Texas 2021 - 87th Regular

Texas Senate Bill SB1752 Compare Versions

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

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1	1	87R6313 SCL-F
2	2	By: Johnson S.B. No. 1752
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, or physician, regarding death certificates
9	9	and certain do-not-resuscitate orders.
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 declarant's attending
39	39	physician, or a physician assistant or an advanced practice
40	40	registered nurse providing care to [of] the declarant, must sign
41	41	the order and shall make the fact of the existence of the order and
42	42	the reasons for execution of the order a part of the declarant's
43	43	medical record. The declarant, in lieu of signing in the presence
44	44	of witnesses, may sign the out-of-hospital DNR order and have the
45	45	signature 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, or a physician assistant or 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, physician assistant, or advanced
53	53	practice registered nurse shall sign the order in lieu of the person
54	54	signing under Subsection (b) and may use a digital or electronic
55	55	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 is directing] health care professionals acting
71	71	in out-of-hospital settings, including a hospital emergency
72	72	department, are being directed not to initiate or continue certain
73	73	life-sustaining treatment on behalf of the person, and a listing of
74	74	those procedures not to be initiated or continued;
75	75	(5) a statement that the person understands that the
76	76	person may revoke the out-of-hospital DNR order at any time by
77	77	destroying the order and removing the DNR identification device, if
78	78	any, or by communicating to health care professionals at the scene
79	79	the person's desire to revoke the out-of-hospital DNR order;
80	80	(6) places for the printed names and signatures of the
81	81	witnesses or the notary public's acknowledgment and for the printed
82	82	name and signature of the person's attending physician, or a
83	83	physician assistant or an advanced practice registered nurse of the
84	84	person, and the professional's [medical] license number [of the
85	85	attending physician];
86	86	(7) a separate section for execution of the document
87	87	by the legal guardian of the person, the person's proxy, an agent of
88	88	the person having a medical power of attorney, [or] the attending
89	89	physician, the physician assistant, or the advanced practice
90	90	registered nurse attesting to the issuance of an out-of-hospital
91	91	DNR order by nonwritten means of communication or acting in
92	92	accordance with a previously executed or previously issued
93	93	directive to physicians under Section 166.082(c) that includes the
94	94	following:
95	95	(A) a statement that the legal guardian, the
96	96	proxy, the agent, the person by nonwritten means of communication,
97	97	[or] the physician, the physician assistant, or the advanced
98	98	practice registered nurse directs that each listed life-sustaining
99	99	treatment should not be initiated or continued in behalf of the
100	100	person; and
101	101	(B) places for the printed names and signatures
102	102	of the witnesses and, as applicable, the legal guardian, proxy,
103	103	agent, [or] physician, physician assistant, or advanced practice
104	104	registered nurse;
105	105	(8) a separate section for execution of the document
106	106	by at least one qualified relative of the person when the person
107	107	does not have a legal guardian, proxy, or agent having a medical
108	108	power of attorney and is incompetent or otherwise mentally or
109	109	physically incapable of communication, including:
110	110	(A) a statement that the relative of the person
111	111	is qualified to make a treatment decision to withhold
112	112	cardiopulmonary resuscitation and certain other designated
113	113	life-sustaining treatment under Section 166.088 and, based on the
114	114	known desires of the person or a determination of the best interest
115	115	of the person, directs that each listed life-sustaining treatment
116	116	should not be initiated or continued in behalf of the person; and
117	117	(B) places for the printed names and signatures
118	118	of the witnesses and qualified relative of the person;
119	119	(9) a place for entry of the date of execution of the
120	120	document;
121	121	(10) a statement that the document is in effect on the
122	122	date of its execution and remains in effect until the death of the
123	123	person or until the document is revoked;
124	124	(11) a statement that the document must accompany the
125	125	person during transport;
126	126	(12) a statement regarding the proper disposition of
127	127	the document or copies of the document, as the executive
128	128	commissioner determines appropriate; and
129	129	(13) a statement at the bottom of the document, with
130	130	places for the signature of each person executing the document,
131	131	that the document has been properly completed.
