By: Deuell, Lucio	S.B. No. 303
	(In the Senate - Filed January 31, 2013; February 5, 2013,
	read first time and referred to Committee on Health and Human
	Services; April 15, 2013, reported adversely, with favorable
	Committee Substitute by the following vote:  Yeas 7, Nays 0;
	April 15, 2013, sent to printer.)
	COMMITTEE SUBSTITUTE FOR S.B. No. 303	By:  Deuell

	A BILL TO BE ENTITLED
	AN ACT
	relating to advance directives and health care and treatment
	decisions.
	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
	SECTION 1.  Section 166.002, Health and Safety Code, is
	amended by amending Subdivisions (2) and (10) and adding
	Subdivision (16) to read as follows:
	(2)  "Artificially administered [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).
	(10)  "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
	artificially administered [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.
	(16)  "Surrogate" means a legal guardian, an agent
	under a medical power of attorney, or a person authorized under
	Section 166.039(b) to make a health care or treatment decision for
	an incompetent patient under this chapter.
	SECTION 2.  Subchapter A, Chapter 166, Health and Safety
	Code, is amended by adding Section 166.012 to read as follows:
	Sec. 166.012.  STATEMENT RELATING TO
	DO-NOT-ATTEMPT-RESUSCITATION ORDERS. (a)  In this section,
	"do-not-attempt-resuscitation order" or "DNAR order" means an
	order instructing health care professionals not to attempt
	cardiopulmonary resuscitation of the patient if circulatory or
	respiratory function ceases.
	(b)  Upon admission, a health care facility shall provide a
	patient or surrogate written notice of the facility's policies
	regarding the rights of the patient or surrogate under this
	section.
	(c)  Before placing a do-not-attempt-resuscitation (DNAR)
	order in a patient's medical record, the physician or the facility's
	personnel shall inform the patient or, if the patient is
	incompetent, make a reasonably diligent effort to contact or cause
	to be contacted the surrogate.  The facility shall establish a
	policy regarding the notification required under this section. The
	policy must authorize the notification to be given verbally by a
	physician or facility personnel.
	(d)  The DNAR order takes effect at the time it is written in
	the patient's chart or otherwise placed in the patient's medical
	record.
	(e)  If the patient or surrogate disagrees with the DNAR
	order being placed in or removed from the medical record, the
	patient or surrogate may request in writing and is entitled to a
	consultation or a review of the disagreement by the ethics or
	medical committee in the manner described by Section 166.046, with
	the patient or surrogate afforded all rights provided to the
	surrogate under that section, and with the physician afforded all
	protections from liability provided under Section 166.045(d).  The
	patient or surrogate may discontinue the process initiated under
	Section 166.046 by providing written notice to the ethics or
	medical committee.
	(f)  A DNAR order in the patient's medical record at the time
	a consultation or review is requested under Subsection (e) must be
	removed from the patient's medical record at that time.  A DNAR
	order may not be placed in the patient's medical record until the
	process initiated under Section 166.046 is concluded or
	discontinued at the request of the patient or surrogate.
	(g)  Subsection (c) does not apply to a DNAR order placed in
	the medical record of a patient:
	(1)  whose death, based on reasonable medical judgment,
	is imminent despite attempted resuscitation;
	(2)  for whom, based on reasonable medical judgment,
	resuscitation would be medically ineffective and there is
	insufficient time to contact the surrogate; or
	(3)  for whom the DNAR order is consistent with a
	patient's or surrogate's request or a patient's advance directive to
	not attempt resuscitation.
	(h)  Subsection (e) does not apply to a DNAR order placed in
	the medical record of a patient with respect to whom, based on
	reasonable medical judgment, death is imminent and resuscitation
	would be medically ineffective.
	(i)  This section does not create a cause of action or
	liability against a physician, health professional acting under the
	direction of a physician, or health care facility.
	(j)  A physician, health professional acting under the
	direction of a physician, or health care facility is not civilly or
	criminally liable or subject to review or disciplinary action by
	the appropriate licensing authority if the actor has complied with
	the procedures under this section and Section 166.046.
	(k)  This section does not affect the immunity from liability
	under Section 74.151, Civil Practice and Remedies Code.
