80(R) SB 28 - Introduced version

	80R702 YDB-D

	By: Nelson	S.B. No. 28

A BILL TO BE ENTITLED

AN ACT

relating to transferable physician orders for life-sustaining and

related treatment.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:

SECTION 1. The heading to Chapter 166, Health and Safety

Code, is amended to read as follows:

CHAPTER 166. ADVANCE DIRECTIVES; TRANSFERABLE PHYSICIAN ORDERS

SECTION 2. Section 166.001, Health and Safety Code, is

amended to read as follows:

Sec. 166.001. SHORT TITLE. This chapter may be cited as

the Advance Directives and Transferable Physician Orders Act.

SECTION 3. Section 166.002, Health and Safety Code, is

amended by adding Subdivision (16) to read as follows:

(16) "Transferable physician orders" has the meaning

assigned by Section 166.201.

SECTION 4. Sections 166.006 and 166.007, Health and Safety

Code, are amended to read as follows:

Sec. 166.006. EFFECT OF ADVANCE DIRECTIVE OR TRANSFERABLE

PHYSICIAN ORDERS ON INSURANCE POLICY AND PREMIUMS. (a) The fact

that a person has executed or issued an advance directive or is the

subject of transferable physician orders does not:

(1) restrict, inhibit, or impair in any manner the

sale, procurement, or issuance of a life insurance policy to that

person; or

(2) modify the terms of an existing life insurance

policy.

(b) Notwithstanding the terms of any life insurance policy,

the fact that life-sustaining treatment is withheld or withdrawn

from an insured [~~qualified~~] patient under this chapter does not

legally impair or invalidate that person's life insurance policy

and may not be a factor for the purpose of determining, under the

life insurance policy, whether benefits are payable or the cause of

death.

to execute or issue an advance directive or is the subject of

transferable physician orders may not be considered in any way in

establishing insurance premiums.

Sec. 166.007. EXECUTION OF ADVANCE DIRECTIVE OR

TRANSFERABLE PHYSICIAN ORDERS MAY NOT BE REQUIRED. A physician,

health facility, health care provider, insurer, or health care

service plan may not require a person to execute or issue an advance

directive or to execute or have executed on the person's behalf

transferable physician orders as a condition for obtaining

insurance for health care services or receiving health care

services.

SECTION 5. Subchapter A, Chapter 166, Health and Safety

Code, is amended by adding Section 166.0075 to read as follows:

Sec. 166.0075. PERSON'S CHOICE. (a) A person may elect to

execute or have executed on the person's behalf under this chapter:

(1) a directive under Subchapter B;

(2) an out-of-hospital DNR order under Subchapter C;

(3) a medical power of attorney under Subchapter D; or

(4) a transferable physician orders form under

Subchapter E.

(b) As an alternative to or in addition to an advance

directive executed under this chapter, a person may elect to

execute or have executed on the person's behalf transferable

physician orders under Subchapter E for the provision or

withholding of life-sustaining and related treatment based on the

person's medical condition and wishes. The provisions of this

chapter applicable to advance directives do not apply to

transferable physician orders or a transferable physician orders

form unless specifically provided otherwise by this chapter.

SECTION 6. Section 166.008, Health and Safety Code, is

amended to read as follows:

Sec. 166.008. CONFLICT BETWEEN ADVANCE DIRECTIVES AND

TRANSFERABLE PHYSICIAN ORDERS. To the extent that a treatment

decision or an advance directive or transferable physician orders

form validly executed or issued under this chapter conflicts with

another treatment decision or an advance directive or transferable

physician orders form executed or issued under this chapter, the

treatment decision made or instrument executed later in time

controls.

SECTION 7. Chapter 166, Health and Safety Code, is amended

by adding Subchapter E to read as follows:

SUBCHAPTER E. TRANSFERABLE PHYSICIAN ORDERS

FOR LIFE-SUSTAINING AND RELATED TREATMENT

Sec. 166.201. DEFINITIONS. In this subchapter:

(1) "Advanced practice nurse" has the meaning assigned

by Section 301.152, Occupations Code.

(2) "Executive commissioner" means the executive

commissioner of the Health and Human Services Commission.

(3) "Health care professional" has the meaning

assigned by Section 166.081.

(4) "Health care provider" means a health care

provider as defined by Section 166.151. The term includes a health

care provider described by Section 166.004 and a health care

professional.

(5) "Minor" means an unmarried person younger than 18

years of age who has not had the person's disabilities of minority

removed for general purposes.

(6) "Transferable physician orders" means physician

orders executed by a physician or advanced practice nurse and by the

patient who is the subject of the orders or another person described

by Section 166.202(b)(2) on the form specified under Section

166.203 that:

(A) is prepared in accordance with this

subchapter by a health care professional in consultation with:

(i) the patient, including a minor;

(ii) the person described by Section

166.209 if the patient is a minor; or

(iii) a representative authorized to make

health care decisions for the patient; and

(B) instructs health care providers regarding

the provision or withholding of life-sustaining and related

treatment based on the patient's medical condition and wishes.

Sec. 166.202. TRANSFERABLE PHYSICIAN ORDERS. (a) A

physician, advanced practice nurse, or other health care

professional may enter a patient's preferences and the physician

orders for the provision or withholding of life-sustaining and

related treatment on a transferable physician orders form that

complies with this subchapter.

(b) To be valid, a transferable physician orders form under

this subchapter must be executed by:

(1) a physician or an advanced practice nurse; and

(2) the patient who is the subject of the transferable

physician orders, the person described by Section 166.209 if the

patient is a minor, or a representative authorized to make health

care decisions for the patient.

execution.

