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A BILL TO BE ENTITLED
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AN ACT
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relating to in-hospital and out-of-hospital do-not-resuscitate |
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orders and advance directives; providing a criminal penalty. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 166.002, Health and Safety Code, is |
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amended by adding Subdivision (16) to read as follows: |
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(16) "Reasonable medical judgment" means a medical |
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judgment that would be made by a reasonably prudent physician, |
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knowledgeable about the case and the treatment possibilities with |
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respect to the medical conditions involved. |
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SECTION 2. The heading to Subchapter C, Chapter 166, Health |
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and Safety Code, is amended to read as follows: |
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SUBCHAPTER C. OUT-OF-HOSPITAL AND IN-HOSPITAL |
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DO-NOT-RESUSCITATE ORDERS |
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SECTION 3. Section 166.081, Health and Safety Code, is |
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amended by adding Subdivision (5-a) and amending Subdivision (6) to |
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read as follows: |
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(5-a) "In-hospital DNR order": |
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(A) means an order placed in a patient's medical |
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file that complies with the requirements of Sections 166.0855 and |
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166.0856 and that directs health care professionals in a hospital |
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setting not to initiate or continue the following life-sustaining |
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treatment: |
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(i) cardiopulmonary resuscitation; |
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(ii) advanced airway management; |
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(iii) artificial ventilation; |
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(iv) defibrillation; |
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(v) transcutaneous cardiac pacing; and |
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(vi) other life-sustaining treatment |
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specified by the board under Section 166.101(a); and |
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(B) does not include authorization to withhold: |
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(i) medical interventions or therapies |
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necessary to provide comfort care or to alleviate pain; or |
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(ii) fluids or nutrition, including fluids |
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or nutrition by mouth or by nasogastric tube or artificial |
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nutrition and hydration. |
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(6) "Out-of-hospital DNR order": |
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(A) means a legally binding out-of-hospital |
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do-not-resuscitate order, in the form specified by the board under |
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Section 166.083, prepared and signed in accordance with Section |
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166.082, 166.084, or 166.085 [by the attending physician of a
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person], that documents the instructions of a person or the |
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person's legally authorized representative and directs health care |
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professionals acting in an out-of-hospital setting not to initiate |
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or continue the following life-sustaining treatment: |
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(i) cardiopulmonary resuscitation; |
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(ii) advanced airway management; |
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(iii) artificial ventilation; |
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(iv) defibrillation; |
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(v) transcutaneous cardiac pacing; and |
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(vi) other life-sustaining treatment |
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specified by the board under Section 166.101(a); and |
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(B) does not include authorization to withhold: |
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(i) medical interventions or therapies |
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[considered] necessary to provide comfort care or to alleviate |
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pain; or |
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(ii) fluids [to provide water] or |
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nutrition, including fluids or nutrition by mouth or by nasogastric |
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tube or artificial nutrition and hydration. |
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SECTION 4. Subchapter C, Chapter 166, Health and Safety |
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Code, is amended by adding Sections 166.0855 and 166.0856 to read as |
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follows: |
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Sec. 166.0855. DNR ORDERS APPLICABLE IN-HOSPITAL. An |
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in-hospital DNR order is valid only if it is issued in compliance |
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with: |
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(1) the directions of the patient, if competent, given |
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orally or otherwise; |
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(2) the directions in an advance directive issued in |
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accordance with Section 166.005 or 166.032; |
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(3) the directions of the patient's legal guardian or |
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agent under a medical power of attorney; |
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(4) a treatment decision made in accordance with |
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Section 166.039; or |
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(5) a reasonable medical judgment that the patient's |
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death is imminent within minutes to hours even if cardiopulmonary |
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resuscitation is provided. |
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Sec. 166.0856. FORM OF IN-HOSPITAL DNR ORDER; PROCEDURE. |
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(a) A written in-hospital DNR order shall be in the standard form |
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specified by board rule as recommended by the department. |
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(b) A written in-hospital DNR order may be executed based on |
