in the subcutaneous tissues, or
in the stomach (gastrointestinal tract).
(10) "Life-sustaining treatment" means treatment
that, based on reasonable medical judgment, sustains the life of a
patient and without which the patient will die. The term includes
both life-sustaining medications and artificial life support, such
as mechanical breathing machines, kidney dialysis treatment, and
artificially administered [artificial] nutrition and hydration.
The term does not include the administration of pain management
medication or the performance of a medical procedure considered to
be necessary to provide comfort care, or any other medical care
provided to alleviate a patient's pain.
(16) "Surrogate" means a legal guardian, an agent
under a medical power of attorney, or a person authorized under
Section 166.039(b) to make a health care or treatment decision for
an incompetent patient under this chapter.
SECTION 2. Subchapter A, Chapter 166, Health and Safety
Code, is amended by adding Section 166.012 to read as follows:
Sec. 166.012. STATEMENT RELATING TO
DO-NOT-ATTEMPT-RESUSCITATION ORDERS. (a) In this section,
"do-not-attempt-resuscitation order" or "DNAR order" means an
order instructing health care professionals not to attempt
cardiopulmonary resuscitation of the patient if circulatory or
respiratory function ceases.
(b) Upon admission, a health care facility shall provide a
patient or surrogate written notice of the facility's policies
regarding the rights of the patient or surrogate under this
section.
(c) Before placing a do-not-attempt-resuscitation (DNAR)
order in a patient's medical record, the physician or the facility's
personnel shall inform the patient or, if the patient is
incompetent, make a reasonably diligent effort to contact or cause
to be contacted the surrogate. The facility shall establish a
policy regarding the notification required under this section. The
policy must authorize the notification to be given verbally by a
physician or facility personnel.
(d) The DNAR order takes effect at the time it is written in
the patient's chart or otherwise placed in the patient's medical
record.
(e) If the patient or surrogate disagrees with the DNAR
order being placed in or removed from the medical record, the
patient or surrogate may request in writing and is entitled to a
consultation or a review of the disagreement by the ethics or
medical committee in the manner described by Section 166.046, with
the patient or surrogate afforded all rights provided to the
surrogate under that section, and with the physician afforded all
protections from liability provided under Section 166.045(d). The
patient or surrogate may discontinue the process initiated under
Section 166.046 by providing written notice to the ethics or
medical committee.
(f) A DNAR order in the patient's medical record at the time
a consultation or review is requested under Subsection (e) must be
removed from the patient's medical record at that time. A DNAR
order may not be placed in the patient's medical record until the
process initiated under Section 166.046 is concluded or
discontinued at the request of the patient or surrogate.
(g) Subsection (c) does not apply to a DNAR order placed in
the medical record of a patient:
(1) whose death, based on reasonable medical judgment,
is imminent despite attempted resuscitation;
(2) for whom, based on reasonable medical judgment,
resuscitation would be medically ineffective and there is
insufficient time to contact the surrogate; or
(3) for whom the DNAR order is consistent with a
patient's or surrogate's request or a patient's advance directive to
not attempt resuscitation.
(h) Subsection (e) does not apply to a DNAR order placed in
the medical record of a patient with respect to whom, based on
reasonable medical judgment, death is imminent and resuscitation
would be medically ineffective.
(i) This section does not create a cause of action or
liability against a physician, health professional acting under the
direction of a physician, or health care facility.
(j) A physician, health professional acting under the
direction of a physician, or health care facility is not civilly or
criminally liable or subject to review or disciplinary action by
the appropriate licensing authority if the actor has complied with
the procedures under this section and Section 166.046.
(k) This section does not affect the immunity from liability
under Section 74.151, Civil Practice and Remedies Code.
(l) This section does not apply to an assisted living
facility licensed under Chapter 247.
SECTION 3. Section 166.033, Health and Safety Code, is
amended to read as follows:
Sec. 166.033. FORM OF WRITTEN DIRECTIVE. A written
directive may be in the following form:
DIRECTIVE TO PHYSICIANS AND FAMILY OR SURROGATES
Instructions for completing this document:
This is an important legal document known as an Advance
Directive. It is designed to help you communicate your wishes about
medical treatment at some time in the future when you are unable to
make your wishes known because of illness or injury. These wishes
are usually based on personal values. In particular, you may want
to consider what burdens or hardships of treatment you would be
willing to accept for a particular amount of benefit obtained if you
were seriously ill.
