84R11966 AJZ-F
	By: Klick	H.B. No. 2949

	A BILL TO BE ENTITLED
	AN ACT
	relating to advance directives, including do-not-resuscitate
	orders; creating a criminal offense.
	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
	SECTION 1.  Section 166.002, Health and Safety Code, is
	amended by amending Subdivision (1) and adding Subdivision (12-a)
	to read as follows:
	(1)  "Advance directive" means:
	(A)  a directive, as that term is defined by
	Section 166.031;
	(B)  a [an out-of-hospital] DNR order, as that
	term is defined by Section 166.081; or
	(C)  a medical power of attorney under Subchapter
	D.
	(12-a)  "Reasonable medical judgment" means a medical
	judgment that would be made by a reasonably prudent physician,
	knowledgeable about the case and the treatment possibilities with
	respect to the medical conditions involved.
	SECTION 2.  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. A Do-Not-Resuscitate
	Order requires the consent of the patient and the signature of a
	physician.  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; 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
	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 3.  Section 166.039, Health and Safety Code, is
	amended by amending Subsections (b), (e), and (g) and adding
	Subsections (e-1), (e-2), and (e-3) to read as follows:
	(b)  If the patient does not have a legal guardian, [or] an
	agent under a medical power of attorney, or an advance directive,
	the attending physician and one person[, if available,] from one of
	the following categories, in the following priority, may make a
	treatment decision that may include a decision to withhold or
	withdraw life-sustaining treatment:
	(1)  the patient's spouse;
	(2)  the patient's reasonably available adult children;
	(3)  the patient's parents; or
	(4)  the patient's nearest living relative.
	(e)  If the patient does not have a legal guardian and a
	person listed in Subsection (b) is not available, in order for a
	treatment decision under Subsection (b) to be made, the health care
	facility must file an application for temporary guardianship under
	Chapter 1251, Estates Code, for the appointment of a person who is
	not involved in the treatment of the patient or associated with or
	employed by the health care facility to serve as a temporary
	guardian for the patient for the limited purpose of making a
	treatment decision [made] under Subsection (b) [must be concurred
	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].
	(e-1)  The term of a temporary guardian appointed under a
	temporary guardianship created pursuant to Subsection (e) expires
	on the date a court enters an order finding that the patient's legal
	guardian or a person listed in Subsection (b) is available to make a
	treatment decision under this section.  When the patient's legal
	guardian or a person listed in Subsection (b) becomes available,
	that person may make a treatment decision according to Subsection
	(b).
	(e-2)  If a person listed in Subsection (b) is not
	immediately available to make a treatment decision under this
	section, the attending physician or the attending physician's
	designee shall notify each person listed in Subsection (b) of the
	need for a qualified person to make a treatment decision under this
	section by:
	(1)  personally delivering notice to the person; or
	(2)  providing written notice sent by certified mail,
	restricted delivery, return receipt requested, to the last known
	address of the person.
	(e-3)  A person is considered not available for the purposes
	of Subsection (e) if 48 hours have elapsed since personal notice was
	provided under Subsection (e-2)(1), or 72 hours have elapsed since
	the return receipt for the written notice was received under
	Subsection (e-2)(2), and the person who was notified remains
	unavailable to make a treatment decision under this section.
	(g)  A person listed in Subsection (b) who wishes to
	challenge a treatment decision made under this section may [must]
	apply for temporary guardianship under Chapter 1251, Estates
	[Section 875, Texas Probate] Code. The court may waive applicable
	fees in that proceeding.
	SECTION 4.  Subchapter B, Chapter 166, Health and Safety
	Code, is amended by adding Section 166.054 to read as follows:
	Sec. 166.054.  APPLICABILITY OF SUBCHAPTER. This subchapter
	applies to facilities licensed under Chapter 142.
	SECTION 5.  The heading to Subchapter C, Chapter 166, Health
	and Safety Code, is amended to read as follows:
	SUBCHAPTER C.  [OUT-OF-HOSPITAL] DO-NOT-RESUSCITATE ORDERS
	SECTION 6.  Sections 166.081(2), (6), (9), and (10), Health
	and Safety Code, are amended to read as follows:
	(2)  "DNR identification device" means an
	identification device specified by department rule [the board]
	under Section 166.101 that is worn for the purpose of identifying a
	person who has executed or issued a [an out-of-hospital] DNR order
	or on whose behalf a [an out-of-hospital] DNR order has been
	executed or issued under this subchapter.
	(6)  "[Out-of-hospital] DNR order":
	(A)  means a legally binding [out-of-hospital]
	do-not-resuscitate order, in the form specified by department rule
	[the board] under Section 166.083, prepared and signed in
	accordance with Section 166.082, 166.084, 166.085, or 166.0855 [by
	the attending physician of a person], that documents the
	instructions of a person or the person's legally authorized
	representative and directs health care professionals to withhold or
	withdraw one or more of [acting in an out-of-hospital setting not to
	initiate or continue] the following treatments [life-sustaining
	treatment]:
	(i)  cardiopulmonary resuscitation;
	(ii)  [advanced airway management;
	[(iii)  artificial ventilation;
	[(iv)]  defibrillation; and
	(iii) [(v)]  transcutaneous cardiac
	pacing[; and
	[(vi)     other life-sustaining treatment
	specified by the board under Section 166.101(a)]; and
	(B)  does not include authorization to withhold or
	withdraw:
	(i)  medical interventions or therapies
	[considered] necessary to provide comfort care or to alleviate
	pain; or
	(ii)  fluids [to provide water] or
	nutrition, including fluids or nutrition by mouth or by nasogastric
	tube or artificial nutrition and hydration.