Sec. 166.203. FORM OF TRANSFERABLE PHYSICIAN ORDERS. (a)

Transferable physician orders must be contained in the standard

written form specified by rule. The Department of State Health

Services and the Department of Aging and Disability Services shall

develop the form.

(b) The standard form must be a one-page document that is

printed on paper of a distinctive color and is in a format that

makes the document readily identifiable as a transferable physician

orders form. The form must be designed to provide information

regarding life-sustaining and related treatment of a patient in

accordance with the patient's medical condition and wishes.

Information may be noted on the front and back of the form.

(1) a title that readily identifies the document as

transferable physician orders for life-sustaining treatment;

(2) the printed or typed name of the patient for whom

the document is prepared and the patient's date of birth;

(3) at the top of the document a statement that:

(A) a health care provider is to follow the

transferable physician orders and then contact the physician or

advanced practice nurse who executed the document;

(B) the orders are based on the patient's medical

condition and wishes; and

treatment for that section;

(4) a separate section that addresses the patient's

desires and physician's orders for each of the following:

(A) whether to attempt or not attempt

cardiopulmonary resuscitation if the patient does not have a pulse

and is not breathing;

(B) the level of medical interventions if the

patient has a pulse or is breathing, including the provision of

comfort measures only, limited additional interventions, or full

treatment;

antibiotics; and

(D) the use of artificially administered

nutrition;

(5) a separate section for a summary of the patient's

medical condition and identification of the persons with whom the

physician or advanced practice nurse discussed the patient's

medical condition, including:

(A) the patient;

(B) the patient's parent or legal guardian if the

patient is a minor; and

care decisions for the patient, including an adult patient's legal

guardian;

(6) a place for the date the document was executed,

places for the printed name and signature of the physician or

advanced practice nurse, and a place for the physician's or

advanced practice nurse's telephone information;

(7) a place for the signature of the patient, the

person described by Section 166.209 if the patient is a minor, and a

representative authorized to make health care decisions for the

patient;

(8) places for the optional inclusion of contact

information of the health care professional preparing the form and

the person described by Section 166.209 if the patient is a minor or

a representative authorized to make health care decisions for the

patient;

(9) directions for health care providers regarding:

(A) the completion of the document, including a

statement that:

(i) the document must be completed by a

health care professional based on patient preferences and medical

indications;

(ii) the document, to be valid, must be

signed by a physician or advanced practice nurse and the patient,

the person described by Section 166.209 if the patient is a minor,

or a representative authorized to make health care decisions for

the patient;

(iii) verbal orders are acceptable, in

accordance with health care provider policy, with follow-up

signature by a physician or advanced practice nurse and the

patient, the person described by Section 166.209 if the patient is a

minor, or a representative authorized to make health care decisions

for the patient; and

(iv) use of the original document is

strongly encouraged, but that photocopies and faxes of the signed

document are legal and valid;

(B) the use of the document and the medical

procedures that may or may not be performed under each category

described in Subdivision (4), including a statement that:

(i) any incomplete section of the document

implies full treatment for that section;

(ii) a defibrillator, including an

automated external defibrillator (AED), should not be used on a

patient who has chosen "Do Not Attempt Resuscitation";

(iii) oral fluids and nutrition must always

be offered if medically feasible;

(iv) if comfort cannot be achieved in the

current setting, the patient, including a patient who has chosen

"Comfort Measures Only," should be transferred to a setting able to

provide comfort;

(v) intravenous (IV) medication to enhance

comfort may be appropriate for a patient who has chosen "Comfort

Measures Only";

(vi) treatment of dehydration is a measure

that prolongs life and that a patient who desires IV fluids should

indicate "Limited Interventions" or "Full Treatment"; and

(vii) a patient (including a minor), the

person described by Section 166.209 if the patient is a minor, or a

representative authorized to make health care decisions for the

patient, may request alternative treatment;

(i) the patient is transferred from one

care setting or care level to another;

(ii) the patient's treatment preferences

change; or

(iii) there is a substantial change in the

patient's health status; and

(D) the drawing of a line through sections

described by Subdivisions (4)-(6) and the writing of "VOID" in

large letters on the document if the document is replaced or becomes

invalid;

(10) a statement that the federal Health Insurance

Portability and Accountability Act (HIPAA) permits disclosure of

the information on the document to other health care providers as

necessary; and

(11) a statement that the document is to be sent with

the patient when the patient is transferred or discharged from a

facility that is a health care provider.

(d) On the recommendation of the Department of State Health

Services and the Department of Aging and Disability Services, or at

the executive commissioner's discretion, the executive

commissioner by rule may modify the standard form of the

transferable physician orders described in this section to

accomplish the purposes of this subchapter.

(e) A photocopy or other complete facsimile of the original

written transferable physician orders form executed under this

subchapter may be used for any purpose for which the original form

may be used under this subchapter.

Sec. 166.204. STATEMENT RELATING TO TRANSFERABLE PHYSICIAN

ORDERS. (a) This section applies only to a health care provider

that is:

(1) a hospital;

(2) an institution licensed under Chapter 242,

including a skilled nursing facility;

(3) a home and community support services agency;

(4) a personal care facility; or

(5) a special care facility.

(b) A health care provider shall maintain written policies

regarding the implementation of transferable physician orders. The

policies must include a clear and precise statement of any

procedure the health care provider is unwilling or unable to

provide or withhold in accordance with transferable physician

orders.

provider shall provide written notice of the policies described by

Subsection (b) to an individual at the earlier of:

(1) the time the individual is admitted to receive

services from the provider; or

(2) the time the provider begins providing care to the

individual.