You are encouraged to discuss your values and wishes with
your family or chosen spokesperson, as well as your physician. Your
physician, other health care provider, or medical institution may
provide you with various resources to assist you in completing your
advance directive. Brief definitions are listed below and may aid
you in your discussions and advance planning. Initial the
treatment choices that best reflect your personal preferences.
Provide a copy of your directive to your physician, usual hospital,
and family or spokesperson. Consider a periodic review of this
document. By periodic review, you can best assure that the
directive reflects your preferences.
In addition to this advance directive, Texas law provides for
two other types of directives that can be important during a serious
illness. These are the Medical Power of Attorney and the
Out-of-Hospital Do-Not-Resuscitate Order. You may wish to discuss
these with your physician, family, hospital representative, or
other advisers. You may also wish to complete a directive related
to the donation of organs and tissues.
DIRECTIVE
I, __________, recognize that the best health care is based
upon a partnership of trust and communication with my physician. My
physician and I will make health care or treatment decisions
together as long as I am of sound mind and able to make my wishes
known. If there comes a time that I am unable to make medical
decisions about myself because of illness or injury, I direct that
the following treatment preferences be honored:
If, in the judgment of my physician, I am suffering with a
terminal condition from which I am expected to die within six
months, even with available life-sustaining treatment provided in
accordance with prevailing standards of medical care:
__________ 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;
__________ 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;
OR OR
OR
__________ 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.)
__________ I request that I be kept alive in this terminal condition using available life-sustaining treatment. (THIS SELECTION DOES NOT APPLY TO HOSPICE CARE.)
If, in the judgment of my physician, I am suffering with an
irreversible condition so that I cannot care for myself or make
decisions for myself and am expected to die without life-sustaining
treatment provided in accordance with prevailing standards of care:
__________ 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;
__________ 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;
OR OR
OR
__________ 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.)
__________ I request that I be kept alive in this irreversible condition using available life-sustaining treatment. (THIS SELECTION DOES NOT APPLY TO HOSPICE CARE.)
Additional requests: (After discussion with your physician,
you may wish to consider listing particular treatments in this
space that you do or do not want in specific circumstances, such as
artificially administered [artificial] nutrition and hydration
[fluids], intravenous antibiotics, etc. Be sure to state whether
you do or do not want the particular treatment.)
After signing this directive, if my representative or I elect
hospice care, I understand and agree that only those treatments
needed to keep me comfortable would be provided and I would not be
given available life-sustaining treatments.
If I do not have a Medical Power of Attorney, and I am unable
to make my wishes known, I designate the following person(s) to make
health care or treatment decisions with my physician compatible
with my personal values:
1. __________
2. __________
(If a Medical Power of Attorney has been executed, then an
agent already has been named and you should not list additional
names in this document.)
If the above persons are not available, or if I have not
designated a spokesperson, I understand that a spokesperson will be
chosen for me following standards specified in the laws of Texas.
If, in the judgment of my physician, my death is imminent within
minutes to hours, even with the use of all available medical
treatment provided within the prevailing standard of care, I
acknowledge that all treatments may be withheld or removed except
those needed to maintain my comfort. I understand that under Texas
law this directive has no effect if I have been diagnosed as
pregnant. This directive will remain in effect until I revoke it.
No other person may do so.
Signed__________ Date__________ City, County, State of
Residence __________
Two competent adult witnesses must sign below, acknowledging
the signature of the declarant. The witness designated as Witness 1
may not be a person designated to make a health care or treatment
decision for the patient and may not be related to the patient by
blood or marriage. This witness may not be entitled to any part of
the estate and may not have a claim against the estate of the
patient. This witness may not be the attending physician or an
employee of the attending physician. If this witness is an employee
of a health care facility in which the patient is being cared for,
this witness may not be involved in providing direct patient care to
the patient. This witness may not be an officer, director, partner,
or business office employee of a health care facility in which the
patient is being cared for or of any parent organization of the
health care facility.
Witness 1 __________ Witness 2 __________
Definitions:
"Artificially administered [Artificial] nutrition and
hydration" means the provision of nutrients or fluids by a tube
inserted in a vein, under the skin in the subcutaneous tissues, or
in the stomach (gastrointestinal tract).
