88R3162 JG-D
 
  By: Johnson S.B. No. 2039
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to health care practitioner authority regarding certain
  do-not-resuscitate orders, including the use of electronic copies
  and photographs of out-of-hospital do-not-resuscitate orders.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Section 166.081(6), Health and Safety Code, is
  amended to read as follows:
               (6)  "Out-of-hospital DNR order":
                     (A)  means a legally binding out-of-hospital
  do-not-resuscitate order, in the form specified by department rule
  under Section 166.083, prepared and signed as required by this
  subchapter [by the attending physician of a person], that documents
  the instructions of a person or the person's legally authorized
  representative and directs health care professionals acting in an
  out-of-hospital setting not to initiate or continue the following
  life-sustaining treatment:
                           (i)  cardiopulmonary resuscitation;
                           (ii)  advanced airway management;
                           (iii)  artificial ventilation;
                           (iv)  defibrillation;
                           (v)  transcutaneous cardiac pacing; and
                           (vi)  other life-sustaining treatment
  specified by department rule under Section 166.101(a); and
                     (B)  does not include authorization to withhold
  medical interventions or therapies considered necessary to provide
  comfort care or to alleviate pain or to provide water or nutrition.
         SECTION 2.  Sections 166.082(b) and (c), Health and Safety
  Code, are amended to read as follows:
         (b)  Except as provided by this subsection, the declarant
  must sign the out-of-hospital DNR order in the presence of two
  witnesses who qualify under Section 166.003, at least one of whom
  must be a witness who qualifies under Section 166.003(2). The
  witnesses must sign the order.  The declarant's attending
  physician, or a physician assistant or an advanced practice
  registered nurse providing care to [of] the declarant, must sign
  the order and shall make the fact of the existence of the order and
  the reasons for execution of the order a part of the declarant's
  medical record. The declarant, in lieu of signing in the presence
  of witnesses, may sign the out-of-hospital DNR order and have the
  signature acknowledged before a notary public.
         (c)  If the person is incompetent but previously executed or
  issued a directive to physicians in accordance with Subchapter B,
  the physician, or a physician assistant or advanced practice
  registered nurse providing care to the person, 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, physician assistant, or advanced
  practice registered nurse 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 3.  Sections 166.083(b) and (d), Health and Safety
  Code, are amended to read as follows:
         (b)  The standard form of an out-of-hospital DNR order
  specified by department rule must, at a minimum, contain the
  following:
               (1)  a distinctive single-page format that readily
  identifies the document as an out-of-hospital DNR order;
               (2)  a title that readily identifies the document as an
  out-of-hospital DNR order;
               (3)  the printed or typed name of the person who
  executed or issued the document or for whom the document was
  executed or issued;
               (4)  a statement that the physician, physician
  assistant, or advanced practice registered nurse signing the
  document is the person's attending physician, or a physician
  assistant or advanced practice registered nurse providing care to 
  [of] the person, and that [the physician is directing] health care
  professionals acting in out-of-hospital settings, including a
  hospital emergency department, are directed not to initiate or
  continue certain life-sustaining treatment on behalf of the person,
  and a listing of those procedures not to be initiated or continued;
               (5)  a statement that the person understands that the
  person may revoke the out-of-hospital DNR order at any time by
  destroying the order and removing the DNR identification device, if
  any, or by communicating to health care professionals at the scene
  the person's desire to revoke the out-of-hospital DNR order;
               (6)  places for the printed names and signatures of the
  witnesses or the notary public's acknowledgment and for the printed
  name and signature of the person's attending physician, or a
  physician assistant or an advanced practice registered nurse
  providing care to [of] the person, and the professional's [medical]
  license number [of the attending physician];
               (7)  a separate section for execution of the document
  by the legal guardian of the person, the person's proxy, an agent of
  the person having a medical power of attorney, [or] the attending
  physician, the physician assistant, or the advanced practice
  registered nurse attesting to the issuance of an out-of-hospital
  DNR order by nonwritten means of communication or acting in