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the oral instructions of a person provided the order complies with |
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Section 166.0855. |
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(c) An in-hospital DNR order by a physician must be in |
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writing and comply with the requirements of Section 166.0855. |
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SECTION 5. Sections 166.086 and 166.087, Health and Safety |
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Code, are amended to read as follows: |
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Sec. 166.086. DESIRE OF PERSON SUPERSEDES OUT-OF-HOSPITAL |
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OR IN-HOSPITAL DNR ORDER. The desire of a competent person, |
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including a competent minor, supersedes the effect of an |
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out-of-hospital or in-hospital DNR order executed or issued by or |
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on behalf of the person when the desire is communicated to |
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responding health care professionals as provided by this |
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subchapter. |
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Sec. 166.087. PROCEDURE WHEN DECLARANT IS INCOMPETENT OR |
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INCAPABLE OF COMMUNICATION. (a) This section applies when a person |
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18 years of age or older has executed or issued an out-of-hospital |
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or in-hospital DNR order and subsequently becomes incompetent or |
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otherwise mentally or physically incapable of communication. |
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(b) If the adult person has designated a person to make a |
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treatment decision as authorized by Section 166.032(c), the |
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attending physician and the designated person shall comply with the |
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out-of-hospital or in-hospital DNR order. |
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(c) If the adult person has not designated a person to make a |
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treatment decision as authorized by Section 166.032(c), the |
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attending physician shall comply with the out-of-hospital or |
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in-hospital DNR order unless the physician believes that the order |
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does not reflect the person's present desire. |
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SECTION 6. Section 166.092, Health and Safety Code, is |
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amended by amending Subsections (a) and (b) and adding Subsections |
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(b-1) and (d) to read as follows: |
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(a) A declarant or another person may revoke an |
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out-of-hospital DNR order at any time without regard to the |
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declarant's mental state or competency. A patient or another person |
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may revoke an in-hospital DNR order at any time without regard to |
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the patient's mental state or competency. An order may be revoked |
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by: |
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(1) the declarant or patient or someone in the |
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declarant's or patient's presence and at the declarant's or |
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patient's direction destroying the order form and removing the DNR |
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identification device, if any; |
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(2) a person who identifies himself or herself as the |
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legal guardian, as a qualified relative, or as the agent of the |
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declarant or patient having a medical power of attorney [who
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executed the out-of-hospital DNR order] or another person in the |
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person's presence and at the person's direction destroying the |
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order form and removing the DNR identification device, if any; |
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(3) the declarant or patient communicating, orally or |
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in another manner, the declarant's or patient's intent to revoke the |
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order; or |
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(4) a person who identifies himself or herself as the |
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legal guardian, a qualified relative, or the agent of the declarant |
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or patient having a medical power of attorney [who executed the
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out-of-hospital DNR order] orally stating the person's intent to |
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revoke the order. |
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(b) An oral revocation under Subsection (a)(3) or (a)(4) of |
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an out-of-hospital DNR order takes effect only when the declarant |
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or patient or a person who identifies himself or herself as the |
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legal guardian, a qualified relative, or the agent of the declarant |
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or patient having a medical power of attorney [who executed the
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out-of-hospital DNR order] communicates the intent to revoke the |
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order to the responding health care professionals or the attending |
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physician at the scene. The responding health care professionals |
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shall record the time, date, and place of the revocation in |
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accordance with the statewide out-of-hospital DNR protocol and |
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rules adopted by the board and any applicable local out-of-hospital |
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DNR protocol. The attending physician or the physician's designee |
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shall record in the person's medical record the time, date, and |
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place of the revocation and, if different, the time, date, and place |
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that the physician received notice of the revocation. The |
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attending physician or the physician's designee shall also enter |
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the word "VOID" on each page of the copy of the order in the person's |
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medical record and enter and note the revocation in all relevant |