(d) If, at the time notice is to be provided under

Subsection (c), the individual is incompetent or otherwise

incapacitated and unable to receive the notice required by this

section, the health care provider shall provide the required

written notice to appropriate individuals to the same extent and in

the same manner as notice of policies on the implementation of

advance directives is required to be provided under Sections

166.004(d)-(f) in the case of an individual who is incompetent or

otherwise incapacitated and unable to receive the notice required

by those subsections.

(e) This section does not apply to outpatient hospital

services, including emergency services.

Sec. 166.205. DUTY OF CERTAIN HEALTH CARE PROVIDERS. (a) A

health care provider that is a facility, on admission of a patient

to the facility, shall make a good faith effort to determine whether

the patient is the subject of transferable physician orders.

(b) A health care provider that is a facility shall offer

each patient with a terminal or irreversible condition, and may

offer other patients, an opportunity to have a transferable

physician orders form prepared on the patient's admission to the

facility.

patient's transferable physician orders form in a prominent

location in the patient's medical records and may retain a copy of

the transferable physician orders form in the records if the

original document is transferred with the patient to another

facility or is provided to the patient on discharge.

(d) A health care professional at a health care provider

that is a facility shall review the transferable physician orders

with the patient, the person described by Section 166.209 if the

patient is a minor, or, if the patient is incompetent, a

representative authorized to make health care decisions for the

patient, when:

(1) there is a substantial, permanent change in the

patient's health status;

(2) the patient is transferred from one care setting

to another; or

(3) the patient's treatment preferences change.

(e) A transferable physician orders form is fully

transferable between all facilities licensed to provide health care

services in this state.

(f) A transferring health care provider that is a facility

shall send any original transferable physician orders form with the

patient to a receiving facility or with the patient when the patient

is discharged. The receiving facility and the health care

professionals at the facility shall honor the transferable

physician orders as provided by this subchapter until the document

becomes invalid.

Sec. 166.206. DUTY OF HEALTH CARE PROFESSIONAL RESPONDING

TO CALL FOR ASSISTANCE IN OUT-OF-HOSPITAL SETTING. (a) When

responding to a call for assistance in an out-of-hospital setting,

as defined by Section 166.081, a health care professional shall

honor transferable physician orders if the health care

professional:

(1) discovers an executed transferable physician

orders form on arrival at the scene; and

(2) complies with this section.

(b) The responding health care professional must establish

the identity of the person as the person who is the subject of the

transferable physician orders.

that the transferable physician orders form appears to be valid in

that the document includes:

(1) written responses in the places designated on the

document for the names, signatures, and other information required

of persons executing the orders;

(2) a date in the place designated on the document for

the date the orders were executed; and

(3) in the appropriate places designated on the

document for indicating that the document has been properly

executed, the signature of:

(A) the physician or advanced practice nurse; and

(B) the person who is the subject of the

transferable physician orders, the person described by Section

166.209 if the person is a minor, or a representative authorized to

make health care decisions for the person.

(d) If the conditions prescribed by Subsections (a)-(c) are

not determined to apply by the responding health care professional

at the scene, the transferable physician orders may not be honored

and life-sustaining treatment otherwise required by law or local

emergency medical services protocols shall be initiated or

continued. A responding health care professional acting in an

out-of-hospital setting is not required to accept or interpret a

transferable physician orders form that does not meet the

requirements of this subchapter.

(e) The original transferable physician orders form, or a

copy of the original form when the original form is not available,

must accompany the person during transport.

(f) A record shall be made and maintained of the

circumstances of each emergency medical services response in which

a transferable physician orders form is encountered.

(g) Transferable physician orders documented or evidenced

in the manner prescribed by this subchapter are valid and shall be

honored by a responding health care professional in an

out-of-hospital setting unless a person found at the scene:

(1) identifies himself or herself as the person who is

the subject of the transferable physician orders or as the person's

attending physician, the person described by Section 166.209 if the

person is a minor, or a representative authorized to make health

care decisions for the person; and

(2) requests that cardiopulmonary resuscitation or

other life-sustaining treatment be initiated or continued.

Sec. 166.207. COMPLIANCE WITH ORDERS BY CERTAIN HEALTH CARE

PROVIDERS. If the policies of a health care provider that is a

facility preclude compliance with the transferable physician

orders that apply to a person who is admitted to or is a resident of

the facility, that facility shall take all reasonable steps to:

(1) notify the person, the person described by Section

166.209 if the person is a minor, or, if the person is incompetent

or otherwise incapacitated and unable to receive the notice

required by this section, the representative authorized to make

health care decisions for the person, of the facility's policy; and

(2) 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.

Sec. 166.208. PATIENT DESIRE SUPERSEDES TRANSFERABLE

PHYSICIAN ORDERS. The desire of a patient, including a patient who

is a minor, supersedes the effect of transferable physician orders

when the desire is communicated to a health care provider.

Sec. 166.209. TRANSFERABLE PHYSICIAN ORDERS FORM PREPARED

FOR MINOR PATIENT. The following persons may execute a

transferable physician orders form on behalf of a patient who is a

minor:

(1) the patient's parents; or

(2) the patient's legal guardian.

Sec. 166.210. DURATION OF TRANSFERABLE PHYSICIAN ORDERS

FORM. A transferable physician orders form remains in effect

until:

(1) the document is replaced or voided as prescribed

by Section 166.211; or

(2) the document otherwise becomes invalid.

Sec. 166.211. TRANSFERABLE PHYSICIAN ORDERS VOIDABLE. (a)

A patient who is the subject of transferable physician orders may,

at any time without regard to the patient's mental state or

competency, void the transferable physician orders form.