"Irreversible condition" means a condition, injury, or
illness:
(1) that may be treated, but is never cured or
eliminated;
(2) that leaves a person unable to care for or make
decisions for the person's own self; and
(3) that, without life-sustaining treatment provided
in accordance with the prevailing standard of medical care, is
fatal.
Explanation: Many serious illnesses such as cancer, failure
of major organs (kidney, heart, liver, or lung), and serious brain
disease such as Alzheimer's dementia may be considered irreversible
early on. There is no cure, but the patient may be kept alive for
prolonged periods of time if the patient receives life-sustaining
treatments. Late in the course of the same illness, the disease may
be considered terminal when, even with treatment, the patient is
expected to die. You may wish to consider which burdens of
treatment you would be willing to accept in an effort to achieve a
particular outcome. This is a very personal decision that you may
wish to discuss with your physician, family, or other important
persons in your life.
"Life-sustaining treatment" means treatment that, based on
reasonable medical judgment, sustains the life of a patient and
without which the patient will die. The term includes both
life-sustaining medications and artificial life support such as
mechanical breathing machines, kidney dialysis treatment, and
artificially administered nutrition and [artificial] hydration
[and nutrition]. The term does not include the administration of
pain management medication, the performance of a medical procedure
necessary to provide comfort care, or any other medical care
provided to alleviate a patient's pain.
"Terminal condition" means an incurable condition caused by
injury, disease, or illness that according to reasonable medical
judgment will produce death within six months, even with available
life-sustaining treatment provided in accordance with the
prevailing standard of medical care.
Explanation: Many serious illnesses may be considered
irreversible early in the course of the illness, but they may not be
considered terminal until the disease is fairly advanced. In
thinking about terminal illness and its treatment, you again may
wish to consider the relative benefits and burdens of treatment and
discuss your wishes with your physician, family, or other important
persons in your life.
SECTION 4. Section 166.039, Health and Safety Code, is
amended by adding Subsections (a-1) and (b-1) and amending
Subsections (e) and (f) to read as follows:
(a-1) In making the decision described by Subsection (a),
the attending physician may consult with a physician who previously
treated the patient if the previous physician:
(1) is known and available, regardless of whether the
previous physician has discontinued providing care for the patient
or does not have privileges at the treating facility;
(2) had a conversation with the patient on end-of-life
issues at a time when the patient was competent and capable of
communication; and
(3) documented the conversation described by
Subdivision (2) in the patient's medical record.
(b-1) The attending physician and the health care
facility's personnel shall make a reasonably diligent effort to
contact or cause to be contacted the persons listed in Subsection
(b) in the order of priority under Subsection (b) until one of the
persons is contacted or the list is exhausted regarding making a
health care or treatment decision for the patient.
(e) If the patient does not have a legal guardian or agent
under a medical power of attorney and a person listed in Subsection
(b) is not available, a health care or treatment decision made under
Subsection (b) must be concurred with [in] by another physician who
is not involved in the treatment of the patient or who is a
representative of an ethics or medical committee of the health care
facility in which the person is a patient.
(f) The fact that an adult [qualified] patient has not
executed or issued a directive does not create a presumption
regarding the provision, withholding, or withdrawal of [that the
patient does not want a treatment decision to be made to withhold or
withdraw] life-sustaining treatment.
SECTION 5. Subsection (c), Section 166.045, Health and
Safety Code, is amended to read as follows:
(c) If an attending physician disagrees with and refuses to
comply with a patient's directive or a health care or treatment
decision of a patient or of a surrogate made on behalf of an
incompetent patient, and the attending physician does not wish to
follow the procedure established under Section 166.046,
life-sustaining treatment shall be provided to the patient, but
only until a reasonable opportunity has been afforded for the
transfer of the patient to another physician or health care
facility willing to comply with the health care [directive] or
treatment decision.
SECTION 6. The heading to Section 166.046, Health and
Safety Code, is amended to read as follows:
Sec. 166.046. PROCEDURE IF PHYSICIAN DISAGREES WITH AND
REFUSES TO COMPLY WITH HEALTH CARE [NOT EFFECTUATING A DIRECTIVE]
OR TREATMENT DECISION.
