Texas 2015 - 84th Regular

Texas House Bill HB3074 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
1		-	By: Springer, et al. (Senate Sponsor - Schwertner) H.B. No. 3074
2		-	(In the Senate - Received from the House May 18, 2015;
3		-	May 18, 2015, read first time and referred to Committee on Health
4		-	and Human Services; May 22, 2015, reported favorably by the
5		-	following vote: Yeas 9, Nays 0; May 22, 2015, sent to printer.)
6		-	Click here to see the committee vote
	1	+	H.B. No. 3074
7	2
8	3
9		-	A BILL TO BE ENTITLED
10	4		AN ACT
11	5		relating to the provision of artificially administered nutrition
12	6		and hydration and life-sustaining treatment.
13	7		BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
14	8		SECTION 1. Sections 166.002(2) and (10), Health and Safety
15	9		Code, are amended to read as follows:
16	10		(2) "Artificially administered [Artificial] nutrition
17	11		and hydration" means the provision of nutrients or fluids by a tube
18	12		inserted in a vein, under the skin in the subcutaneous tissues, or
19	13		in the [stomach (]gastrointestinal tract[)].
20	14		(10) "Life-sustaining treatment" means treatment
21	15		that, based on reasonable medical judgment, sustains the life of a
22	16		patient and without which the patient will die. The term includes
23	17		both life-sustaining medications and artificial life support, such
24	18		as mechanical breathing machines, kidney dialysis treatment, and
25	19		artificially administered [artificial] nutrition and hydration.
26	20		The term does not include the administration of pain management
27	21		medication or the performance of a medical procedure considered to
28	22		be necessary to provide comfort care, or any other medical care
29	23		provided to alleviate a patient's pain.
30	24		SECTION 2. Section 166.003, Health and Safety Code, is
31	25		amended to read as follows:
32	26		Sec. 166.003. WITNESSES. In any circumstance in which this
33	27		chapter requires the execution of an advance directive or the
34	28		issuance of a nonwritten advance directive to be witnessed:
35	29		(1) each witness must be a competent adult; and
36	30		(2) at least one of the witnesses must be a person who
37	31		is not:
38	32		(A) a person designated by the declarant to make
39	33		a health care or treatment decision;
40	34		(B) a person related to the declarant by blood or
41	35		marriage;
42	36		(C) a person entitled to any part of the
43	37		declarant's estate after the declarant's death under a will or
44	38		codicil executed by the declarant or by operation of law;
45	39		(D) the attending physician;
46	40		(E) an employee of the attending physician;
47	41		(F) an employee of a health care facility in
48	42		which the declarant is a patient if the employee is providing direct
49	43		patient care to the declarant or is an officer, director, partner,
50	44		or business office employee of the health care facility or of any
51	45		parent organization of the health care facility; or
52	46		(G) a person who, at the time the written advance
53	47		directive is executed or, if the directive is a nonwritten
54	48		directive issued under this chapter, at the time the nonwritten
55	49		directive is issued, has a claim against any part of the declarant's
56	50		estate after the declarant's death.
57	51		SECTION 3. Section 166.032(c), Health and Safety Code, is
58	52		amended to read as follows:
59	53		(c) A declarant may include in a directive directions other
60	54		than those provided by Section 166.033 and may designate in a
61	55		directive a person to make a health care or treatment decision for
62	56		the declarant in the event the declarant becomes incompetent or
63	57		otherwise mentally or physically incapable of communication.
64	58		SECTION 4. Section 166.033, Health and Safety Code, is
65	59		amended to read as follows:
66	60		Sec. 166.033. FORM OF WRITTEN DIRECTIVE. A written
67	61		directive may be in the following form:
68	62		DIRECTIVE TO PHYSICIANS AND FAMILY OR SURROGATES
69	63		Instructions for completing this document:
70	64		This is an important legal document known as an Advance
71	65		Directive. It is designed to help you communicate your wishes about
72	66		medical treatment at some time in the future when you are unable to
73	67		make your wishes known because of illness or injury. These wishes
74	68		are usually based on personal values. In particular, you may want
75	69		to consider what burdens or hardships of treatment you would be
76	70		willing to accept for a particular amount of benefit obtained if you
77	71		were seriously ill.