  accordance with a previously executed or previously issued
  directive to physicians under Section 166.082(c) that includes the
  following:
                     (A)  a statement that the legal guardian, the
  proxy, the agent, the person by nonwritten means of communication,
  [or] the physician, the physician assistant, or the advanced
  practice registered nurse directs that each listed life-sustaining
  treatment should not be initiated or continued in behalf of the
  person; and
                     (B)  places for the printed names and signatures
  of the witnesses and, as applicable, the legal guardian, proxy,
  agent, [or] physician, physician assistant, or advanced practice
  registered nurse;
               (8)  a separate section for execution of the document
  by at least one qualified relative of the person when the person
  does not have a legal guardian, proxy, or agent having a medical
  power of attorney and is incompetent or otherwise mentally or
  physically incapable of communication, including:
                     (A)  a statement that the relative of the person
  is qualified to make a treatment decision to withhold
  cardiopulmonary resuscitation and certain other designated
  life-sustaining treatment under Section 166.088 and, based on the
  known desires of the person or a determination of the best interest
  of the person, directs that each listed life-sustaining treatment
  should not be initiated or continued in behalf of the person; and
                     (B)  places for the printed names and signatures
  of the witnesses and qualified relative of the person;
               (9)  a place for entry of the date of execution of the
  document;
               (10)  a statement that the document is in effect on the
  date of its execution and remains in effect until the death of the
  person or until the document is revoked;
               (11)  a statement that the document must accompany the
  person during transport;
               (12)  a statement regarding the proper disposition of
  the document or copies of the document, as the executive
  commissioner determines appropriate; and
               (13)  a statement at the bottom of the document, with
  places for the signature of each person executing the document,
  that the document has been properly completed.
         (d)  A photocopy or other complete facsimile, including an
  electronic copy or photograph, of the original written
  out-of-hospital DNR order executed under this subchapter may be
  used for any purpose for which the original written order may be
  used under this subchapter.
         SECTION 4.  Sections 166.084(b) and (c), Health and Safety
  Code, are amended to read as follows:
         (b)  A declarant must issue the nonwritten out-of-hospital
  DNR order in the presence of the declarant's attending physician,
  or a physician assistant or advanced practice registered nurse
  providing care to the declarant, and two witnesses who qualify
  under Section 166.003, at least one of whom must be a witness who
  qualifies under Section 166.003(2).
         (c)  The attending physician, the physician assistant, or
  the advanced practice registered nurse and witnesses shall sign the
  out-of-hospital DNR order in the place of the document provided by
  Section 166.083(b)(7) and the attending physician, the physician
  assistant, or the advanced practice registered nurse shall sign the
  document in the place required by Section 166.083(b)(13). The
  physician, physician assistant, or advanced practice registered
  nurse shall make the fact of the existence of the out-of-hospital
  DNR order a part of the declarant's medical record and the names of
  the witnesses shall be entered in the medical record.
         SECTION 5.  Sections 166.087(b) and (c), Health and Safety
  Code, are amended to read as follows:
         (b)  If the adult person has designated a person to make a
  treatment decision as authorized by Section 166.032(c), the adult
  person's attending physician, or a physician assistant or advanced
  practice registered nurse providing care to the person, and the
  designated person shall comply with the out-of-hospital DNR order.
         (c)  If the adult person has not designated a person to make a
  treatment decision as authorized by Section 166.032(c), the
  person's attending physician, or a physician assistant or advanced
  practice registered nurse providing care to the person, shall
  comply with the out-of-hospital DNR order unless the physician,
  physician assistant, or advanced practice registered nurse
  believes that the order does not reflect the person's present
  desire.
         SECTION 6.  Sections 166.088(a), (b), and (f), Health and
  Safety Code, are amended to read as follows:
         (a)  If an adult person has not executed or issued an
  out-of-hospital DNR order and is incompetent or otherwise mentally
  or physically incapable of communication, the person's attending
  physician, or a physician assistant or advanced practice registered
  nurse providing care to the person, and the person's legal
  guardian, proxy, or agent having a medical power of attorney may
  execute an out-of-hospital DNR order on behalf of the person.
