Texas 2017 - 85th Regular

Texas House Bill HB3857 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1	85R7044 DMS-D
2	2	By: Coleman H.B. No. 3857
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to the authority of an advanced practice registered nurse
8	8	or physician assistant to sign a death certificate or
9	9	out-of-hospital do-not-resuscitate order.
10	10	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
11	11	SECTION 1. Section 166.081(6), Health and Safety Code, is
12	12	amended to read as follows:
13	13	(6) "Out-of-hospital DNR order":
14	14	(A) means a legally binding out-of-hospital
15	15	do-not-resuscitate order, in the form specified by department rule
16	16	under Section 166.083, prepared and signed as required by this
17	17	subchapter [by the attending physician of a person], that documents
18	18	the instructions of a person or the person's legally authorized
19	19	representative and directs health care professionals acting in an
20	20	out-of-hospital setting not to initiate or continue the following
21	21	life-sustaining treatment:
22	22	(i) cardiopulmonary resuscitation;
23	23	(ii) advanced airway management;
24	24	(iii) artificial ventilation;
25	25	(iv) defibrillation;
26	26	(v) transcutaneous cardiac pacing; and
27	27	(vi) other life-sustaining treatment
28	28	specified by department rule under Section 166.101(a); and
29	29	(B) does not include authorization to withhold
30	30	medical interventions or therapies considered necessary to provide
31	31	comfort care or to alleviate pain or to provide water or nutrition.
32	32	SECTION 2. Sections 166.082(b) and (c), Health and Safety
33	33	Code, are amended to read as follows:
34	34	(b) Except as provided by this subsection, the declarant
35	35	must sign the out-of-hospital DNR order in the presence of two
36	36	witnesses who qualify under Section 166.003, at least one of whom
37	37	must be a witness who qualifies under Section 166.003(2). The
38	38	witnesses must sign the order. The attending physician, a
39	39	physician assistant, or an advanced practice registered nurse
40	40	providing care to [of] the declarant must sign the order and shall
41	41	make the fact of the existence of the order and the reasons for
42	42	execution of the order a part of the declarant's medical record.
43	43	The declarant, in lieu of signing in the presence of witnesses, may
44	44	sign the out-of-hospital DNR order and have the signature
45	45	acknowledged before a notary public.
46	46	(c) If the person is incompetent but previously executed or
47	47	issued a directive to physicians in accordance with Subchapter B,
48	48	the physician, a physician assistant, or an advanced practice
49	49	registered nurse providing care to the person may rely on the
50	50	directive as the person's instructions to issue an out-of-hospital
51	51	DNR order and shall place a copy of the directive in the person's
52	52	medical record. The physician, the physician assistant, or the
53	53	advanced practice registered nurse shall sign the order in lieu of
54	54	the person signing under Subsection (b) and may use a digital or
55	55	electronic signature authorized under Section 166.011.
56	56	SECTION 3. Section 166.083(b), Health and Safety Code, is
57	57	amended to read as follows:
58	58	(b) The standard form of an out-of-hospital DNR order
59	59	specified by department rule must, at a minimum, contain the
60	60	following:
61	61	(1) a distinctive single-page format that readily
62	62	identifies the document as an out-of-hospital DNR order;
63	63	(2) a title that readily identifies the document as an
64	64	out-of-hospital DNR order;
65	65	(3) the printed or typed name of the person;
66	66	(4) a statement that the physician, physician
67	67	assistant, or advanced practice registered nurse signing the
68	68	document is the person's attending physician or a physician
69	69	assistant or advanced practice registered nurse of the person and
70	70	that the physician, physician assistant, or advanced practice
71	71	registered nurse is directing health care professionals acting in
72	72	out-of-hospital settings, including a hospital emergency
73	73	department, not to initiate or continue certain life-sustaining
74	74	treatment on behalf of the person, and a listing of those procedures
75	75	not to be initiated or continued;
76	76	(5) a statement that the person understands that the
77	77	person may revoke the out-of-hospital DNR order at any time by
78	78	destroying the order and removing the DNR identification device, if
79	79	any, or by communicating to health care professionals at the scene
80	80	the person's desire to revoke the out-of-hospital DNR order;
81	81	(6) places for the printed names and signatures of the
82	82	witnesses or the notary public's acknowledgment and for the printed
83	83	name and signature of the attending physician, the physician
84	84	assistant, or the advanced practice registered nurse of the person
85	85	and the professional's [medical] license number [of the attending
86	86	physician];
87	87	(7) a separate section for execution of the document
88	88	by the legal guardian of the person, the person's proxy, an agent of
89	89	the person having a medical power of attorney, [or] the attending
90	90	physician, the physician assistant, or the advanced practice