SECTION 7. Section 166.046, Health and Safety Code, is
amended by amending Subsections (a), (b), (c), (d), (e), (e-1),
(g), and (h) and adding Subsections (a-1), (a-2), (a-3), (a-4),
(a-5), (a-6), (a-7), (a-8), and (b-1) to read as follows:
(a) If an attending physician disagrees with and refuses to
comply with [honor] a patient's advance directive or a health care
or treatment decision [made by or on behalf] of a patient or of a
surrogate made on behalf of an incompetent patient, the
disagreement and the physician's refusal shall be reviewed by an
ethics or medical committee under this section. The ethics or
medical committee of a facility other than a nursing home licensed
under Chapter 242 may not include any health care provider involved
in the direct care of a patient whose treatment the committee
reviews or a subcommittee of such an ethics or medical committee.
(a-1) If the patient has been diagnosed with a terminal
condition, the ethics or medical committee shall determine if,
based on reasonable medical judgment, the treatment requested by
the patient or, if the patient is incompetent, by the surrogate
would:
(1) hasten the patient's death;
(2) seriously exacerbate other major medical problems
not outweighed by the benefit of the provision of the treatment;
(3) result in substantial irremediable physical pain
or discomfort not outweighed by the benefit of the provision of the
treatment; or
(4) be medically ineffective in prolonging the
patient's life.
(a-2) If the patient has been diagnosed with an irreversible
nonterminal condition, the ethics or medical committee may sustain
the decision to withdraw life-sustaining treatment requested by the
patient or, if the patient is incompetent, by the surrogate only if,
based on reasonable medical judgment, the treatment would:
(1) threaten the patient's life;
(2) seriously exacerbate other major medical problems
not outweighed by the benefit of the provision of the treatment;
(3) result in substantial irremediable physical pain
or discomfort not outweighed by the benefit of the provision of the
treatment; or
(4) be medically ineffective in prolonging the
patient's life.
(a-3) In all deliberations under this section, the ethics or
medical committee should strive to honor the values of each unique
patient. All patients will be treated equally without regard to
permanent physical or mental disabilities, age, gender, religion,
ethnic background, or financial or insurance status. The committee
should make the same decision about whether or not a requested
treatment is medically appropriate for individuals with or without
a permanent disability, advanced age, gender, religious or cultural
differences, or financial circumstances.
(a-4) The fact that life-sustaining treatment is delivered
in an intensive care unit is not itself sufficient to justify the
refusal to provide that treatment. This section does not authorize
withholding or withdrawing pain management medication, medical
procedures considered necessary to provide comfort care, or any
other medical care provided to alleviate a patient's pain.
(a-5) [The attending physician may not be a member of that
committee.] The patient shall be given life-sustaining treatment
pending [during] the ethics or medical committee's review.
(a-6) When an ethics or medical committee review has been
initiated under this chapter, the ethics or medical committee
shall:
(1) inform the patient or surrogate that the patient
or surrogate may discontinue the process under this section by
providing written notice to the ethics or medical committee;
(2) appoint a patient liaison familiar with
end-of-life issues and hospice care options to assist the patient
or surrogate throughout the process described by this section; and
(3) appoint one or more representatives of the ethics
or medical committee to conduct an advisory ethics consultation
with the patient or surrogate, the outcome of which must be
documented in the patient's medical record by a representative of
the committee.
(a-7) If a disagreement over a health care or treatment
decision persists following the consultation described in
Subsection (a-6)(3), the ethics or medical committee shall hold a
meeting to review the disagreement.
(a-8) The ethics or medical committee in holding a review
required under this section, including a review following a
consultation described by Subsection (a-6)(3), shall advise the
patient or surrogate that the patient's attending physician may
present medical facts at the meeting. The patient's attending
physician may attend and present facts but may not participate as a
member of the committee in the case being evaluated.