         (b)  If the person does not have a legal guardian, proxy, or
  agent under a medical power of attorney, the person's attending
  physician, or a physician assistant or advanced practice registered
  nurse providing care to the person, and at least one qualified
  relative from a category listed by Section 166.039(b), subject to
  the priority established under that subsection, may execute an
  out-of-hospital DNR order in the same manner as a treatment
  decision made under Section 166.039(b).
         (f)  If there is not a qualified relative available to act
  for the person under Subsection (b), an out-of-hospital DNR order
  must be concurred in by another physician, physician assistant, or
  advanced practice registered nurse who is not involved in the
  treatment of the patient or who is a representative of the ethics or
  medical committee of the health care facility in which the person is
  a patient.
         SECTION 7.  Sections 166.089(d), (h), and (i), Health and
  Safety Code, are amended to read as follows:
         (d)  The responding health care professionals must determine
  that the out-of-hospital DNR order form appears to be valid in that
  it includes:
               (1)  written responses in the places designated on the
  form for the names, signatures, and other information required of
  persons executing or issuing, or witnessing or acknowledging as
  applicable, the execution or issuance of, the order;
               (2)  a date in the place designated on the form for the
  date the order was executed or issued; and
               (3)  the signature or digital or electronic signature
  of the declarant or persons executing or issuing the order and the
  attending physician, a physician assistant, or an advanced practice
  registered nurse in the appropriate places designated on the form
  for indicating that the order form has been properly completed.
         (h)  An out-of-hospital DNR order executed or issued and
  documented or evidenced in the manner prescribed by this subchapter
  is valid and shall be honored by responding health care
  professionals unless the person or persons found at the scene:
               (1)  identify themselves as the declarant or as the 
  attending physician of the person who executed or issued the
  out-of-hospital DNR order or for whom the out-of-hospital DNR order
  was executed or issued, a physician assistant or advanced practice
  registered nurse providing care to the person, or the legal
  guardian, qualified relative, or agent of the person having a
  medical power of attorney who executed or issued the
  out-of-hospital DNR order on behalf of the person; and
               (2)  request that cardiopulmonary resuscitation or
  certain other life-sustaining treatment designated by department
  rule be initiated or continued.
         (i)  If the policies of a health care facility preclude
  compliance with the out-of-hospital DNR order of a person or an
  out-of-hospital DNR order issued by an attending physician, a
  physician assistant, or an advanced practice registered nurse on
  behalf of a person who is admitted to or a resident of the facility,
  or if the facility is unwilling to accept DNR identification
  devices as evidence of the existence of an out-of-hospital DNR
  order, that facility shall take all reasonable steps to notify the
  person or, if the person is incompetent, the person's guardian or
  the person or persons designated as having authority to make health
  care treatment decisions on behalf of the person for whom the order
  was executed or issued, of the facility's policy and shall take all
  reasonable steps to effect the transfer of the person to the
  person's home or to a facility where the provisions of this
  subchapter can be carried out.
         SECTION 8.  Section 166.092(b), Health and Safety Code, is
  amended to read as follows:
         (b)  An oral revocation under Subsection (a)(3) or (a)(4)
  takes effect only when the declarant or a person who identifies
  himself or herself as the legal guardian, a qualified relative, or
  the agent of the declarant having a medical power of attorney who
  executed the out-of-hospital DNR order communicates the intent to
  revoke the order to the responding health care professionals or the
  declarant's attending physician, or the physician assistant or
  advanced practice registered nurse providing care to the declarant,
  at the scene.  The responding health care professionals shall
  record the time, date, and place of the revocation in accordance
  with the statewide out-of-hospital DNR protocol and rules adopted
  by the executive commissioner and any applicable local
  out-of-hospital DNR protocol.  The attending physician, [or] the
  physician's designee, the physician assistant, or the advanced
  practice registered nurse shall record in the declarant's 
  [person's] medical record the time, date, and place of the
  revocation and, if different, the time, date, and place that the
  physician, physician assistant, or advanced practice registered
  nurse received notice of the revocation.  The attending physician,
  [or] the physician's designee, the physician assistant, or the
  advanced practice registered nurse shall also enter the word "VOID"
  on each page of the copy of the order in the declarant's [person's]
  medical record.