91	91	registered nurse attesting to the issuance of an out-of-hospital
92	92	DNR order by nonwritten means of communication or acting in
93	93	accordance with a previously executed or previously issued
94	94	directive to physicians under Section 166.082(c) that includes the
95	95	following:
96	96	(A) a statement that the legal guardian, the
97	97	proxy, the agent, the person by nonwritten means of communication,
98	98	[or] the physician, the physician assistant, or the advanced
99	99	practice registered nurse directs that each listed life-sustaining
100	100	treatment should not be initiated or continued in behalf of the
101	101	person; and
102	102	(B) places for the printed names and signatures
103	103	of the witnesses and, as applicable, the legal guardian, proxy,
104	104	agent, [or] physician, physician assistant, or advanced practice
105	105	registered nurse;
106	106	(8) a separate section for execution of the document
107	107	by at least one qualified relative of the person when the person
108	108	does not have a legal guardian, proxy, or agent having a medical
109	109	power of attorney and is incompetent or otherwise mentally or
110	110	physically incapable of communication, including:
111	111	(A) a statement that the relative of the person
112	112	is qualified to make a treatment decision to withhold
113	113	cardiopulmonary resuscitation and certain other designated
114	114	life-sustaining treatment under Section 166.088 and, based on the
115	115	known desires of the person or a determination of the best interest
116	116	of the person, directs that each listed life-sustaining treatment
117	117	should not be initiated or continued in behalf of the person; and
118	118	(B) places for the printed names and signatures
119	119	of the witnesses and qualified relative of the person;
120	120	(9) a place for entry of the date of execution of the
121	121	document;
122	122	(10) a statement that the document is in effect on the
123	123	date of its execution and remains in effect until the death of the
124	124	person or until the document is revoked;
125	125	(11) a statement that the document must accompany the
126	126	person during transport;
127	127	(12) a statement regarding the proper disposition of
128	128	the document or copies of the document, as the executive
129	129	commissioner determines appropriate; and
130	130	(13) a statement at the bottom of the document, with
131	131	places for the signature of each person executing the document,
132	132	that the document has been properly completed.
133	133	SECTION 4. Sections 166.084(b) and (c), Health and Safety
134	134	Code, are amended to read as follows:
135	135	(b) A declarant must issue the nonwritten out-of-hospital
136	136	DNR order in the presence of the person's attending physician or a
137	137	physician assistant or advanced practice registered nurse of the
138	138	person and two witnesses who qualify under Section 166.003, at
139	139	least one of whom must be a witness who qualifies under Section
140	140	166.003(2).
141	141	(c) The attending physician, the physician assistant, or
142	142	the advanced practice registered nurse and witnesses shall sign the
143	143	out-of-hospital DNR order in the place of the document provided by
144	144	Section 166.083(b)(7) and the attending physician, the physician
145	145	assistant, or the advanced practice registered nurse shall sign the
146	146	document in the place required by Section 166.083(b)(13). The
147	147	physician, physician assistant, or advanced practice registered
148	148	nurse shall make the fact of the existence of the out-of-hospital
149	149	DNR order a part of the declarant's medical record and the names of
150	150	the witnesses shall be entered in the medical record.
151	151	SECTION 5. Sections 166.087(b) and (c), Health and Safety
152	152	Code, are amended to read as follows:
153	153	(b) If the adult person has designated a person to make a
154	154	treatment decision as authorized by Section 166.032(c), the
155	155	person's attending physician or a physician assistant or advanced
156	156	practice registered nurse of the person and the designated person
157	157	shall comply with the out-of-hospital DNR order.
158	158	(c) If the adult person has not designated a person to make a
159	159	treatment decision as authorized by Section 166.032(c), the
160	160	person's attending physician or a physician assistant or advanced
161	161	practice registered nurse of the person shall comply with the
162	162	out-of-hospital DNR order unless the physician, physician
163	163	assistant, or advanced practice registered nurse believes that the
164	164	order does not reflect the person's present desire.
165	165	SECTION 6. Sections 166.088(a), (b), and (f), Health and
166	166	Safety Code, are amended to read as follows:
167	167	(a) If an adult person has not executed or issued an
168	168	out-of-hospital DNR order and is incompetent or otherwise mentally
169	169	or physically incapable of communication, the person's attending
170	170	physician or a physician assistant or advanced practice registered
171	171	nurse of the person and the person's legal guardian, proxy, or agent
172	172	having a medical power of attorney may execute an out-of-hospital
173	173	DNR order on behalf of the person.