(b) An action taken under Subsection (a) takes effect only

when the attending physician receives notice of the action. The

attending physician or the physician's designee shall record in the

patient's medical record the time, date, and place the form is

voided and, if different, the time, date, and place that the

physician received the notice. In addition to following the

applicable instructions on the transferable physician orders form,

the attending physician or the physician's designee shall enter the

word "VOID" on the front and back of the copy of the transferable

physician orders form, if any, in the patient's medical record.

transferable physician orders under this section unless the person

has actual knowledge of that action.

Sec. 166.212. EXECUTING ORDERS OR WITHHOLDING

LIFE-SUSTAINING PROCEDURES IN GOOD FAITH. (a) A physician or

advanced practice nurse who in good faith executes transferable

physician orders with respect to a patient in accordance with this

subchapter is not civilly or criminally liable for that action.

(b) A health care provider who in good faith causes or

participates in withholding life-sustaining or related treatment

from a patient in accordance with transferable physician orders

executed under this subchapter is not:

(1) civilly or criminally liable for that action;

(2) guilty of unprofessional conduct as a result of

that action;

(3) in violation of any licensing or regulatory law or

rules of this state as a result of that action; or

(4) subject to any disciplinary action or sanction by

any licensing or regulatory agency of this state as a result of that

action.

Sec. 166.213. FAILURE TO EFFECT TRANSFERABLE PHYSICIAN

ORDERS. (a) A health care provider who has no actual knowledge of

transferable physician orders executed under this subchapter is not

civilly or criminally liable for failing to act in accordance with

the transferable physician orders.

(b) Except as provided by Subsection (e), a health care

provider is subject to review and disciplinary action by the

appropriate licensing board for failing to act in accordance with a

patient's transferable physician orders. This subsection does not

limit remedies available under other laws of this state.

transferable physician orders form, the physician shall inform the

patient, the person described by Section 166.209 if the patient is a

minor, or a representative authorized to make health care decisions

for the patient and, if that person so directs, shall make a

reasonable effort to transfer the person to another physician who

is willing to execute a transferable physician orders form.

(d) If an attending physician refuses to comply with

transferable physician orders regarding life-sustaining treatment

executed under this subchapter and does not wish to follow the

procedure established under Section 166.214, life-sustaining

treatment shall be provided to the patient, but only until a

reasonable opportunity has been afforded for the transfer of the

patient to another physician or health care provider that is a

facility that is willing to comply with the transferable physician

orders.

(e) A physician or other health care provider is not civilly

or criminally liable or subject to review or disciplinary action by

the person's appropriate licensing board if the person has complied

with the procedures outlined in Section 166.214.

Sec. 166.214. PROCEDURE IF NOT EFFECTING TRANSFERABLE

PHYSICIAN ORDERS. (a) If an attending physician refuses to honor a

patient's transferable physician orders regarding life-sustaining

treatment, the physician's refusal shall be reviewed by an ethics

or medical committee in the same manner and to the same extent as an

attending physician's refusal to honor an advance directive is

reviewed under Section 166.046. The attending physician may not be

a member of that committee. The patient shall be given

life-sustaining treatment during the review.

(b) At the time of being informed of the committee review

process, the patient, the person described by Section 166.209 if

the patient is a minor, or a representative authorized to make

health care decisions for the patient shall be provided:

(1) a copy of the appropriate statement described by

Section 166.219; and

(2) a copy of the registry list of health care

providers and referral groups that have volunteered their readiness

to consider accepting transfer or to assist in locating a provider

willing to accept transfer that is posted on the website maintained

by the department under Section 166.053.

review process must be included in the patient's medical record.

(d) If the attending physician, the patient, the person

described by Section 166.209 if the patient is a minor, or a

representative authorized to make health care decisions for the

patient does not agree with the decision reached during the review

process under this section, the physician shall make a reasonable

effort to transfer the patient to a physician who is willing to

comply with the transferable physician orders. If the patient is a

patient of a health care provider that is a facility, the facility's

personnel shall assist the physician in arranging the patient's

transfer to:

(1) another physician;

(2) an alternative care setting within that facility;

(3) another facility.

(e) If the patient, the person described by Section 166.209

if the patient is a minor, or a representative authorized to make

health care decisions for the patient is requesting life-sustaining

treatment that the attending physician has decided and the review

process has affirmed is inappropriate treatment, the patient shall

be given available life-sustaining treatment pending transfer

under Subsection (d). The patient is responsible for any costs

incurred in transferring the patient to another facility. The

physician and the facility are not obligated to provide

life-sustaining treatment after the 10th day after the date the

written decision required under the review process is provided to

the patient, the person described by Section 166.209 if the patient

is a minor, or a representative authorized to make health care

decisions for the patient unless ordered to do so under Subsection

(h).

(f) If during a previous admission to a health care provider

that is a facility a patient's attending physician and the review

process under this section have determined that life-sustaining

treatment is inappropriate, and the patient is readmitted to the

same facility within six months from the date of the decision

reached during the review process conducted on the previous

admission, the applicable procedures as described by Section

166.046(b) and Subsections (b)-(e) of this section need not be

followed if the patient's attending physician and a consulting

physician who is a member of the ethics or medical committee of the

facility document on the patient's readmission that the patient's

condition either has not improved or has deteriorated since the

review process was conducted.

(g) Life-sustaining treatment under this section may not be

entered in the patient's medical record as medically unnecessary

treatment until the period provided under Subsection (e) has

expired.