(b) When a meeting of the ethics or medical committee is
required under this section [The patient or the person responsible
for the health care decisions of the individual who has made the
decision regarding the directive or treatment decision]:
(1) not later than the seventh calendar day before the
scheduled date of the meeting required under this section, unless
the time period is waived by mutual agreement, the committee shall
provide to the patient or surrogate:
(A) [may be given] a written description of the
ethics or medical committee review process and any other policies
and procedures related to this section adopted by the health care
facility;
(B) notice that the patient or surrogate is
entitled to receive the continued assistance of a patient liaison
to assist the patient or surrogate throughout the process described
in this section;
(C) notice that the patient or surrogate may seek
a second opinion at the patient's or surrogate's expense from other
medical professionals regarding the patient's medical status and
treatment requirements and communicate the resulting information
to the members of the committee for consideration before the
meeting;
(D) [(2) shall be informed of the committee
review process not less than 48 hours before the meeting called to
discuss the patient's directive, unless the time period is waived
by mutual agreement;
[(3) at the time of being so informed, shall be
provided:
[(A)] a copy of the appropriate statement set
forth in Section 166.052; and
(E) [(B)] a copy of the registry list of health
care providers, health care facilities, and referral groups that,
in compliance with any state laws prohibiting barratry, have
volunteered their readiness to consider accepting transfer or to
assist in locating a provider willing to accept transfer that is
posted on the website maintained by the department [Texas Health
Care Information Council] under Section 166.053; and
(2) if requested in writing, the patient or surrogate
is entitled to receive from the facility:
(A) not later than 72 hours after the request is
made, a free copy of the portion of the patient's medical record
related to the current admission to the facility or the treatment
received by the patient during the preceding 30 calendar days in the
facility, whichever is shorter, together with any reasonably
available diagnostic results and reports; and
(B) not later than the fifth calendar day after
the date of the request or at another time specified by mutual
agreement, a free copy of the remainder of the patient's medical
record, if any, related to the current admission to the facility.
(b-1) The patient or surrogate[; and
[(4)] is entitled to:
(1) [(A)] attend and participate in the meeting of the
ethics or medical committee, excluding the committee's
deliberations;
(2) be accompanied at the meeting by up to five
persons, or more persons at the committee's discretion, for
support, subject to the facility's reasonable written attendance
policy as necessary to:
(A) facilitate information sharing and
discussion of the patient's medical status and treatment
requirements; and
(B) preserve the order and decorum of the
meeting; and
(3) [(B)] receive a written explanation of the
decision reached during the review process.
(c) The written explanation required by Subsection (b-1)(3)
[(b)(2)(B)] must be included in the patient's medical record.
(d) If the attending physician, the patient, or the
surrogate [person responsible for the health care decisions of the
individual] does not agree with the decision reached during the
review process [under Subsection (b)], the physician and the
facility shall make a reasonably diligent [reasonable] effort to
transfer the patient to a physician of the patient's or surrogate's
choice who is willing to accept the patient [comply with the
directive]. The [If the patient is a patient in a health care
facility, the] facility's personnel shall assist the physician in
arranging the patient's transfer to:
(1) another physician;
(2) an alternative care setting within that facility;
or
(3) another facility.
(e) If the patient or surrogate [the person responsible for
the health care decisions of the patient] is requesting
life-sustaining treatment that the attending physician has decided
and the ethics or medical committee [review process] has affirmed
is medically inappropriate treatment, the patient shall be given
available life-sustaining treatment pending transfer under
Subsection (d). This subsection does not authorize withholding or
withdrawing pain management medication, medical procedures
considered necessary to provide comfort care, or any other medical
care provided to alleviate a patient's pain. The patient is
responsible for any costs incurred in transferring the patient to
another facility. The attending physician, any other physician
responsible for the care of the patient, and the health care
facility are not obligated to provide life-sustaining treatment
after the 21st calendar [10th] day after the written decision
required under Subsection (b-1) [(b)] is provided to the patient or
the surrogate [person responsible for the health care decisions of
the patient] unless ordered to do so under Subsection (g), except
that artificially administered nutrition and hydration must be
provided unless, based on reasonable medical judgment, providing
artificially administered nutrition and hydration would:
(1) hasten the patient's death;
(2) seriously exacerbate other major medical problems
not outweighed by the benefit of the provision of the treatment;
(3) result in substantial irremediable physical pain
or discomfort not outweighed by the benefit of the provision of the
treatment; or
(4) be medically ineffective in prolonging the
patient's life.
(e-1) If during a previous admission to a facility the [a
patient's] attending physician and the ethics or medical committee
[review process under Subsection (b) have] determined that
life-sustaining treatment is inappropriate, a subsequent committee
review is not required if [and] the patient is readmitted to the
same facility for the same condition within six months from the date
of the previous decision, provided that the [reached during the
review process conducted upon the previous admission, Subsections
(b) through (e) need not be followed if the patient's] attending
physician and a consulting physician who is a member of the ethics
or medical committee of the facility document on the patient's
readmission that the patient's condition [either has not improved
or] has deteriorated since the previous review [process] was
conducted.