132	132	SECTION 4. Sections 166.084(b) and (c), Health and Safety
133	133	Code, are amended to read as follows:
134	134	(b) A declarant must issue the nonwritten out-of-hospital
135	135	DNR order in the presence of the person's attending physician, or a
136	136	physician assistant or advanced practice registered nurse of the
137	137	person, and two witnesses who qualify under Section 166.003, at
138	138	least one of whom must be a witness who qualifies under Section
139	139	166.003(2).
140	140	(c) The attending physician, the physician assistant, or
141	141	the advanced practice registered nurse and witnesses shall sign the
142	142	out-of-hospital DNR order in the place of the document provided by
143	143	Section 166.083(b)(7) and the attending physician, the physician
144	144	assistant, or the advanced practice registered nurse shall sign the
145	145	document in the place required by Section 166.083(b)(13). The
146	146	physician, physician assistant, or advanced practice registered
147	147	nurse shall make the fact of the existence of the out-of-hospital
148	148	DNR order a part of the declarant's medical record and the names of
149	149	the witnesses shall be entered in the medical record.
150	150	SECTION 5. Sections 166.087(b) and (c), Health and Safety
151	151	Code, are amended to read as follows:
152	152	(b) If the adult person has designated a person to make a
153	153	treatment decision as authorized by Section 166.032(c), the
154	154	person's attending physician, or a physician assistant or advanced
155	155	practice registered nurse of the person, and the designated person
156	156	shall comply with the out-of-hospital DNR order.
157	157	(c) If the adult person has not designated a person to make a
158	158	treatment decision as authorized by Section 166.032(c), the
159	159	person's attending physician, or a physician assistant or advanced
160	160	practice registered nurse of the person, shall comply with the
161	161	out-of-hospital DNR order unless the physician, physician
162	162	assistant, or advanced practice registered nurse believes that the
163	163	order does not reflect the person's present desire.
164	164	SECTION 6. Sections 166.088(a), (b), and (f), Health and
165	165	Safety Code, are amended to read as follows:
166	166	(a) If an adult person has not executed or issued an
167	167	out-of-hospital DNR order and is incompetent or otherwise mentally
168	168	or physically incapable of communication, the person's attending
169	169	physician, or a physician assistant or advanced practice registered
170	170	nurse providing care to the person, and the person's legal
171	171	guardian, proxy, or agent having a medical power of attorney may
172	172	execute an out-of-hospital DNR order on behalf of the person.
173	173	(b) If the person does not have a legal guardian, proxy, or
174	174	agent under a medical power of attorney, the person's attending
175	175	physician, or a physician assistant or advanced practice registered
176	176	nurse providing care to the person, and at least one qualified
177	177	relative from a category listed by Section 166.039(b), subject to
178	178	the priority established under that subsection, may execute an
179	179	out-of-hospital DNR order in the same manner as a treatment
180	180	decision made under Section 166.039(b).
181	181	(f) If there is not a qualified relative available to act
182	182	for the person under Subsection (b), an out-of-hospital DNR order
183	183	must be concurred in by another physician, physician assistant, or
184	184	advanced practice registered nurse who is not involved in the
185	185	treatment of the patient or who is a representative of the ethics or
186	186	medical committee of the health care facility in which the person is
187	187	a patient.
188	188	SECTION 7. Sections 166.089(d), (h), and (i), Health and
189	189	Safety Code, are amended to read as follows:
190	190	(d) The responding health care professionals must determine
191	191	that the out-of-hospital DNR order form appears to be valid in that
192	192	it includes:
193	193	(1) written responses in the places designated on the
194	194	form for the names, signatures, and other information required of
195	195	persons executing or issuing, or witnessing or acknowledging as
196	196	applicable, the execution or issuance of, the order;
197	197	(2) a date in the place designated on the form for the
198	198	date the order was executed or issued; and
199	199	(3) the signature or digital or electronic signature
200	200	of the declarant or persons executing or issuing the order and the
201	201	attending physician, a physician assistant, or an advanced practice
202	202	registered nurse in the appropriate places designated on the form
203	203	for indicating that the order form has been properly completed.