(h) At the request of the patient, the person described by

Section 166.209 if the patient is a minor, or a representative

authorized to make health care decisions for the patient, the

appropriate district or county court shall extend the period

provided under Subsection (e) only if the court finds, by a

preponderance of the evidence, that there is a reasonable

expectation that a physician or another health care provider that

will honor the patient's transferable physician orders will be

found if the time extension is granted.

(i) This section may not be construed to impose an

obligation on a health care provider that is a facility, including a

home and community support services agency licensed under Chapter

142 or similar organization, that is beyond the scope of the

services or resources of the facility. This section does not apply

to hospice services provided by a home and community support

services agency licensed under Chapter 142.

Sec. 166.215. HONORING TRANSFERABLE PHYSICIAN ORDERS DOES

NOT CONSTITUTE OFFENSE OF AIDING SUICIDE. A person does not commit

an offense under Section 22.08, Penal Code, by withholding

life-sustaining or related treatment from a person in accordance

with transferable physician orders executed under this subchapter.

Sec. 166.216. PREGNANT PATIENTS. A person may not withhold

life-sustaining treatment under transferable physician orders

executed under this subchapter from a patient known by the person to

be pregnant.

Sec. 166.217. MERCY KILLING NOT CONDONED. This subchapter

does not condone, authorize, or approve mercy killing or permit an

affirmative or deliberate act or omission to end life except to

permit the natural process of dying as provided by this subchapter.

Sec. 166.218. LEGAL RIGHT OR RESPONSIBILITY NOT AFFECTED.

This subchapter does not impair or supersede any legal right or

responsibility a person may have to effect the withholding or

withdrawal of life-sustaining or related treatment in a lawful

manner, provided that if an attending physician or health care

provider is unwilling to honor a patient's transferable physician

orders to provide life-sustaining treatment, life-sustaining

treatment is required to be provided to the patient, but only until

a reasonable opportunity has been afforded for transfer of the

patient to another physician or health care provider willing to

comply with the transferable physician orders.

Sec. 166.219. STATEMENTS EXPLAINING PATIENT'S RIGHT TO

TRANSFER. (a) In cases in which the attending physician refuses to

honor a patient's transferable physician orders requesting the

provision of life-sustaining treatment, the statement required by

Section 166.214(b)(1) shall be in substantially the form provided

in Section 166.052(a), except that the form may be revised as

necessary to apply to transferable physician orders.

(b) In cases in which the attending physician refuses to

comply with a patient's transferable physician orders requesting

the withholding of life-sustaining treatment, the statement

required by Section 166.214(b)(1) shall be in substantially the

form provided in Section 166.052(b), except that the form may be

revised as necessary to apply to transferable physician orders.

Sec. 166.220. RULES. The executive commissioner shall

adopt rules necessary to implement and administer this subchapter.

SECTION 8. Section 166.033, Health and Safety Code, is

amended to read as follows:

Sec. 166.033. FORM OF WRITTEN DIRECTIVE. A written

directive may be in the following form:

DIRECTIVE TO PHYSICIANS AND FAMILY OR SURROGATES

Instructions for completing this document:

This is an important legal document known as an Advance

Directive. It is designed to help you communicate your wishes about

medical treatment at some time in the future when you are unable to

make your wishes known because of illness or injury. These wishes

are usually based on personal values. In particular, you may want

to consider what burdens or hardships of treatment you would be

willing to accept for a particular amount of benefit obtained if you

were seriously ill.

You are encouraged to discuss your values and wishes with

your family or chosen spokesperson, as well as your physician. Your

physician, other health care provider, or medical institution may

provide you with various resources to assist you in completing your

advance directive. Brief definitions are listed below and may aid

you in your discussions and advance planning. Initial the

treatment choices that best reflect your personal preferences.

Provide a copy of your directive to your physician, usual hospital,

and family or spokesperson. Consider a periodic review of this

document. By periodic review, you can best assure that the

directive reflects your preferences.

In addition to this advance directive, Texas law provides for

two other types of directives that can be important during a serious

illness. These are the Medical Power of Attorney and the

Out-of-Hospital Do-Not-Resuscitate Order. Texas law also provides

for transferable physician orders. You may wish to discuss these

with your physician, family, hospital representative, or other

advisers. You may also wish to complete a directive related to the

donation of organs and tissues.

DIRECTIVE

I, __________, recognize that the best health care is based

upon a partnership of trust and communication with my physician. My

physician and I will make health care decisions together as long as

I am of sound mind and able to make my wishes known. If there comes

a time that I am unable to make medical decisions about myself

because of illness or injury, I direct that the following treatment

preferences be honored:

If, in the judgment of my physician, I am suffering with a

terminal condition from which I am expected to die within six

months, even with available life-sustaining treatment provided in

accordance with prevailing standards of medical care:

__________

I request that all treatments other than those needed to keep me comfortable be discontinued or withheld and my physician allow me to die as gently as possible; OR

__________

I request that I be kept alive in this terminal condition using available life-sustaining treatment. (THIS SELECTION DOES NOT APPLY TO HOSPICE CARE.)

If, in the judgment of my physician, I am suffering with an

irreversible condition so that I cannot care for myself or make

decisions for myself and am expected to die without life-sustaining

treatment provided in accordance with prevailing standards of care:

__________

I request that all treatments other than those needed to keep me comfortable be discontinued or withheld and my physician allow me to die as gently as possible;

__________

I request that I be kept alive in this irreversible condition using available life-sustaining treatment. (THIS SELECTION DOES NOT APPLY TO HOSPICE CARE.)