174	174	(b) If the person does not have a legal guardian, proxy, or
175	175	agent under a medical power of attorney, the person's attending
176	176	physician or a physician assistant or advanced practice registered
177	177	nurse of the person and at least one qualified relative from a
178	178	category listed by Section 166.039(b), subject to the priority
179	179	established under that subsection, may execute an out-of-hospital
180	180	DNR order in the same manner as a treatment decision made under
181	181	Section 166.039(b).
182	182	(f) If there is not a qualified relative available to act
183	183	for the person under Subsection (b), an out-of-hospital DNR order
184	184	must be concurred in by another physician, physician assistant, or
185	185	advanced practice registered nurse who is not involved in the
186	186	treatment of the patient or who is a representative of the ethics or
187	187	medical committee of the health care facility in which the person is
188	188	a patient.
189	189	SECTION 7. Sections 166.089(d), (h), and (i), Health and
190	190	Safety Code, are amended to read as follows:
191	191	(d) The responding health care professionals must determine
192	192	that the out-of-hospital DNR order form appears to be valid in that
193	193	it includes:
194	194	(1) written responses in the places designated on the
195	195	form for the names, signatures, and other information required of
196	196	persons executing or issuing, or witnessing or acknowledging as
197	197	applicable, the execution or issuance of, the order;
198	198	(2) a date in the place designated on the form for the
199	199	date the order was executed or issued; and
200	200	(3) the signature or digital or electronic signature
201	201	of the declarant or persons executing or issuing the order and the
202	202	attending physician, a physician assistant, or an advanced practice
203	203	registered nurse in the appropriate places designated on the form
204	204	for indicating that the order form has been properly completed.
205	205	(h) An out-of-hospital DNR order executed or issued and
206	206	documented or evidenced in the manner prescribed by this subchapter
207	207	is valid and shall be honored by responding health care
208	208	professionals unless the person or persons found at the scene:
209	209	(1) identify themselves as the declarant or as the
210	210	person's attending physician or a physician assistant or advanced
211	211	practice registered nurse of the person, legal guardian, qualified
212	212	relative, or agent of the person having a medical power of attorney
213	213	who executed or issued the out-of-hospital DNR order on behalf of
214	214	the person; and
215	215	(2) request that cardiopulmonary resuscitation or
216	216	certain other life-sustaining treatment designated by department
217	217	rule be initiated or continued.
218	218	(i) If the policies of a health care facility preclude
219	219	compliance with the out-of-hospital DNR order of a person or an
220	220	out-of-hospital DNR order issued by an attending physician, a
221	221	physician assistant, or an advanced practice registered nurse on
222	222	behalf of a person who is admitted to or a resident of the facility,
223	223	or if the facility is unwilling to accept DNR identification
224	224	devices as evidence of the existence of an out-of-hospital DNR
225	225	order, that facility shall take all reasonable steps to notify the
226	226	person or, if the person is incompetent, the person's guardian or
227	227	the person or persons having authority to make health care
228	228	treatment decisions on behalf of the person, of the facility's
229	229	policy and shall take all reasonable steps to effect the transfer of
230	230	the person to the person's home or to a facility where the
231	231	provisions of this subchapter can be carried out.
232	232	SECTION 8. Section 166.092(b), Health and Safety Code, is
233	233	amended to read as follows:
234	234	(b) An oral revocation under Subsection (a)(3) or (a)(4)
235	235	takes effect only when the declarant or a person who identifies
236	236	himself or herself as the legal guardian, a qualified relative, or
237	237	the agent of the declarant having a medical power of attorney who
238	238	executed the out-of-hospital DNR order communicates the intent to
239	239	revoke the order to the responding health care professionals or the
240	240	person's attending physician or the physician assistant or advanced
241	241	practice registered nurse of the person at the scene. The
242	242	responding health care professionals shall record the time, date,
243	243	and place of the revocation in accordance with the statewide
244	244	out-of-hospital DNR protocol and rules adopted by the executive
245	245	commissioner and any applicable local out-of-hospital DNR
246	246	protocol. The attending physician, [or] the physician's designee,
247	247	the physician assistant, or the advanced practice registered nurse
248	248	shall record in the person's medical record the time, date, and
249	249	place of the revocation and, if different, the time, date, and place
250	250	that the physician, physician assistant, or advanced practice
251	251	registered nurse received notice of the revocation. The attending
252	252	physician, [or] the physician's designee, the physician assistant,
253	253	or the advanced practice registered nurse shall also enter the word
254	254	"VOID" on each page of the copy of the order in the person's medical
255	255	record.