204	204	(h) An out-of-hospital DNR order executed or issued and
205	205	documented or evidenced in the manner prescribed by this subchapter
206	206	is valid and shall be honored by responding health care
207	207	professionals unless the person or persons found at the scene:
208	208	(1) identify themselves as the declarant or as the
209	209	person's attending physician, or a physician assistant or advanced
210	210	practice registered nurse of the person, legal guardian, qualified
211	211	relative, or agent of the person having a medical power of attorney
212	212	who executed or issued the out-of-hospital DNR order on behalf of
213	213	the person; and
214	214	(2) request that cardiopulmonary resuscitation or
215	215	certain other life-sustaining treatment designated by department
216	216	rule be initiated or continued.
217	217	(i) If the policies of a health care facility preclude
218	218	compliance with the out-of-hospital DNR order of a person or an
219	219	out-of-hospital DNR order issued by an attending physician, a
220	220	physician assistant, or an advanced practice registered nurse on
221	221	behalf of a person who is admitted to or a resident of the facility,
222	222	or if the facility is unwilling to accept DNR identification
223	223	devices as evidence of the existence of an out-of-hospital DNR
224	224	order, that facility shall take all reasonable steps to notify the
225	225	person or, if the person is incompetent, the person's guardian or
226	226	the person or persons having authority to make health care
227	227	treatment decisions on behalf of the person, of the facility's
228	228	policy and shall take all reasonable steps to effect the transfer of
229	229	the person to the person's home or to a facility where the
230	230	provisions of this subchapter can be carried out.
231	231	SECTION 8. Section 166.092(b), Health and Safety Code, is
232	232	amended to read as follows:
233	233	(b) An oral revocation under Subsection (a)(3) or (a)(4)
234	234	takes effect only when the declarant or a person who identifies
235	235	himself or herself as the legal guardian, a qualified relative, or
236	236	the agent of the declarant having a medical power of attorney who
237	237	executed the out-of-hospital DNR order communicates the intent to
238	238	revoke the order to the responding health care professionals or the
239	239	person's attending physician, or the physician assistant or
240	240	advanced practice registered nurse of the person, at the scene. The
241	241	responding health care professionals shall record the time, date,
242	242	and place of the revocation in accordance with the statewide
243	243	out-of-hospital DNR protocol and rules adopted by the executive
244	244	commissioner and any applicable local out-of-hospital DNR
245	245	protocol. The attending physician, [or] the physician's designee,
246	246	the physician assistant, or the advanced practice registered nurse
247	247	shall record in the person's medical record the time, date, and
248	248	place of the revocation and, if different, the time, date, and place
249	249	that the physician, physician assistant, or advanced practice
250	250	registered nurse received notice of the revocation. The attending
251	251	physician, [or] the physician's designee, the physician assistant,
252	252	or the advanced practice registered nurse shall also enter the word
253	253	"VOID" on each page of the copy of the order in the person's medical
254	254	record.
255	255	SECTION 9. Section 166.095(c), Health and Safety Code, is
256	256	amended to read as follows:
257	257	(c) If a person's [an] attending physician, or a physician
258	258	assistant or advanced practice registered nurse providing care to
259	259	the person, refuses to execute or comply with an out-of-hospital
260	260	DNR order, the physician, physician assistant, or advanced practice
261	261	registered nurse shall inform the person, the legal guardian or
262	262	qualified relatives of the person, or the agent of the person having
263	263	a medical power of attorney and, if the person or another authorized
264	264	to act on behalf of the person so directs, shall make a reasonable
265	265	effort to transfer the person to another physician, physician
266	266	assistant, or advanced practice registered nurse who is willing to
267	267	execute or comply with an out-of-hospital DNR order.
268	268	SECTION 10. The heading to Section 166.102, Health and
269	269	Safety Code, is amended to read as follows:
270	270	Sec. 166.102. [PHYSICIAN'S] DNR ORDER MAY BE HONORED BY
271	271	HEALTH CARE PERSONNEL OTHER THAN EMERGENCY MEDICAL SERVICES
272	272	PERSONNEL.