Additional requests: (After discussion with your physician,

you may wish to consider listing particular treatments in this

space that you do or do not want in specific circumstances, such as

artificial nutrition and fluids, intravenous antibiotics, etc. Be

sure to state whether you do or do not want the particular

treatment.)

________________________________________________________________

After signing this directive, if my representative or I elect

hospice care, I understand and agree that only those treatments

needed to keep me comfortable would be provided and I would not be

given available life-sustaining treatments.

If I do not have a Medical Power of Attorney, and I am unable

to make my wishes known, I designate the following person(s) to make

treatment decisions with my physician compatible with my personal

values:

1. __________

2. __________

(If a Medical Power of Attorney has been executed, then an

agent already has been named and you should not list additional

names in this document.)

If the above persons are not available, or if I have not

designated a spokesperson, I understand that a spokesperson will be

chosen for me following standards specified in the laws of Texas.

If, in the judgment of my physician, my death is imminent within

minutes to hours, even with the use of all available medical

treatment provided within the prevailing standard of care, I

acknowledge that all treatments may be withheld or removed except

those needed to maintain my comfort. I understand that under Texas

law this directive has no effect if I have been diagnosed as

pregnant. This directive will remain in effect until I revoke it.

No other person may do so.

Signed__________ Date__________ City, County, State of

Residence __________

Two competent adult witnesses must sign below, acknowledging

the signature of the declarant. The witness designated as Witness 1

may not be a person designated to make a treatment decision for the

patient and may not be related to the patient by blood or marriage.

This witness may not be entitled to any part of the estate and may

not have a claim against the estate of the patient. This witness

may not be the attending physician or an employee of the attending

physician. If this witness is an employee of a health care facility

in which the patient is being cared for, this witness may not be

involved in providing direct patient care to the patient. This

witness may not be an officer, director, partner, or business

office employee of a health care facility in which the patient is

being cared for or of any parent organization of the health care

facility.

Witness 1 __________ Witness 2 __________

Definitions:

"Artificial nutrition and hydration" means the provision of

nutrients or fluids by a tube inserted in a vein, under the skin in

the subcutaneous tissues, or in the stomach (gastrointestinal

tract).

"Irreversible condition" means a condition, injury, or

illness:

(1) that may be treated, but is never cured or

eliminated;

(2) that leaves a person unable to care for or make

decisions for the person's own self; and

(3) that, without life-sustaining treatment provided

in accordance with the prevailing standard of medical care, is

fatal.

Explanation: Many serious illnesses such as cancer, failure

of major organs (kidney, heart, liver, or lung), and serious brain

disease such as Alzheimer's dementia may be considered irreversible

early on. There is no cure, but the patient may be kept alive for

prolonged periods of time if the patient receives life-sustaining

treatments. Late in the course of the same illness, the disease may

be considered terminal when, even with treatment, the patient is

expected to die. You may wish to consider which burdens of

treatment you would be willing to accept in an effort to achieve a

particular outcome. This is a very personal decision that you may

wish to discuss with your physician, family, or other important

persons in your life.

"Life-sustaining treatment" means treatment that, based on

reasonable medical judgment, sustains the life of a patient and

without which the patient will die. The term includes both

life-sustaining medications and artificial life support such as

mechanical breathing machines, kidney dialysis treatment, and

artificial hydration and nutrition. The term does not include the

administration of pain management medication, the performance of a

medical procedure necessary to provide comfort care, or any other

medical care provided to alleviate a patient's pain.

"Terminal condition" means an incurable condition caused by

injury, disease, or illness that according to reasonable medical

judgment will produce death within six months, even with available

life-sustaining treatment provided in accordance with the

prevailing standard of medical care.

Explanation: Many serious illnesses may be considered

irreversible early in the course of the illness, but they may not be

considered terminal until the disease is fairly advanced. In

thinking about terminal illness and its treatment, you again may

wish to consider the relative benefits and burdens of treatment and

discuss your wishes with your physician, family, or other important

persons in your life.

SECTION 9. Section 166.046(b), Health and Safety Code, is

amended to read as follows:

(b) The patient or the person responsible for the health

care decisions of the individual who has made the decision

regarding the directive or treatment decision:

(1) may be given a written description of the ethics or

medical committee review process and any other policies and

procedures related to this section adopted by the health care

facility;

(2) shall be informed of the committee review process

not less than 48 hours before the meeting called to discuss the

patient's directive, unless the time period is waived by mutual

agreement;

(3) at the time of being so informed, shall be

provided:

(A) a copy of the appropriate statement set forth

in Section 166.052; and

(B) a copy of the registry list of health care

providers and referral groups that have volunteered their readiness

to consider accepting transfer or to assist in locating a provider

willing to accept transfer that is posted on the website maintained

by the department [~~Texas Health Care Information Council~~] under

Section 166.053; and

(4) is entitled to:

(A) attend the meeting; and

(B) receive a written explanation of the decision

reached during the review process.

SECTION 10. Sections 166.052(a) and (b), Health and Safety

Code, are amended to read as follows:

(a) In cases in which the attending physician refuses to

honor an advance directive or treatment decision requesting the

provision of life-sustaining treatment, the statement required by

Section 166.046(b)(3)(A) [~~166.046(b)(2)(A)~~] shall be in

substantially the following form:

When There Is A Disagreement About Medical Treatment:

The Physician Recommends Against Life-Sustaining Treatment

That You Wish To Continue

You have been given this information because you have

requested life-sustaining treatment,* which the attending

physician believes is not appropriate. This information is being

provided to help you understand state law, your rights, and the

resources available to you in such circumstances. It outlines the

process for resolving disagreements about treatment among

patients, families, and physicians. It is based upon Section

166.046 of the Texas Advance Directives and Transferable Physician

Orders Act, codified in Chapter 166 of the Texas Health and Safety

Code.