(g) On motion [At the request] of the patient or surrogate
[the person responsible for the health care decisions of the
patient], the appropriate district or county court shall extend the
time period provided under Subsection (e) [only] if the court
finds, by a preponderance of the evidence, that there is a
reasonable expectation that the patient or surrogate may find a
physician or health care facility that will honor the patient's or
surrogate's health care or treatment decision [directive will be
found] if the time extension is granted.
(h) This section may not be construed to impose an
obligation on a facility or a home and community support services
agency licensed under Chapter 142, an assisted living facility
licensed under Chapter 247, or a similar organization that is
beyond the scope of the services or resources of the facility, [or]
agency, or organization. This section does not apply to hospice
services provided by a home and community support services agency
licensed under Chapter 142 or services provided by an assisted
living facility licensed under Chapter 247.
SECTION 8. Subsections (a) and (b), Section 166.052, Health
and Safety Code, are amended to read as follows:
(a) In cases in which the attending physician disagrees with
and refuses to comply with a health care [honor an advance
directive] or treatment decision requesting the provision of
life-sustaining treatment, the statement required by Section
166.046(b)(1)(D) [166.046(b)(2)(A)] shall be in substantially the
following form:
When There Is A Disagreement About Medical Treatment: The
Physician Recommends Against Certain Life-Sustaining Treatment
That You Wish To Continue
You have been given this information because you have
requested life-sustaining treatment[,]* for yourself as the
patient or on behalf of the patient, as applicable, which the
attending physician believes is not medically appropriate. This
information is being provided to help you understand state law,
your rights, and the resources available to you in such
circumstances. It outlines the process for resolving disagreements
about treatment among patients, families, and physicians. It is
based upon Section 166.046 of the Texas Advance Directives Act,
codified in Chapter 166 of the Texas Health and Safety Code.
When an attending physician disagrees with and refuses to
comply with a [an advance directive or other] request for
life-sustaining treatment because of the physician's medical
judgment that the treatment would be medically inappropriate, the
case will be reviewed by an ethics or medical committee.
Life-sustaining treatment will be provided through the review.
As the patient or the patient's decision-maker, you [You]
will receive notification of this review at least seven calendar
days [48 hours] before a meeting of the committee related to your
case. [You are entitled to attend the meeting.] With your
agreement, the meeting may be held sooner than seven calendar days
[48 hours], if possible.
The committee will appoint a patient liaison to assist you
through this process. You are entitled to attend the meeting,
address the committee, and be accompanied by up to five persons, or
more persons at the committee's discretion, to support you, subject
to the facility's reasonable written attendance policy to
facilitate information sharing and discussion of the patient's
medical status and treatment requirements and preserve the order
and decorum of the meeting. On written request, you are also
entitled to receive:
(1) not later than 72 hours after the request is made,
a free copy of the portion of the patient's medical record related
to the current admission to the facility or the treatment received
during the preceding 30 calendar days in the facility, whichever is
shorter, together with any reasonably available diagnostic results
and reports; and
(2) not later than the fifth calendar day following
the request or at another time specified by mutual agreement, a free
copy of the remainder of the medical record, if any, related to the
current admission to the facility.
As the patient or the patient's decision-maker, you are free
to seek a second opinion at the patient's or your expense from other
medical professionals regarding the patient's medical status and
treatment requirements and communicate the resulting information
to the members of the ethics or medical committee for consideration
before the meeting.
You are entitled to receive a written explanation of the
decision reached during the review process.
If after this review process both the attending physician and
the ethics or medical committee conclude that life-sustaining
treatment is medically inappropriate and yet you continue to
request such treatment, then the following procedure will occur:
1. The physician, with the help of the health care facility,
will assist you in trying to find a physician and facility willing
to provide the requested treatment.
2. You are being given a list of health care providers,
health care facilities, and referral groups that have volunteered
their readiness to consider accepting transfer, or to assist in
locating a provider willing to accept transfer, maintained by the
Department of State [Texas] Health Services [Care Information
Council]. You may wish to contact providers, facilities, or
referral groups on the list or others of your choice to get help in
arranging a transfer.
3. The patient will continue to be given life-sustaining
treatment and treatment to enhance pain management and reduce
suffering, including artificially administered nutrition and
hydration, until the patient [he or she] can be transferred to a
willing provider for up to 21 calendar [10] days from the time you
were given the committee's written decision that life-sustaining
treatment is not medically appropriate.