78	72		You are encouraged to discuss your values and wishes with
79	73		your family or chosen spokesperson, as well as your physician. Your
80	74		physician, other health care provider, or medical institution may
81	75		provide you with various resources to assist you in completing your
82	76		advance directive. Brief definitions are listed below and may aid
83	77		you in your discussions and advance planning. Initial the
84	78		treatment choices that best reflect your personal preferences.
85	79		Provide a copy of your directive to your physician, usual hospital,
86	80		and family or spokesperson. Consider a periodic review of this
87	81		document. By periodic review, you can best assure that the
88	82		directive reflects your preferences.
89	83		In addition to this advance directive, Texas law provides for
90	84		two other types of directives that can be important during a serious
91	85		illness. These are the Medical Power of Attorney and the
92	86		Out-of-Hospital Do-Not-Resuscitate Order. You may wish to discuss
93	87		these with your physician, family, hospital representative, or
94	88		other advisers. You may also wish to complete a directive related
95	89		to the donation of organs and tissues.
96	90		DIRECTIVE
97	91		I, __________, recognize that the best health care is based
98	92		upon a partnership of trust and communication with my physician. My
99	93		physician and I will make health care or treatment decisions
100	94		together as long as I am of sound mind and able to make my wishes
101	95		known. If there comes a time that I am unable to make medical
102	96		decisions about myself because of illness or injury, I direct that
103	97		the following treatment preferences be honored:
104	98		If, in the judgment of my physician, I am suffering with a
105	99		terminal condition from which I am expected to die within six
106	100		months, even with available life-sustaining treatment provided in
107	101		accordance with prevailing standards of medical care:
108	102		__________ 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 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
109	103		__________ 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
110	104		__________ 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.)
111	105		__________ I request that I be kept alive in this terminal condition using available life-sustaining treatment. (THIS SELECTION DOES NOT APPLY TO HOSPICE CARE.)
112	106		If, in the judgment of my physician, I am suffering with an
113	107		irreversible condition so that I cannot care for myself or make
114	108		decisions for myself and am expected to die without life-sustaining
115	109		treatment provided in accordance with prevailing standards of care:
116	110		__________ 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 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
117	111		__________ 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
118	112		__________ 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.)
119	113		__________ I request that I be kept alive in this irreversible condition using available life-sustaining treatment. (THIS SELECTION DOES NOT APPLY TO HOSPICE CARE.)
120	114		Additional requests: (After discussion with your physician,
121	115		you may wish to consider listing particular treatments in this
122	116		space that you do or do not want in specific circumstances, such as
123	117		artificially administered [artificial] nutrition and hydration
124	118		[fluids], intravenous antibiotics, etc. Be sure to state whether
125	119		you do or do not want the particular treatment.)
126	120		After signing this directive, if my representative or I elect
127	121		hospice care, I understand and agree that only those treatments
128	122		needed to keep me comfortable would be provided and I would not be
129	123		given available life-sustaining treatments.
130	124		If I do not have a Medical Power of Attorney, and I am unable
131	125		to make my wishes known, I designate the following person(s) to make
132	126		health care or treatment decisions with my physician compatible
133	127		with my personal values:
134	128		1. __________
135	129		2. __________
136	130		(If a Medical Power of Attorney has been executed, then an
137	131		agent already has been named and you should not list additional
138	132		names in this document.)
139	133		If the above persons are not available, or if I have not
140	134		designated a spokesperson, I understand that a spokesperson will be
141	135		chosen for me following standards specified in the laws of Texas.
142	136		If, in the judgment of my physician, my death is imminent within
143	137		minutes to hours, even with the use of all available medical
144	138		treatment provided within the prevailing standard of care, I
145	139		acknowledge that all treatments may be withheld or removed except
146	140		those needed to maintain my comfort. I understand that under Texas
147	141		law this directive has no effect if I have been diagnosed as
148	142		pregnant. This directive will remain in effect until I revoke it.
149	143		No other person may do so.