When an attending physician refuses to comply with an advance

directive or other request for life-sustaining treatment because of

the physician's judgment that the treatment would be inappropriate,

the case will be reviewed by an ethics or medical committee.

Life-sustaining treatment will be provided through the review.

You will receive notification of this review at least 48

hours before a meeting of the committee related to your case. You

are entitled to attend the meeting. With your agreement, the

meeting may be held sooner than 48 hours, if possible.

You are entitled to receive a written explanation of the

decision reached during the review process.

If after this review process both the attending physician and

the ethics or medical committee conclude that life-sustaining

treatment is inappropriate and yet you continue to request such

treatment, then the following procedure will occur:

1. The physician, with the help of the health care facility,

will assist you in trying to find a physician and facility willing

to provide the requested treatment.

2. You are being given a list of health care providers and

referral groups that have volunteered their readiness to consider

accepting transfer, or to assist in locating a provider willing to

accept transfer, maintained by the Department of State Health

Services [~~Texas Health Care Information Council~~]. You may wish to

contact providers or referral groups on the list or others of your

choice to get help in arranging a transfer.

3. The patient will continue to be given life-sustaining

treatment until he or she can be transferred to a willing provider

for up to 10 days from the time you were given the committee's

written decision that life-sustaining treatment is not

appropriate.

4. If a transfer can be arranged, the patient will be

responsible for the costs of the transfer.

5. If a provider cannot be found willing to give the

requested treatment within 10 days, life-sustaining treatment may

be withdrawn unless a court of law has granted an extension.

6. You may ask the appropriate district or county court to

extend the 10-day period if the court finds that there is a

reasonable expectation that a physician or health care facility

willing to provide life-sustaining treatment will be found if the

extension is granted.

*"Life-sustaining treatment" means treatment that, based on

reasonable medical judgment, sustains the life of a patient and

without which the patient will die. The term includes both

life-sustaining medications and artificial life support, such as

mechanical breathing machines, kidney dialysis treatment, and

artificial nutrition and hydration. The term does not include the

administration of pain management medication or the performance of

a medical procedure considered to be necessary to provide comfort

care, or any other medical care provided to alleviate a patient's

pain.

(b) In cases in which the attending physician refuses to

comply with an advance directive or treatment decision requesting

the withholding or withdrawal of life-sustaining treatment, the

statement required by Section 166.046(b)(3)(A) shall be in

substantially the following form:

When There Is A Disagreement About Medical Treatment:

The Physician Recommends Life-Sustaining Treatment

That You Wish To Stop

You have been given this information because you have

requested the withdrawal or withholding of life-sustaining

treatment* and the attending physician refuses to comply with that

request. The information is being provided to help you understand

state law, your rights, and the resources available to you in such

circumstances. It outlines the process for resolving disagreements

about treatment among patients, families, and physicians. It is

based upon Section 166.046 of the Texas Advance Directives and

Transferable Physician Orders Act, codified in Chapter 166 of the

Texas Health and Safety Code.

When an attending physician refuses to comply with an advance

directive or other request for withdrawal or withholding of

life-sustaining treatment for any reason, the case will be reviewed

by an ethics or medical committee. Life-sustaining treatment will

be provided through the review.

You will receive notification of this review at least 48

hours before a meeting of the committee related to your case. You

are entitled to attend the meeting. With your agreement, the

meeting may be held sooner than 48 hours, if possible.

You are entitled to receive a written explanation of the

decision reached during the review process.

If you or the attending physician do not agree with the

decision reached during the review process, and the attending

physician still refuses to comply with your request to withhold or

withdraw life-sustaining treatment, then the following procedure

will occur:

1. The physician, with the help of the health care facility,

will assist you in trying to find a physician and facility willing

to withdraw or withhold the life-sustaining treatment.

2. You are being given a list of health care providers and

referral groups that have volunteered their readiness to consider

accepting transfer, or to assist in locating a provider willing to

accept transfer, maintained by the Department of State Health

Services [~~Texas Health Care Information Council~~]. You may wish to

contact providers or referral groups on the list or others of your

choice to get help in arranging a transfer.

*"Life-sustaining treatment" means treatment that, based on

reasonable medical judgment, sustains the life of a patient and

without which the patient will die. The term includes both

life-sustaining medications and artificial life support, such as

mechanical breathing machines, kidney dialysis treatment, and

artificial nutrition and hydration. The term does not include the

administration of pain management medication or the performance of

a medical procedure considered to be necessary to provide comfort

care, or any other medical care provided to alleviate a patient's

pain.

SECTION 11. Sections 166.053(a), (c), and (d), Health and

Safety Code, are amended to read as follows:

(a) The department [~~Texas Health Care Information Council~~]

shall maintain a registry listing the identity of and contact

information for health care providers and referral groups, situated

inside and outside this state, that have voluntarily notified the

department [~~council~~] they may consider accepting or may assist in

locating a provider willing to accept transfer of a patient under

Section 166.045, [or] 166.046, 166.213(d), or 166.214.

shall post the current registry list on its website in a form

appropriate for easy comprehension by patients and persons

responsible for the health care decisions of patients and shall

provide a clearly identifiable link from its home page to the

registry page. The list shall separately indicate those providers

and groups that have indicated their interest in assisting the

transfer of:

(1) those patients on whose behalf life-sustaining

treatment is being sought;

(2) those patients on whose behalf the withholding or

withdrawal of life-sustaining treatment is being sought; and

(3) patients described in both Subdivisions (1) and

(2).