	(l)  This section does not apply to an assisted living
	facility licensed under Chapter 247.
	SECTION 3.  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. 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 or treatment 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;
	OR
	__________ 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
	artificially administered [artificial] nutrition and hydration
	[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
	health care or 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 health care or 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:
	"Artificially administered [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
	artificially administered nutrition 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 4.  Section 166.039, Health and Safety Code, is
	amended by adding Subsections (a-1) and (b-1) and amending
	Subsections (e) and (f) to read as follows:
	(a-1)  In making the decision described by Subsection (a),
	the attending physician may consult with a physician who previously
	treated the patient if the previous physician:
	(1)  is known and available, regardless of whether the
	previous physician has discontinued providing care for the patient
	or does not have privileges at the treating facility;
	(2)  had a conversation with the patient on end-of-life
	issues at a time when the patient was competent and capable of
	communication; and
	(3)  documented the conversation described by
	Subdivision (2) in the patient's medical record.
	(b-1)  The attending physician and the health care
	facility's personnel shall make a reasonably diligent effort to
	contact or cause to be contacted the persons listed in Subsection
	(b) in the order of priority under Subsection (b) until one of the
	persons is contacted or the list is exhausted regarding making a
	health care or treatment decision for the patient.
	(e)  If the patient does not have a legal guardian or agent
	under a medical power of attorney and a person listed in Subsection
	(b) is not available, a health care or treatment decision made under
	Subsection (b) must be concurred with [in] by another physician who
	is not involved in the treatment of the patient or who is a
	representative of an ethics or medical committee of the health care
	facility in which the person is a patient.
	(f)  The fact that an adult [qualified] patient has not
	executed or issued a directive does not create a presumption
	regarding the provision, withholding, or withdrawal of [that the
	patient does not want a treatment decision to be made to withhold or
	withdraw] life-sustaining treatment.
	SECTION 5.  Subsection (c), Section 166.045, Health and
	Safety Code, is amended to read as follows:
	(c)  If an attending physician disagrees with and refuses to
	comply with a patient's directive or a health care or treatment
	decision of a patient or of a surrogate made on behalf of an
	incompetent patient, and the attending physician does not wish to
	follow the procedure established under Section 166.046,
	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
	facility willing to comply with the health care [directive] or
	treatment decision.
	SECTION 6.  The heading to Section 166.046, Health and
	Safety Code, is amended to read as follows:
	Sec. 166.046.  PROCEDURE IF PHYSICIAN DISAGREES WITH AND
	REFUSES TO COMPLY WITH HEALTH CARE [NOT EFFECTUATING A DIRECTIVE]
	OR TREATMENT DECISION.
	SECTION 7.  Section 166.046, Health and Safety Code, is
	amended by amending Subsections (a), (b), (c), (d), (e), (e-1),
	(g), and (h) and adding Subsections (a-1), (a-2), (a-3), (a-4),
	(a-5), (a-6), (a-7), (a-8), and (b-1) to read as follows:
	(a)  If an attending physician disagrees with and refuses to
	comply with [honor] a patient's advance directive or a health care
	or treatment decision [made by or on behalf] of a patient or of a
	surrogate made on behalf of an incompetent patient, the
	disagreement and the physician's refusal shall be reviewed by an
	ethics or medical committee under this section.  The ethics or
	medical committee of a facility other than a nursing home licensed
	under Chapter 242 may not include any health care provider involved
	in the direct care of a patient whose treatment the committee
	reviews or a subcommittee of such an ethics or medical committee.
	(a-1)  If the patient has been diagnosed with a terminal
	condition, the ethics or medical committee shall determine if,
	based on reasonable medical judgment, the treatment requested by
	the patient or, if the patient is incompetent, by the surrogate
	would:
	(1)  hasten the patient's death;
	(2)  seriously exacerbate other major medical problems
	not outweighed by the benefit of the provision of the treatment;
	(3)  result in substantial irremediable physical pain
	or discomfort not outweighed by the benefit of the provision of the
	treatment; or
	(4)  be medically ineffective in prolonging the
	patient's life.