150	144		Signed__________ Date__________ City, County, State of
151	145		Residence __________
152	146		Two competent adult witnesses must sign below, acknowledging
153	147		the signature of the declarant. The witness designated as Witness 1
154	148		may not be a person designated to make a health care or treatment
155	149		decision for the patient and may not be related to the patient by
156	150		blood or marriage. This witness may not be entitled to any part of
157	151		the estate and may not have a claim against the estate of the
158	152		patient. This witness may not be the attending physician or an
159	153		employee of the attending physician. If this witness is an employee
160	154		of a health care facility in which the patient is being cared for,
161	155		this witness may not be involved in providing direct patient care to
162	156		the patient. This witness may not be an officer, director, partner,
163	157		or business office employee of a health care facility in which the
164	158		patient is being cared for or of any parent organization of the
165	159		health care facility.
166	160		Witness 1 __________ Witness 2 __________
167	161		Definitions:
168	162		"Artificially administered [Artificial] nutrition and
169	163		hydration" means the provision of nutrients or fluids by a tube
170	164		inserted in a vein, under the skin in the subcutaneous tissues, or
171	165		in the [stomach (]gastrointestinal tract[)].
172	166		"Irreversible condition" means a condition, injury, or
173	167		illness:
174	168		(1) that may be treated, but is never cured or
175	169		eliminated;
176	170		(2) that leaves a person unable to care for or make
177	171		decisions for the person's own self; and
178	172		(3) that, without life-sustaining treatment provided
179	173		in accordance with the prevailing standard of medical care, is
180	174		fatal.
181	175		Explanation: Many serious illnesses such as cancer, failure
182	176		of major organs (kidney, heart, liver, or lung), and serious brain
183	177		disease such as Alzheimer's dementia may be considered irreversible
184	178		early on. There is no cure, but the patient may be kept alive for
185	179		prolonged periods of time if the patient receives life-sustaining
186	180		treatments. Late in the course of the same illness, the disease may
187	181		be considered terminal when, even with treatment, the patient is
188	182		expected to die. You may wish to consider which burdens of
189	183		treatment you would be willing to accept in an effort to achieve a
190	184		particular outcome. This is a very personal decision that you may
191	185		wish to discuss with your physician, family, or other important
192	186		persons in your life.
193	187		"Life-sustaining treatment" means treatment that, based on
194	188		reasonable medical judgment, sustains the life of a patient and
195	189		without which the patient will die. The term includes both
196	190		life-sustaining medications and artificial life support such as
197	191		mechanical breathing machines, kidney dialysis treatment, and
198	192		artificially administered nutrition and [artificial] hydration
199	193		[and nutrition]. The term does not include the administration of
200	194		pain management medication, the performance of a medical procedure
201	195		necessary to provide comfort care, or any other medical care
202	196		provided to alleviate a patient's pain.
203	197		"Terminal condition" means an incurable condition caused by
204	198		injury, disease, or illness that according to reasonable medical
205	199		judgment will produce death within six months, even with available
206	200		life-sustaining treatment provided in accordance with the
207	201		prevailing standard of medical care.
208	202		Explanation: Many serious illnesses may be considered
209	203		irreversible early in the course of the illness, but they may not be
210	204		considered terminal until the disease is fairly advanced. In
211	205		thinking about terminal illness and its treatment, you again may
212	206		wish to consider the relative benefits and burdens of treatment and
213	207		discuss your wishes with your physician, family, or other important
214	208		persons in your life.