(d) The registry list described in this section shall

include the following disclaimer:

"This registry lists providers and groups that have indicated

to the Department of State Health Services [~~Texas Health Care~~

~~Information Council~~] their interest in assisting the transfer of

patients in the circumstances described, and is provided for

information purposes only. Neither the Department of State Health

Services [~~Texas Health Care Information Council~~] nor the State of

Texas endorses or assumes any responsibility for any

representation, claim, or act of the listed providers or groups."

SECTION 12. Subchapter B, Chapter 157, Occupations Code, is

amended by adding Section 157.0575 to read as follows:

Sec. 157.0575. DELEGATION FOR EXECUTING TRANSFERABLE

PHYSICIAN ORDERS. (a) A physician may delegate to an advanced

practice nurse the execution of transferable physician orders under

Subchapter E, Chapter 166, Health and Safety Code.

(b) Pursuant to the physician's order and in accordance with

applicable facility policies or medical staff bylaws, the advanced

practice nurse may execute on behalf of a patient transferable

physician orders in accordance with Subchapter E, Chapter 166,

Health and Safety Code.

SECTION 13. The heading to Section 142.0145, Health and

Safety Code, is amended to read as follows:

Sec. 142.0145. VIOLATION OF LAW RELATING TO ADVANCE

DIRECTIVES AND TRANSFERABLE PHYSICIAN ORDERS.

SECTION 14. Section 142.0145(a), Health and Safety Code, is

amended to read as follows:

(a) The department shall assess an administrative penalty

against a home and community support services agency that violates

Section 166.004 or 166.204.

SECTION 15. The heading to Section 242.0663, Health and

Safety Code, is amended to read as follows:

Sec. 242.0663. VIOLATION OF LAW RELATING TO ADVANCE

DIRECTIVES AND TRANSFERABLE PHYSICIAN ORDERS.

SECTION 16. Section 242.0663(a), Health and Safety Code, is

amended to read as follows:

(a) The department shall assess an administrative penalty

under this subchapter against an institution that violates Section

166.004 or 166.204.

SECTION 17. The heading to Section 247.0459, Health and

Safety Code, is amended to read as follows:

Sec. 247.0459. VIOLATION OF LAW RELATING TO ADVANCE

DIRECTIVES AND TRANSFERABLE PHYSICIAN ORDERS.

SECTION 18. Section 247.0459(a), Health and Safety Code, is

amended to read as follows:

(a) The department shall assess an administrative penalty

against an assisted living facility that violates Section 166.004

or 166.204.

SECTION 19. The heading to Section 248.0545, Health and

Safety Code, is amended to read as follows:

Sec. 248.0545. VIOLATION OF LAW RELATING TO ADVANCE

DIRECTIVES AND TRANSFERABLE PHYSICIAN ORDERS.

SECTION 20. Section 248.0545(a), Health and Safety Code, is

amended to read as follows:

(a) The department shall assess an administrative penalty

against a special care facility that violates Section 166.004 or

166.204.

SECTION 21. Section 81.1011, Government Code, is amended to

read as follows:

Sec. 81.1011. EXCEPTION FOR CERTAIN LEGAL ASSISTANCE. (a)

Notwithstanding Section 81.101(a), the "practice of law" does not

include technical advice, consultation, and document completion

assistance provided by an employee or volunteer of an area agency on

aging affiliated with the [~~Texas~~] Department of Aging and

Disability Services [~~on Aging~~] who meets the requirements of

Subsection (b) if that advice, consultation, and assistance relates

to:

(1) a medical power of attorney or other advance

directive or transferable physician orders under Chapter 166,

Health and Safety Code; or

(2) a designation of guardian before need arises under

Section 679, Texas Probate Code.

(b) An employee or volunteer described by Subsection (a)

must:

(1) provide benefits counseling through an area agency

on aging system of access and assistance to agency clients;

(2) comply with rules adopted by the executive

commissioner of the Health and Human Services Commission [~~Texas~~

~~Department on Aging~~] regarding qualifications, training

requirements, and other requirements for providing benefits

counseling services, including legal assistance and legal

awareness services;

(3) have received specific training in providing the

technical advice, consultation, and assistance described by

Subsection (a); and

(4) be certified by the [~~Texas~~] Department of Aging

and Disability Services [~~on Aging~~] as having met the requirements

of this subsection.

Services Commission [~~Texas Department on Aging~~] by rule shall

develop certification procedures by which the Department of Aging

and Disability Services [~~department~~] certifies that an employee or

volunteer described by Subsection (a) has met the requirements of

Subsections (b)(1), (2), and (3).

SECTION 22. (a) Not later than January 1, 2008, the

Department of State Health Services and the Department of Aging and

Disability Services shall develop the transferable physician

orders form required by Subchapter E, Chapter 166, Health and

Safety Code, as added by this Act.

(b) Not later than May 1, 2008, the executive commissioner

of the Health and Human Services Commission shall adopt the rules

necessary to implement Subchapter E, Chapter 166, Health and Safety

Code, as added by this Act.

required by Subchapter E, Chapter 166, Health and Safety Code, as

added by this Act, the Department of State Health Services and the

Department of Aging and Disability Services shall consider the

Physician Orders for Life-Sustaining Treatment (POLST) form

distributed by the Oregon Health and Science University's Center

for Ethics in Health Care.

SECTION 23. (a) Except as provided by Subsection (b), this

Act takes effect September 1, 2007.

(b) Sections 166.202, 166.204, 166.205, 166.206, and

166.207, Health and Safety Code, as added by this Act, take effect

May 1, 2008.