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electronic medical records of the patient. |
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(b-1) An oral revocation under Subsection (a)(3) or (a)(4) |
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of an in-hospital DNR order takes effect only when the patient or a |
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person who identifies himself or herself as the legal guardian, a |
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qualified relative, or the agent of the patient having a medical |
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power of attorney communicates the intent to revoke the order to a |
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health care professional at the hospital. The health care |
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professional shall record the time and date of the revocation. The |
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attending physician or the physician's designee shall record in the |
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person's medical record the time and date of the revocation and, if |
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different, the time, date, and place that the physician received |
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notice of the revocation. The attending physician or the |
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physician's designee shall also remove the order from the person's |
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physical and electronic medical record. |
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(d) If a health care professional fails to comply with a |
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revocation under Subsection (a), the declarant or patient, the |
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legal guardian, a qualified relative, or an agent of the declarant |
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or patient having medical power of attorney may obtain an |
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injunction to enforce the revocation. |
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SECTION 7. The heading to Section 166.096, Health and |
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Safety Code, is amended to read as follows: |
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Sec. 166.096. HONORING OUT-OF-HOSPITAL OR IN-HOSPITAL DNR |
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ORDER DOES NOT CONSTITUTE OFFENSE OF AIDING SUICIDE. |
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SECTION 8. Section 166.097, Health and Safety Code, is |
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amended by adding Subsection (c) to read as follows: |
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(c) A person other than the declarant or patient commits an |
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offense if the person knowingly executes an out-of-hospital or |
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in-hospital DNR order that is not in compliance with the provisions |
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of this subchapter. An offense under this subsection is a Class A |
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misdemeanor. |
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SECTION 9. Section 166.101(a), Health and Safety Code, is |
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amended to read as follows: |
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(a) The board shall, on the recommendation of the |
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department, adopt all reasonable and necessary rules to carry out |
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the purposes of this subchapter, including rules: |
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(1) adopting a statewide out-of-hospital DNR order |
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protocol that sets out standard procedures for the withholding of |
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cardiopulmonary resuscitation and certain other life-sustaining |
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treatment by health care professionals acting in out-of-hospital |
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settings that addresses each of the methods for executing the order |
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described in Section 166.082, subject to Sections 166.084 and |
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166.085; |
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(2) designating life-sustaining treatment that may be |
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included in an out-of-hospital or in-hospital DNR order, including |
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all procedures listed in Sections 166.081(6)(A)(i) through (v) or |
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Sections 166.081(5-a)(A)(i) through (v), as applicable; [and] |
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(3) governing recordkeeping in circumstances in |
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which: |
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(A) an out-of-hospital DNR order or DNR |
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identification device is encountered by responding health care |
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professionals; or |
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(B) an in-hospital DNR order is encountered by |
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health care professionals in a hospital setting; and |
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(4) explicitly specifying that: |
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(A) an out-of-hospital DNR order may be issued by |
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a physician only in compliance with the methods for executing the |
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order described in Section 166.082, subject to Sections 166.084 and |
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166.085; and |
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(B) an in-hospital DNR order may be issued only |
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in compliance with Section 166.0855. |
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SECTION 10. Not later than December 1, 2013, the executive |
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commissioner of the Health and Human Services Commission shall |
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adopt the rules required by Section 166.101(a), Health and Safety |
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Code, as amended by this Act. |
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SECTION 11. (a) Except as otherwise provided by Subsection |
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(b) of this section, the changes in law made by this Act apply to an |
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in-hospital order withholding life-sustaining treatment in a |
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patient's medical file on or after the effective date of this Act, |
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regardless of whether the order was issued before, on, or after the |
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effective date of this Act. |
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(b) Sections 166.0855 and 166.0856, Health and Safety Code, |
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as added by this Act, apply only to an in-hospital DNR order that is |
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issued on or after the effective date of this Act. |
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SECTION 12. This Act takes effect September 1, 2013. |