256	256	SECTION 9. Section 166.095(c), Health and Safety Code, is
257	257	amended to read as follows:
258	258	(c) If a person's [an] attending physician or a physician
259	259	assistant or advanced practice registered nurse of the person
260	260	refuses to execute or comply with an out-of-hospital DNR order, the
261	261	physician, physician assistant, or advanced practice registered
262	262	nurse shall inform the person, the legal guardian or qualified
263	263	relatives of the person, or the agent of the person having a medical
264	264	power of attorney and, if the person or another authorized to act on
265	265	behalf of the person so directs, shall make a reasonable effort to
266	266	transfer the person to another physician, physician assistant, or
267	267	advanced practice registered nurse who is willing to execute or
268	268	comply with an out-of-hospital DNR order.
269	269	SECTION 10. The heading to Section 166.102, Health and
270	270	Safety Code, is amended to read as follows:
271	271	Sec. 166.102. [PHYSICIAN'S] DNR ORDER MAY BE HONORED BY
272	272	HEALTH CARE PERSONNEL OTHER THAN EMERGENCY MEDICAL SERVICES
273	273	PERSONNEL.
274	274	SECTION 11. Section 166.102(a), Health and Safety Code, is
275	275	amended to read as follows:
276	276	(a) Except as provided by Subsection (b), a licensed nurse
277	277	or person providing health care services in an out-of-hospital
278	278	setting may honor a physician's, physician assistant's, or advanced
279	279	practice registered nurse's do-not-resuscitate order.
280	280	SECTION 12. Sections 193.005(a), (b), and (c), Health and
281	281	Safety Code, are amended to read as follows:
282	282	(a) A person required to file a death certificate or fetal
283	283	death certificate shall obtain the required medical certification
284	284	from the decedent's [an] attending physician or a physician
285	285	assistant or advanced practice registered nurse of the decedent if
286	286	the death occurred under [medical attendance for] the care of the
287	287	person in connection with the [and] treatment of the condition or
288	288	disease process that contributed to the death.
289	289	(b) The attending physician, physician assistant, or
290	290	advanced practice registered nurse shall complete the medical
291	291	certification not later than five days after receiving the death
292	292	certificate.
293	293	(c) An associate physician, the chief medical officer of the
294	294	institution where the death occurred, a physician assistant or
295	295	advanced practice registered nurse at the institution where the
296	296	death occurred, or the physician who performed an autopsy on the
297	297	decedent may complete the medical certification if:
298	298	(1) the attending physician, the physician assistant,
299	299	or the advanced practice registered nurse described by Subsection
300	300	(a) is unavailable;
301	301	(2) the attending physician, the physician assistant,
302	302	or the advanced practice registered nurse described by Subsection
303	303	(a) approves; and
304	304	(3) the person completing the medical certification
305	305	has access to the medical history of the case and the death is due to
306	306	natural causes.
307	307	SECTION 13. Section 671.001(d), Health and Safety Code, is
308	308	amended to read as follows:
309	309	(d) A registered nurse, including an advanced practice
310	310	registered nurse, or physician assistant may determine and
311	311	pronounce a person dead in situations other than those described by
312	312	Subsection (b) if permitted by written policies of a licensed
313	313	health care facility, institution, or entity providing services to
314	314	that person. Those policies must include physician assistants who
315	315	are credentialed or otherwise permitted to practice at the
316	316	facility, institution, or entity. If the facility, institution, or
317	317	entity has an organized nursing staff and an organized medical
318	318	staff or medical consultant, the nursing staff and medical staff or
319	319	consultant shall jointly develop and approve those policies. The
320	320	executive commissioner of the Health and Human Services Commission
321	321	shall adopt rules to govern policies for facilities, institutions,
322	322	or entities that do not have organized nursing staffs and organized
323	323	medical staffs or medical consultants.
324	324	SECTION 14. Section 671.002(a), Health and Safety Code, is
325	325	amended to read as follows:
326	326	(a) A physician who determines death in accordance with
327	327	Section 671.001(b) or a registered nurse, including an advanced
328	328	practice registered nurse, or physician assistant who determines
329	329	death in accordance with Section 671.001(d) is not liable for civil
330	330	damages or subject to criminal prosecution for the physician's,
331	331	registered nurse's, or physician assistant's actions or the actions
332	332	of others based on the determination of death.
333	333	SECTION 15. This Act takes effect immediately if it
334	334	receives a vote of two-thirds of all the members elected to each
335	335	house, as provided by Section 39, Article III, Texas Constitution.
336	336	If this Act does not receive the vote necessary for immediate
337	337	effect, this Act takes effect September 1, 2017.