         SECTION 9.  Section 166.095(c), Health and Safety Code, is
  amended to read as follows:
         (c)  If a person's [an] attending physician, or a physician
  assistant or advanced practice registered nurse providing care to
  the person, refuses to execute or comply with an out-of-hospital
  DNR order, the physician, physician assistant, or advanced practice
  registered nurse shall inform the person, the legal guardian or
  qualified relatives of the person, or the agent of the person having
  a medical power of attorney and, if the person or another authorized
  to act on behalf of the person so directs, shall make a reasonable
  effort to transfer the person to another physician, physician
  assistant, or advanced practice registered nurse who is willing to
  execute or comply with an out-of-hospital DNR order.
         SECTION 10.  The heading to Section 166.102, Health and
  Safety Code, is amended to read as follows:
         Sec. 166.102.  [PHYSICIAN'S] DNR ORDER MAY BE HONORED BY
  HEALTH CARE PERSONNEL OTHER THAN EMERGENCY MEDICAL SERVICES
  PERSONNEL.
         SECTION 11.  Section 166.102(a), Health and Safety Code, is
  amended to read as follows:
         (a)  Except as provided by Subsection (b), a licensed nurse
  or person providing health care services in an out-of-hospital
  setting may honor a physician's, physician assistant's, or advanced
  practice registered nurse's do-not-resuscitate order.
         SECTION 12.  Section 166.203(a), Health and Safety Code, is
  amended to read as follows:
         (a)  A DNR order issued for a patient is valid only if the
  patient's attending physician, or a physician assistant or advanced
  practice registered nurse providing care to the patient, issues the
  order, the order is dated, and the order:
               (1)  is issued in compliance with:
                     (A)  the written and dated directions of a patient
  who was competent at the time the patient wrote the directions;
                     (B)  the oral directions of a competent patient
  delivered to or observed by two competent adult witnesses, at least
  one of whom must be a person not listed under Section 166.003(2)(E)
  or (F);
                     (C)  the directions in an advance directive
  enforceable under Section 166.005 or executed in accordance with
  Section 166.032, 166.034, or 166.035;
                     (D)  the directions of a patient's legal guardian
  or agent under a medical power of attorney acting in accordance with
  Subchapter D; or
                     (E)  a treatment decision made in accordance with
  Section 166.039; or
               (2)  is not contrary to the directions of a patient who
  was competent at the time the patient conveyed the directions and,
  in the reasonable medical judgment of the patient's attending
  physician:
                     (A)  the patient's death is imminent, regardless
  of the provision of cardiopulmonary resuscitation; and
                     (B)  the DNR order is medically appropriate.
         SECTION 13.  Sections 166.205(a), (b), and (c), Health and
  Safety Code, are amended to read as follows:
         (a)  A physician, physician assistant, or advanced practice
  registered nurse providing direct care to a patient for whom a DNR
  order is issued shall revoke the patient's DNR order if the patient
  or, as applicable, the patient's agent under a medical power of
  attorney or the patient's legal guardian if the patient is
  incompetent:
               (1)  effectively revokes an advance directive, in
  accordance with Section 166.042, for which a DNR order is issued
  under Section 166.203(a); or
               (2)  expresses to any person providing direct care to
  the patient a revocation of consent to or intent to revoke a DNR
  order issued under Section 166.203(a).
         (b)  A person providing direct care to a patient under the
  supervision of a physician, physician assistant, or advanced
  practice registered nurse shall notify the physician, physician
  assistant, or advanced practice registered nurse of the request to
  revoke a DNR order under Subsection (a).
         (c)  A patient's attending physician, or a physician
  assistant or advanced practice registered nurse providing care to
  the patient, may at any time revoke a DNR order issued under Section
  166.203(a)(2).
         SECTION 14.  Section 166.083(d), Health and Safety Code, as
  amended by this Act, is intended to clarify rather than change
  existing law.
         SECTION 15.  This Act takes effect immediately if it
  receives a vote of two-thirds of all the members elected to each
  house, as provided by Section 39, Article III, Texas Constitution.  
  If this Act does not receive the vote necessary for immediate
  effect, this Act takes effect September 1, 2023.