215	209		SECTION 5. Sections 166.046(b) and (e), Health and Safety
216	210		Code, as amended by S.B. 219, Acts of the 84th Legislature, Regular
217	211		Session, 2015, are amended to read as follows:
218	212		(b) The patient or the person responsible for the health
219	213		care decisions of the individual who has made the decision
220	214		regarding the directive or treatment decision:
221	215		(1) may be given a written description of the ethics or
222	216		medical committee review process and any other policies and
223	217		procedures related to this section adopted by the health care
224	218		facility;
225	219		(2) shall be informed of the committee review process
226	220		not less than 48 hours before the meeting called to discuss the
227	221		patient's directive, unless the time period is waived by mutual
228	222		agreement;
229	223		(3) at the time of being so informed, shall be
230	224		provided:
231	225		(A) a copy of the appropriate statement set forth
232	226		in Section 166.052; and
233	227		(B) a copy of the registry list of health care
234	228		providers and referral groups that have volunteered their readiness
235	229		to consider accepting transfer or to assist in locating a provider
236	230		willing to accept transfer that is posted on the website maintained
237	231		by the department under Section 166.053; and
238	232		(4) is entitled to:
239	233		(A) attend the meeting; [and]
240	234		(B) receive a written explanation of the decision
241	235		reached during the review process;
242	236		(C) receive a copy of the portion of the
243	237		patient's medical record related to the treatment received by the
244	238		patient in the facility for the lesser of:
245	239		(i) the period of the patient's current
246	240		admission to the facility; or
247	241		(ii) the preceding 30 calendar days; and
248	242		(D) receive a copy of all of the patient's
249	243		reasonably available diagnostic results and reports related to the
250	244		medical record provided under Paragraph (C).
251	245		(e) If the patient or the person responsible for the health
252	246		care decisions of the patient is requesting life-sustaining
253	247		treatment that the attending physician has decided and the ethics
254	248		or medical committee [review process] has affirmed is medically
255	249		inappropriate treatment, the patient shall be given available
256	250		life-sustaining treatment pending transfer under Subsection (d).
257	251		This subsection does not authorize withholding or withdrawing pain
258	252		management medication, medical procedures necessary to provide
259	253		comfort, or any other health care provided to alleviate a patient's
260	254		pain. The patient is responsible for any costs incurred in
261	255		transferring the patient to another facility. The attending
262	256		physician, any other physician responsible for the care of the
263	257		patient, and the health care facility are not obligated to provide
264	258		life-sustaining treatment after the 10th day after both the written
265	259		decision and the patient's medical record required under Subsection
266	260		(b) are [is] provided to the patient or the person responsible for
267	261		the health care decisions of the patient unless ordered to do so
268	262		under Subsection (g), except that artificially administered
269	263		nutrition and hydration must be provided unless, based on
270	264		reasonable medical judgment, providing artificially administered
271	265		nutrition and hydration would:
272	266		(1) hasten the patient's death;
273	267		(2) be medically contraindicated such that the
274	268		provision of the treatment seriously exacerbates life-threatening
275	269		medical problems not outweighed by the benefit of the provision of
276	270		the treatment;
277	271		(3) result in substantial irremediable physical pain
278	272		not outweighed by the benefit of the provision of the treatment;
279	273		(4) be medically ineffective in prolonging life; or
280	274		(5) be contrary to the patient's or surrogate's
281	275		clearly documented desire not to receive artificially administered
282	276		nutrition or hydration.
283	277		SECTION 6. Sections 166.052(a) and (b), Health and Safety
284	278		Code, as amended by S.B. 219, Acts of the 84th Legislature, Regular
285	279		Session, 2015, are amended to read as follows:
286	280		(a) In cases in which the attending physician refuses to
287	281		honor an advance directive or health care or treatment decision
288	282		requesting the provision of life-sustaining treatment, the
289	283		statement required by Section 166.046(b)(3)(A) shall be in
290	284		substantially the following form:
291	285		When There Is A Disagreement About Medical Treatment: The
292	286		Physician Recommends Against Certain Life-Sustaining Treatment
293	287		That You Wish To Continue
294	288		You have been given this information because you have
295	289		requested life-sustaining treatment[,]* for yourself as the
296	290		patient or on behalf of the patient, as applicable, which the
297	291		attending physician believes is not medically appropriate. This
298	292		information is being provided to help you understand state law,
299	293		your rights, and the resources available to you in such
300	294		circumstances. It outlines the process for resolving disagreements
301	295		about treatment among patients, families, and physicians. It is
302	296		based upon Section 166.046 of the Texas Advance Directives Act,
303	297		codified in Chapter 166, [of the] Texas Health and Safety Code.
304	298		When an attending physician refuses to comply with an advance
305	299		directive or other request for life-sustaining treatment because of
306	300		the physician's judgment that the treatment would be medically
307	301		inappropriate, the case will be reviewed by an ethics or medical
308	302		committee. Life-sustaining treatment will be provided through the
309	303		review.