	(a-2)  If the patient has been diagnosed with an irreversible
	nonterminal condition, the ethics or medical committee may sustain
	the decision to withdraw life-sustaining treatment requested by the
	patient or, if the patient is incompetent, by the surrogate only if,
	based on reasonable medical judgment, the treatment would:
	(1)  threaten the patient's life;
	(2)  seriously exacerbate other major medical problems
	not outweighed by the benefit of the provision of the treatment;
	(3)  result in substantial irremediable physical pain
	or discomfort not outweighed by the benefit of the provision of the
	treatment; or
	(4)  be medically ineffective in prolonging the
	patient's life.
	(a-3)  In all deliberations under this section, the ethics or
	medical committee should strive to honor the values of each unique
	patient. All patients will be treated equally without regard to
	permanent physical or mental disabilities, age, gender, religion,
	ethnic background, or financial or insurance status.  The committee
	should make the same decision about whether or not a requested
	treatment is medically appropriate for individuals with or without
	a permanent disability, advanced age, gender, religious or cultural
	differences, or financial circumstances.
	(a-4)  The fact that life-sustaining treatment is delivered
	in an intensive care unit is not itself sufficient to justify the
	refusal to provide that treatment. This section does not authorize
	withholding or withdrawing pain management medication, medical
	procedures considered necessary to provide comfort care, or any
	other medical care provided to alleviate a patient's pain.
	(a-5)  [The attending physician may not be a member of that
	committee.] The patient shall be given life-sustaining treatment
	pending [during] the ethics or medical committee's review.
	(a-6)  When an ethics or medical committee review has been
	initiated under this chapter, the ethics or medical committee
	shall:
	(1)  inform the patient or surrogate that the patient
	or surrogate may discontinue the process under this section by
	providing written notice to the ethics or medical committee;
	(2)  appoint a patient liaison familiar with
	end-of-life issues and hospice care options to assist the patient
	or surrogate throughout the process described by this section; and
	(3)  appoint one or more representatives of the ethics
	or medical committee to conduct an advisory ethics consultation
	with the patient or surrogate, the outcome of which must be
	documented in the patient's medical record by a representative of
	the committee.
	(a-7)  If a disagreement over a health care or treatment
	decision persists following the consultation described in
	Subsection (a-6)(3), the ethics or medical committee shall hold a
	meeting to review the disagreement.
	(a-8)  The ethics or medical committee in holding a review
	required under this section, including a review following a
	consultation described by Subsection (a-6)(3), shall advise the
	patient or surrogate that the patient's attending physician may
	present medical facts at the meeting. The patient's attending
	physician may attend and present facts but may not participate as a
	member of the committee in the case being evaluated.
	(b)  When a meeting of the ethics or medical committee is
	required under this section [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)  not later than the seventh calendar day before the
	scheduled date of the meeting required under this section, unless
	the time period is waived by mutual agreement, the committee shall
	provide to the patient or surrogate:
	(A)  [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;
	(B)  notice that the patient or surrogate is
	entitled to receive the continued assistance of a patient liaison
	to assist the patient or surrogate throughout the process described
	in this section;
	(C)  notice that the patient or surrogate may seek
	a second opinion at the patient's or surrogate's expense from other
	medical professionals regarding the patient's medical status and
	treatment requirements and communicate the resulting information
	to the members of the committee for consideration before the
	meeting;
	(D) [(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
	(E) [(B)]  a copy of the registry list of health
	care providers, health care facilities, and referral groups that,
	in compliance with any state laws prohibiting barratry, 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
	(2)  if requested in writing, the patient or surrogate
	is entitled to receive from the facility:
	(A)  not later than 72 hours after the request is
	made, a free copy of the portion of the patient's medical record
	related to the current admission to the facility or the treatment
	received by the patient during the preceding 30 calendar days in the
	facility, whichever is shorter, together with any reasonably
	available diagnostic results and reports; and
	(B)  not later than the fifth calendar day after
	the date of the request or at another time specified by mutual
	agreement, a free copy of the remainder of the patient's medical
	record, if any, related to the current admission to the facility.