4. If a transfer can be arranged, the patient will be
responsible for the costs of the transfer.
5. If a provider cannot be found willing to give the
requested treatment within 14 calendar [10] days, life-sustaining
treatment may be withdrawn unless a court of law has granted an
extension.
6. You may ask the appropriate district or county court to
extend the 21-day [10-day] period if the court finds that there is a
reasonable expectation that you may find a physician or health care
facility willing to provide life-sustaining treatment [will be
found] if the extension is granted.
*"Life-sustaining treatment" means treatment that, based on
reasonable medical judgment, sustains the life of a patient and
without which the patient will die. The term includes both
life-sustaining medications and artificial life support, such as
mechanical breathing machines, kidney dialysis treatment, and
artificially administered [artificial] nutrition and hydration.
The term does not include the administration of pain management
medication or the performance of a medical procedure considered to
be necessary to provide comfort care, or any other medical care
provided to alleviate a patient's pain.
(b) In cases in which the attending physician disagrees with
and refuses to comply with a health care [an advance directive] or
treatment decision requesting the withholding or withdrawal of
life-sustaining treatment, the statement required by Section
166.046(b)(1)(D) [166.046(b)(3)(A)] shall be in substantially the
following form:
When There Is A Disagreement About Medical Treatment: The
Physician Recommends Life-Sustaining Treatment That You Wish To
Stop
You have been given this information because you have
requested the withdrawal or withholding of life-sustaining
treatment* for yourself as the patient or on behalf of the patient,
as applicable, and the attending physician disagrees with and
refuses to comply with that request. The information is being
provided to help you understand state law, your rights, and the
resources available to you in such circumstances. It outlines the
process for resolving disagreements about treatment among
patients, families, and physicians. It is based upon Section
166.046 of the Texas Advance Directives Act, codified in Chapter
166 of the Texas Health and Safety Code.
When an attending physician disagrees with and refuses to
comply with a [an advance directive or other] request for
withdrawal or withholding of life-sustaining treatment for any
reason, the case will be reviewed by an ethics or medical committee.
Life-sustaining treatment will be provided through the review.
As the patient or the patient's decision-maker, you [You]
will receive notification of this review at least seven calendar
days [48 hours] before a meeting of the committee related to your
case. You are entitled to attend the meeting. With your agreement,
the meeting may be held sooner than seven calendar days [48 hours],
if possible.
You will be appointed a patient liaison familiar with
end-of-life issues and hospice care options to assist you
throughout this process. A representative of the ethics or medical
committee will also conduct an advisory consultation with you.
On written request you are entitled to receive:
(1) not later than 72 hours after the request is made,
a free copy of the portion of the patient's medical record related
to the current admission to the facility or the treatment received
by the patient during the preceding 30 calendar days in the
facility, whichever is shorter, together with any reasonably
available diagnostic results and reports; and
(2) not later than the fifth calendar day following
the date of the request or at another time specified by mutual
agreement, a free copy of the remainder of the medical record, if
any, related to the current admission to the facility.
As the patient or the patient's decision-maker, you are free
to seek a second opinion at the patient's or your expense from other
medical professionals regarding the patient's medical status and
treatment requests and communicate the resulting information to the
members of the ethics or medical committee for consideration before
the meeting.
You are entitled to receive a written explanation of the
decision reached during the review process.
If you or the attending physician do not agree with the
decision reached during the review process, and the attending
physician still disagrees with and refuses to comply with your
request to withhold or withdraw life-sustaining treatment, then the
following procedure will occur:
1. The physician, with the help of the health care facility,
will assist you in trying to find a physician and facility willing
to accept the patient [withdraw or withhold the life-sustaining
treatment].
2. You are being given a list of health care providers,
health care facilities, and referral groups that have volunteered
their readiness to consider accepting transfer, or to assist in
locating a provider willing to accept transfer, maintained by the
Department of State [Texas] Health Services [Care Information
Council]. You may wish to contact providers, facilities, or
referral groups on the list or others of your choice to get help in
arranging a transfer.
*"Life-sustaining treatment" means treatment that, based on
reasonable medical judgment, sustains the life of a patient and
without which the patient will die. The term includes both
life-sustaining medications and artificial life support, such as
mechanical breathing machines, kidney dialysis treatment, and
artificially administered [artificial] nutrition and hydration.