310	304		You will receive notification of this review at least 48
311	305		hours before a meeting of the committee related to your case. You
312	306		are entitled to attend the meeting. With your agreement, the
313	307		meeting may be held sooner than 48 hours, if possible.
314	308		You are entitled to receive a written explanation of the
315	309		decision reached during the review process.
316	310		If after this review process both the attending physician and
317	311		the ethics or medical committee conclude that life-sustaining
318	312		treatment is medically inappropriate and yet you continue to
319	313		request such treatment, then the following procedure will occur:
320	314		1. The physician, with the help of the health care facility,
321	315		will assist you in trying to find a physician and facility willing
322	316		to provide the requested treatment.
323	317		2. You are being given a list of health care providers,
324	318		licensed physicians, health care facilities, and referral groups
325	319		that have volunteered their readiness to consider accepting
326	320		transfer, or to assist in locating a provider willing to accept
327	321		transfer, maintained by the Department of State Health Services.
328	322		You may wish to contact providers, facilities, or referral groups
329	323		on the list or others of your choice to get help in arranging a
330	324		transfer.
331	325		3. The patient will continue to be given life-sustaining
332	326		treatment until the patient [he or she] can be transferred to a
333	327		willing provider for up to 10 days from the time you were given both
334	328		the committee's written decision that life-sustaining treatment is
335	329		not appropriate and the patient's medical record. The patient will
336	330		continue to be given after the 10-day period treatment to enhance
337	331		pain management and reduce suffering, including artificially
338	332		administered nutrition and hydration, unless, based on reasonable
339	333		medical judgment, providing artificially administered nutrition
340	334		and hydration would hasten the patient's death, be medically
341	335		contraindicated such that the provision of the treatment seriously
342	336		exacerbates life-threatening medical problems not outweighed by
343	337		the benefit of the provision of the treatment, result in
344	338		substantial irremediable physical pain not outweighed by the
345	339		benefit of the provision of the treatment, be medically ineffective
346	340		in prolonging life, or be contrary to the patient's or surrogate's
347	341		clearly documented desires.
348	342		4. If a transfer can be arranged, the patient will be
349	343		responsible for the costs of the transfer.
350	344		5. If a provider cannot be found willing to give the
351	345		requested treatment within 10 days, life-sustaining treatment may
352	346		be withdrawn unless a court of law has granted an extension.
353	347		6. You may ask the appropriate district or county court to
354	348		extend the 10-day period if the court finds that there is a
355	349		reasonable expectation that you may find a physician or health care
356	350		facility willing to provide life-sustaining treatment [will be
357	351		found] if the extension is granted. Patient medical records will be
358	352		provided to the patient or surrogate in accordance with Section
359	353		241.154, Texas Health and Safety Code.
360	354		*"Life-sustaining treatment" means treatment that, based on
361	355		reasonable medical judgment, sustains the life of a patient and
362	356		without which the patient will die. The term includes both
363	357		life-sustaining medications and artificial life support, such as
364	358		mechanical breathing machines, kidney dialysis treatment, and
365	359		artificially administered [artificial] nutrition and hydration.
366	360		The term does not include the administration of pain management
367	361		medication or the performance of a medical procedure considered to
368	362		be necessary to provide comfort care, or any other medical care
369	363		provided to alleviate a patient's pain.
370	364		(b) In cases in which the attending physician refuses to
371	365		comply with an advance directive or treatment decision requesting
372	366		the withholding or withdrawal of life-sustaining treatment, the
373	367		statement required by Section 166.046(b)(3)(A) shall be in
374	368		substantially the following form:
375	369		When There Is A Disagreement About Medical Treatment: The
376	370		Physician Recommends Life-Sustaining Treatment That You Wish To
377	371		Stop
378	372		You have been given this information because you have
379	373		requested the withdrawal or withholding of life-sustaining
380	374		treatment* for yourself as the patient or on behalf of the patient,
381	375		as applicable, and the attending physician disagrees with and
382	376		refuses to comply with that request. The information is being
383	377		provided to help you understand state law, your rights, and the
384	378		resources available to you in such circumstances. It outlines the
385	379		process for resolving disagreements about treatment among
386	380		patients, families, and physicians. It is based upon Section
387	381		166.046 of the Texas Advance Directives Act, codified in Chapter
388	382		166, [of the] Texas Health and Safety Code.