	(b-1)  The patient or surrogate[; and
	[(4)]  is entitled to:
	(1) [(A)]  attend and participate in the meeting of the
	ethics or medical committee, excluding the committee's
	deliberations;
	(2)  be accompanied at the meeting by up to five
	persons, or more persons at the committee's discretion, for
	support, subject to the facility's reasonable written attendance
	policy as necessary to:
	(A)  facilitate information sharing and
	discussion of the patient's medical status and treatment
	requirements; and
	(B)  preserve the order and decorum of the
	meeting; and
	(3) [(B)]  receive a written explanation of the
	decision reached during the review process.
	(c)  The written explanation required by Subsection (b-1)(3)
	[(b)(2)(B)] must be included in the patient's medical record.
	(d)  If the attending physician, the patient, or the
	surrogate [person responsible for the health care decisions of the
	individual] does not agree with the decision reached during the
	review process [under Subsection (b)], the physician and the
	facility shall make a reasonably diligent [reasonable] effort to
	transfer the patient to a physician of the patient's or surrogate's
	choice who is willing to accept the patient [comply with the
	directive].  The [If the patient is a patient in a health care
	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;
	or
	(3)  another facility.
	(e)  If the patient or surrogate [the person responsible for
	the health care decisions of the patient] is requesting
	life-sustaining treatment that the attending physician has decided
	and the ethics or medical committee [review process] has affirmed
	is medically inappropriate treatment, the patient shall be given
	available life-sustaining treatment pending transfer under
	Subsection (d). This subsection does not authorize withholding or
	withdrawing pain management medication, medical procedures
	considered necessary to provide comfort care, or any other medical
	care provided to alleviate a patient's pain. The patient is
	responsible for any costs incurred in transferring the patient to
	another facility. The attending physician, any other physician
	responsible for the care of the patient, and the health care
	facility are not obligated to provide life-sustaining treatment
	after the 21st calendar [10th] day after the written decision
	required under Subsection (b-1) [(b)] is provided to the patient or
	the surrogate [person responsible for the health care decisions of
	the patient] unless ordered to do so under Subsection (g), except
	that artificially administered nutrition and hydration must be
	provided unless, based on reasonable medical judgment, providing
	artificially administered nutrition and hydration would:
	(1)  hasten the patient's death;
	(2)  seriously exacerbate other major medical problems
	not outweighed by the benefit of the provision of the treatment;
	(3)  result in substantial irremediable physical pain
	or discomfort not outweighed by the benefit of the provision of the
	treatment; or
	(4)  be medically ineffective in prolonging the
	patient's life.
	(e-1)  If during a previous admission to a facility the [a
	patient's] attending physician and the ethics or medical committee
	[review process under Subsection (b) have] determined that
	life-sustaining treatment is inappropriate, a subsequent committee
	review is not required if [and] the patient is readmitted to the
	same facility for the same condition within six months from the date
	of the previous decision, provided that the [reached during the
	review process conducted upon the previous admission, Subsections
	(b) through (e) 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 previous review [process] was
	conducted.
	(g)  On motion [At the request] of the patient or surrogate
	[the person responsible for the health care decisions of the
	patient], the appropriate district or county court shall extend the
	time period provided under Subsection (e) [only] if the court
	finds, by a preponderance of the evidence, that there is a
	reasonable expectation that the patient or surrogate may find a
	physician or health care facility that will honor the patient's or
	surrogate's health care or treatment decision [directive will be
	found] if the time extension is granted.
	(h)  This section may not be construed to impose an
	obligation on a facility or a home and community support services
	agency licensed under Chapter 142, an assisted living facility
	licensed under Chapter 247, or a similar organization that is
	beyond the scope of the services or resources of the facility, [or]
	agency, or organization. This section does not apply to hospice
	services provided by a home and community support services agency
	licensed under Chapter 142 or services provided by an assisted
	living facility licensed under Chapter 247.