273	273	SECTION 11. Section 166.102(a), Health and Safety Code, is
274	274	amended to read as follows:
275	275	(a) Except as provided by Subsection (b), a licensed nurse
276	276	or person providing health care services in an out-of-hospital
277	277	setting may honor a physician's, physician assistant's, or advanced
278	278	practice registered nurse's do-not-resuscitate order.
279	279	SECTION 12. Section 166.203(a), Health and Safety Code, is
280	280	amended to read as follows:
281	281	(a) A DNR order issued for a patient is valid only if the
282	282	patient's attending physician, or a physician assistant or advanced
283	283	practice registered nurse of the patient, issues the order, the
284	284	order is dated, and the order:
285	285	(1) is issued in compliance with:
286	286	(A) the written and dated directions of a patient
287	287	who was competent at the time the patient wrote the directions;
288	288	(B) the oral directions of a competent patient
289	289	delivered to or observed by two competent adult witnesses, at least
290	290	one of whom must be a person not listed under Section 166.003(2)(E)
291	291	or (F);
292	292	(C) the directions in an advance directive
293	293	enforceable under Section 166.005 or executed in accordance with
294	294	Section 166.032, 166.034, or 166.035;
295	295	(D) the directions of a patient's legal guardian
296	296	or agent under a medical power of attorney acting in accordance with
297	297	Subchapter D; or
298	298	(E) a treatment decision made in accordance with
299	299	Section 166.039; or
300	300	(2) is not contrary to the directions of a patient who
301	301	was competent at the time the patient conveyed the directions and,
302	302	in the reasonable medical judgment of the patient's attending
303	303	physician:
304	304	(A) the patient's death is imminent, regardless
305	305	of the provision of cardiopulmonary resuscitation; and
306	306	(B) the DNR order is medically appropriate.
307	307	SECTION 13. Sections 166.205(a), (b), and (c), Health and
308	308	Safety Code, are amended to read as follows:
309	309	(a) A physician, physician assistant, or advanced practice
310	310	registered nurse providing direct care to a patient for whom a DNR
311	311	order is issued shall revoke the patient's DNR order if the patient
312	312	or, as applicable, the patient's agent under a medical power of
313	313	attorney or the patient's legal guardian if the patient is
314	314	incompetent:
315	315	(1) effectively revokes an advance directive, in
316	316	accordance with Section 166.042, for which a DNR order is issued
317	317	under Section 166.203(a); or
318	318	(2) expresses to any person providing direct care to
319	319	the patient a revocation of consent to or intent to revoke a DNR
320	320	order issued under Section 166.203(a).
321	321	(b) A person providing direct care to a patient under the
322	322	supervision of a physician, physician assistant, or advanced
323	323	practice registered nurse shall notify the physician, physician
324	324	assistant, or advanced practice registered nurse of the request to
325	325	revoke a DNR order under Subsection (a).
326	326	(c) A patient's attending physician, or a physician
327	327	assistant or advanced practice registered nurse of the patient, may
328	328	at any time revoke a DNR order issued under Section 166.203(a)(2).
329	329	SECTION 14. Section 193.005(a), Health and Safety Code, is
330	330	amended to read as follows:
331	331	(a) A person required to file a death certificate or fetal
332	332	death certificate shall obtain the required medical certification
333	333	from the decedent's attending physician, or[, subject to Subsection
334	334	(a-1),] a physician assistant or advanced practice registered nurse
335	335	of the decedent, if the death occurred under the care of the person
336	336	in connection with the treatment of the condition or disease
337	337	process that contributed to the death.
338	338	SECTION 15. Section 193.005(a-1), Health and Safety Code,
339	339	is repealed.
340	340	SECTION 16. This Act takes effect immediately if it
341	341	receives a vote of two-thirds of all the members elected to each
342	342	house, as provided by Section 39, Article III, Texas Constitution.
343	343	If this Act does not receive the vote necessary for immediate
344	344	effect, this Act takes effect September 1, 2021.