389	383		When an attending physician refuses to comply with an advance
390	384		directive or other request for withdrawal or withholding of
391	385		life-sustaining treatment for any reason, the case will be reviewed
392	386		by an ethics or medical committee. Life-sustaining treatment will
393	387		be provided through the review.
394	388		You will receive notification of this review at least 48
395	389		hours before a meeting of the committee related to your case. You
396	390		are entitled to attend the meeting. With your agreement, the
397	391		meeting may be held sooner than 48 hours, if possible.
398	392		You are entitled to receive a written explanation of the
399	393		decision reached during the review process.
400	394		If you or the attending physician do not agree with the
401	395		decision reached during the review process, and the attending
402	396		physician still refuses to comply with your request to withhold or
403	397		withdraw life-sustaining treatment, then the following procedure
404	398		will occur:
405	399		1. The physician, with the help of the health care facility,
406	400		will assist you in trying to find a physician and facility willing
407	401		to withdraw or withhold the life-sustaining treatment.
408	402		2. You are being given a list of health care providers,
409	403		licensed physicians, health care facilities, and referral groups
410	404		that have volunteered their readiness to consider accepting
411	405		transfer, or to assist in locating a provider willing to accept
412	406		transfer, maintained by the Department of State Health Services.
413	407		You may wish to contact providers, facilities, or referral groups
414	408		on the list or others of your choice to get help in arranging a
415	409		transfer.
416	410		*"Life-sustaining treatment" means treatment that, based on
417	411		reasonable medical judgment, sustains the life of a patient and
418	412		without which the patient will die. The term includes both
419	413		life-sustaining medications and artificial life support, such as
420	414		mechanical breathing machines, kidney dialysis treatment, and
421	415		artificially administered [artificial] nutrition and hydration.
422	416		The term does not include the administration of pain management
423	417		medication or the performance of a medical procedure considered to
424	418		be necessary to provide comfort care, or any other medical care
425	419		provided to alleviate a patient's pain.
426	420		SECTION 7. Not later than March 1, 2016, the executive
427	421		commissioner of the Health and Human Services Commission shall
428	422		adopt all rules necessary to implement this Act.
429	423		SECTION 8. The change in law made by this Act applies only
430	424		to a review, consultation, disagreement, or other action relating
431	425		to a health care or treatment decision made on or after April 1,
432	426		2016. A review, consultation, disagreement, or other action
433	427		relating to a health care or treatment decision made before April 1,
434	428		2016, is governed by the law in effect immediately before the
435	429		effective date of this Act, and that law is continued in effect for
436	430		that purpose.
437	431		SECTION 9. This Act takes effect September 1, 2015.
438		-	* * * * *
	432	+	______________________________ ______________________________
	433	+	President of the Senate Speaker of the House
	434	+	I certify that H.B. No. 3074 was passed by the House on May
	435	+	15, 2015, by the following vote: Yeas 129, Nays 0, 1 present, not
	436	+	voting.
	437	+	______________________________
	438	+	Chief Clerk of the House
	439	+	I certify that H.B. No. 3074 was passed by the Senate on May
	440	+	26, 2015, by the following vote: Yeas 31, Nays 0.
	441	+	______________________________
	442	+	Secretary of the Senate
	443	+	APPROVED: _____________________
	444	+	Date
	445	+	_____________________
	446	+	Governor
439	447
440	448		__________ 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
441	449
442	450		__________ I request that I be kept alive in this terminal condition using available life-sustaining treatment. (THIS SELECTION DOES NOT APPLY TO HOSPICE CARE.)
443	451
444	452		__________ 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
445	453
446	454		__________ I request that I be kept alive in this irreversible condition using available life-sustaining treatment. (THIS SELECTION DOES NOT APPLY TO HOSPICE CARE.)