	SECTION 8.  Subsections (a) and (b), Section 166.052, Health
	and Safety Code, are amended to read as follows:
	(a)  In cases in which the attending physician disagrees with
	and refuses to comply with a health care [honor an advance
	directive] or treatment decision requesting the provision of
	life-sustaining treatment, the statement required by Section
	166.046(b)(1)(D) [166.046(b)(2)(A)] shall be in substantially the
	following form:
	When There Is A Disagreement About Medical Treatment: The
	Physician Recommends Against Certain Life-Sustaining Treatment
	That You Wish To Continue
	You have been given this information because you have
	requested life-sustaining treatment[,]* for yourself as the
	patient or on behalf of the patient, as applicable, which the
	attending physician believes is not medically 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 Act,
	codified in Chapter 166 of the Texas Health and Safety Code.
	When an attending physician disagrees with and refuses to
	comply with a [an advance directive or other] request for
	life-sustaining treatment because of the physician's medical
	judgment that the treatment would be medically inappropriate, the
	case will be reviewed by an ethics or medical committee.
	Life-sustaining treatment will be provided through the review.
	As the patient or the patient's decision-maker, you [You]
	will receive notification of this review at least seven calendar
	days [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 seven calendar days
	[48 hours], if possible.
	The committee will appoint a patient liaison to assist you
	through this process. You are entitled to attend the meeting,
	address the committee, and be accompanied by up to five persons, or
	more persons at the committee's discretion, to support you, subject
	to the facility's reasonable written attendance policy to
	facilitate information sharing and discussion of the patient's
	medical status and treatment requirements and preserve the order
	and decorum of the meeting. On written request, you are also
	entitled to receive:
	(1)  not later than 72 hours after the request is made,
	a free copy of the portion of the patient's medical record related
	to the current admission to the facility or the treatment received
	during the preceding 30 calendar days in the facility, whichever is
	shorter, together with any reasonably available diagnostic results
	and reports; and
	(2)  not later than the fifth calendar day following
	the request or at another time specified by mutual agreement, a free
	copy of the remainder of the medical record, if any, related to the
	current admission to the facility.
	As the patient or the patient's decision-maker, you are free
	to seek a second opinion at the patient's or your expense from other
	medical professionals regarding the patient's medical status and
	treatment requirements and communicate the resulting information
	to the members of the ethics or medical committee for consideration
	before the meeting.
	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 medically 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,
	health care facilities, 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 [Texas] Health Services [Care Information
	Council]. You may wish to contact providers, facilities, 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 and treatment to enhance pain management and reduce
	suffering, including artificially administered nutrition and
	hydration, until the patient [he or she] can be transferred to a
	willing provider for up to 21 calendar [10] days from the time you
	were given the committee's written decision that life-sustaining
	treatment is not medically 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 14 calendar [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 21-day [10-day] period if the court finds that there is a
	reasonable expectation that you may find 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
	artificially administered [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 disagrees with
	and refuses to comply with a health care [an advance directive] or
	treatment decision requesting the withholding or withdrawal of
	life-sustaining treatment, the statement required by Section
	166.046(b)(1)(D) [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* for yourself as the patient or on behalf of the patient,
	as applicable, and the attending physician disagrees with and
	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 Act, codified in Chapter
	166 of the Texas Health and Safety Code.
	When an attending physician disagrees with and refuses to
	comply with a [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.
	As the patient or the patient's decision-maker, you [You]
	will receive notification of this review at least seven calendar
	days [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 seven calendar days [48 hours],
	if possible.
	You will be appointed a patient liaison familiar with
	end-of-life issues and hospice care options to assist you
	throughout this process. A representative of the ethics or medical
	committee will also conduct an advisory consultation with you.
	On written request you are entitled to receive:
	(1)  not later than 72 hours after the request is made,
	a free copy of the portion of the patient's medical record related
	to the current admission to the facility or the treatment received
	by the patient during the preceding 30 calendar days in the
	facility, whichever is shorter, together with any reasonably
	available diagnostic results and reports; and
	(2)  not later than the fifth calendar day following
	the date of the request or at another time specified by mutual
	agreement, a free copy of the remainder of the medical record, if
	any, related to the current admission to the facility.
	As the patient or the patient's decision-maker, you are free
	to seek a second opinion at the patient's or your expense from other
	medical professionals regarding the patient's medical status and
	treatment requests and communicate the resulting information to the
	members of the ethics or medical committee for consideration before
	the meeting.
	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 disagrees with and 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 accept the patient [withdraw or withhold the life-sustaining
	treatment].