The term does not include the administration of pain management
medication or the performance of a medical procedure considered to
be necessary to provide comfort care, or any other medical care
provided to alleviate a patient's pain.
SECTION 9. Subchapter B, Chapter 166, Health and Safety
Code, is amended by adding Section 166.054 to read as follows:
Sec. 166.054. REPORTING REQUIREMENTS REGARDING ETHICS OR
MEDICAL COMMITTEE PROCESSES. (a) On submission of a health care
facility's application to renew its license, a facility in which
one or more meetings of an ethics or medical committee are held
under this chapter shall file a report with the department that
contains aggregate information regarding the number of cases
initiated by an ethics or medical committee under Section 166.046
and the disposition of those cases by the facility.
(b) Aggregate data submitted to the department under this
section may include only the following:
(1) the total number of patients for whom a review by
the ethics or medical committee was initiated under Section
166.046(b);
(2) the number of patients under Subdivision (1) who
were transferred to:
(A) another physician within the same facility;
or
(B) a different facility;
(3) the number of patients under Subdivision (1) who
were discharged to home;
(4) the number of patients under Subdivision (1) for
whom treatment was withheld or withdrawn pursuant to surrogate
consent:
(A) before the decision was rendered following a
review under Section 166.046(b);
(B) after the decision was rendered following a
review under Section 166.046(b); or
(C) during or after the 21-day period described
by Section 166.046(e);
(5) the average length of stay before a review meeting
is held under Section 166.046(b); and
(6) the number of patients under Subdivision (1) who
died while still receiving life-sustaining treatment:
(A) before the review meeting under Section
166.046(b);
(B) during the 21-day period; or
(C) during extension of the 21-day period, if
any.
(c) The report required by this section may not contain any
data specific to an individual patient or physician.
(d) The department shall adopt rules to:
(1) establish a standard form for the reporting
requirements of this section; and
(2) post on the department's Internet website the data
submitted under Subsection (b) in the format provided by rule.
(e) Data collected as required by, or submitted to the
department under, this section:
(1) is not admissible in a civil or criminal
proceeding in which a physician, health care professional acting
under the direction of a physician, or health care facility is a
defendant; and
(2) may not be used in relation to any disciplinary
action by a licensing board or other body with professional or
administrative oversight over a physician, health care
professional acting under the direction of a physician, or health
care facility.
SECTION 10. Subsections (a) and (c), Section 166.082,
Health and Safety Code, are amended to read as follows:
(a) A competent adult [person] may at any time execute a
written out-of-hospital DNR order directing health care
professionals acting in an out-of-hospital setting to withhold
cardiopulmonary resuscitation and certain other life-sustaining
treatment designated by the board.
(c) If the person is incompetent but previously executed or
issued a directive to physicians in accordance with Subchapter B
requesting that all treatment, other than treatment necessary for
keeping the person comfortable, be discontinued or withheld, the
physician may rely on the directive as the person's instructions to
issue an out-of-hospital DNR order and shall place a copy of the
directive in the person's medical record. The physician shall sign
the order in lieu of the person signing under Subsection (b) and may
use a digital or electronic signature authorized under Section
166.011.
SECTION 11. Subsection (d), Section 166.152, Health and
Safety Code, is amended to read as follows:
(d) The principal's attending physician shall make
reasonable efforts to inform the principal of any proposed
treatment or of any proposal to withdraw or withhold treatment
before implementing an agent's health care or treatment decision
[advance directive].
SECTION 12. Not later than March 1, 2014, the executive
commissioner of the Health and Human Services Commission shall
adopt the rules necessary to implement the changes in law made by
this Act to Chapter 166, Health and Safety Code.
SECTION 13. The change in law made by this Act applies only
to a review, consultation, disagreement, or other action relating
to a health care or treatment decision made on or after April 1,
2014. A review, consultation, disagreement, or other action
relating to a health care or treatment decision made before April 1,
2014, is governed by the law in effect immediately before the
effective date of this Act, and the former law is continued in
effect for that purpose.
SECTION 14. This Act takes effect September 1, 2013.
* * * * *
__________ 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;
OR
__________ 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 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;
OR
__________ I request that I be kept alive in this irreversible condition using available life-sustaining treatment. (THIS SELECTION DOES NOT APPLY TO HOSPICE CARE.)