	2.  You are being given a list of health care providers,
	health care facilities, 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 [Texas] Health Services [Care Information
	Council]. You may wish to contact providers, facilities, 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
	artificially administered [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 9.  Subchapter B, Chapter 166, Health and Safety
	Code, is amended by adding Section 166.054 to read as follows:
	Sec. 166.054.  REPORTING REQUIREMENTS REGARDING ETHICS OR
	MEDICAL COMMITTEE PROCESSES. (a)  On submission of a health care
	facility's application to renew its license, a facility in which
	one or more meetings of an ethics or medical committee are held
	under this chapter shall file a report with the department that
	contains aggregate information regarding the number of cases
	initiated by an ethics or medical committee under Section 166.046
	and the disposition of those cases by the facility.
	(b)  Aggregate data submitted to the department under this
	section may include only the following:
	(1)  the total number of patients for whom a review by
	the ethics or medical committee was initiated under Section
	166.046(b);
	(2)  the number of patients under Subdivision (1) who
	were transferred to:
	(A)  another physician within the same facility;
	or
	(B)  a different facility;
	(3)  the number of patients under Subdivision (1) who
	were discharged to home;
	(4)  the number of patients under Subdivision (1) for
	whom treatment was withheld or withdrawn pursuant to surrogate
	consent:
	(A)  before the decision was rendered following a
	review under Section 166.046(b);
	(B)  after the decision was rendered following a
	review under Section 166.046(b); or
	(C)  during or after the 21-day period described
	by Section 166.046(e);
	(5)  the average length of stay before a review meeting
	is held under Section 166.046(b); and
	(6)  the number of patients under Subdivision (1) who
	died while still receiving life-sustaining treatment:
	(A)  before the review meeting under Section
	166.046(b);
	(B)  during the 21-day period; or
	(C)  during extension of the 21-day period, if
	any.
	(c)  The report required by this section may not contain any
	data specific to an individual patient or physician.
	(d)  The department shall adopt rules to:
	(1)  establish a standard form for the reporting
	requirements of this section; and
	(2)  post on the department's Internet website the data
	submitted under Subsection (b) in the format provided by rule.
	(e)  Data collected as required by, or submitted to the
	department under, this section:
	(1)  is not admissible in a civil or criminal
	proceeding in which a physician, health care professional acting
	under the direction of a physician, or health care facility is a
	defendant; and
	(2)  may not be used in relation to any disciplinary
	action by a licensing board or other body with professional or
	administrative oversight over a physician, health care
	professional acting under the direction of a physician, or health
	care facility.
	SECTION 10.  Subsections (a) and (c), Section 166.082,
	Health and Safety Code, are amended to read as follows:
	(a)  A competent adult [person] may at any time execute a
	written out-of-hospital DNR order directing health care
	professionals acting in an out-of-hospital setting to withhold
	cardiopulmonary resuscitation and certain other life-sustaining
	treatment designated by the board.
	(c)  If the person is incompetent but previously executed or
	issued a directive to physicians in accordance with Subchapter B
	requesting that all treatment, other than treatment necessary for
	keeping the person comfortable, be discontinued or withheld, the
	physician 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 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 11.  Subsection (d), Section 166.152, Health and
	Safety Code, is amended to read as follows:
	(d)  The principal's attending physician shall make
	reasonable efforts to inform the principal of any proposed
	treatment or of any proposal to withdraw or withhold treatment
	before implementing an agent's health care or treatment decision
	[advance directive].
	SECTION 12.  Not later than March 1, 2014, the executive
	commissioner of the Health and Human Services Commission shall
	adopt the rules necessary to implement the changes in law made by
	this Act to Chapter 166, Health and Safety Code.
	SECTION 13.  The change in law made by this Act applies only
	to a review, consultation, disagreement, or other action relating
	to a health care or treatment decision made on or after April 1,
	2014. A review, consultation, disagreement, or other action
	relating to a health care or treatment decision made before April 1,
	2014, is governed by the law in effect immediately before the
	effective date of this Act, and the former law is continued in
	effect for that purpose.
	SECTION 14.  This Act takes effect September 1, 2013.
	* * * * *