	(9)  "Qualified relatives" means those persons
	authorized to execute or issue a [an out-of-hospital] DNR order on
	behalf of a person who is incompetent or otherwise mentally or
	physically incapable of communication under Section 166.088.
	(10)  "Statewide [out-of-hospital] DNR protocol" means
	a set of statewide standardized procedures adopted by the executive
	commissioner [board] under Section 166.101(a) for withholding or
	withdrawing cardiopulmonary resuscitation and certain other
	treatments listed in Subdivision (6) [life-sustaining treatment]
	by health care professionals [acting in out-of-hospital settings].
	SECTION 7.  Sections 166.082, 166.083, 166.084, and 166.085,
	Health and Safety Code, are amended to read as follows:
	Sec. 166.082.  [OUT-OF-HOSPITAL] DNR ORDER; DIRECTIVE TO
	PHYSICIANS. (a) A competent 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 treatments listed
	in Section 166.081(6) [life-sustaining treatment designated by the
	board].
	(b)  Except as provided by this subsection, the declarant
	must sign the [out-of-hospital] DNR order in the presence of two
	witnesses who qualify under Section 166.003, at least one of whom
	must be a witness who qualifies under Section 166.003(2).  The
	witnesses must sign the order.  The attending physician of the
	declarant must sign the order and shall make the fact of the
	existence of the order and the reasons for execution of the order a
	part of the declarant's medical record.  The declarant, in lieu of
	signing in the presence of witnesses, may sign the
	[out-of-hospital] DNR order and have the signature acknowledged
	before a notary public.
	(c)  If the person is incompetent but previously executed or
	issued a directive to physicians in accordance with Subchapter B,
	the physician may rely on the directive as the person's
	instructions to issue a [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.
	(d)  If the person is incompetent but previously executed or
	issued a directive to physicians in accordance with Subchapter B
	designating a proxy, the proxy may make any decisions required of
	the designating person as to a [an out-of-hospital] DNR order and
	shall sign the order in lieu of the person signing under Subsection
	(b).
	(e)  If the person is now incompetent but previously executed
	or issued a medical power of attorney designating an agent, the
	agent may make any decisions required of the designating person as
	to a [an out-of-hospital] DNR order and shall sign the order in lieu
	of the person signing under Subsection (b).
	(f)  The executive commissioner [board], on the
	recommendation of the department, shall by rule adopt procedures
	for the disposition and maintenance of records of an original
	[out-of-hospital] DNR order and any copies of the order.
	(g)  A [An out-of-hospital] DNR order is effective on its
	execution.
	Sec. 166.083.  FORM OF [OUT-OF-HOSPITAL] DNR ORDER. (a) A
	written [out-of-hospital] DNR order shall be in the standard form
	that complies with this subchapter specified by department [board]
	rule as recommended by the department.
	(b)  The standard form of a [an out-of-hospital] DNR order
	specified by department rule [the board] must, at a minimum,
	contain the following:
	(1)  a distinctive single-page format that readily
	identifies the document as a [an out-of-hospital] DNR order;
	(2)  a title that readily identifies the document as a
	[an out-of-hospital] DNR order;
	(3)  the printed or typed name of the person;
	(4)  a statement that the physician signing the
	document is the attending physician of the person and that the
	physician is directing health care professionals to withhold or
	withdraw [acting in out-of-hospital settings, including a hospital
	emergency department, not to initiate or continue] certain
	treatments listed in Section 166.081(6) [life-sustaining
	treatment] on behalf of the person, and a listing of those
	procedures the patient has decided should be withheld or withdrawn
	[not to be initiated or continued];
	(5)  a statement that the person understands that the
	person may revoke the [out-of-hospital] DNR order at any time by
	destroying the order and removing the DNR identification device, if
	any, or by communicating to health care professionals [at the
	scene] the person's desire to revoke the [out-of-hospital] DNR
	order;
	(6)  places for the printed names and signatures of the
	witnesses or the notary public's acknowledgment and for the printed
	name and signature of the attending physician of the person and the
	medical license number of the attending physician;
	(7)  a separate section for execution of the document
	by the legal guardian of the person, the person's proxy, an agent of
	the person having a medical power of attorney, or the attending
	physician attesting to the issuance of a [an out-of-hospital] DNR
	order by nonwritten means of communication or acting in accordance
	with a previously executed or previously issued directive to
	physicians under Section 166.082(c) that includes the following:
	(A)  a statement that the legal guardian, the
	proxy, the agent, or the person by nonwritten means of
	communication[, or the physician] directs that one or more of the
	treatments listed in Section 166.081(6) [each listed
	life-sustaining treatment] should [not] be withheld or withdrawn on
	[initiated or continued in] behalf of the person; and
	(B)  places for the printed names and signatures
	of the witnesses and, as applicable, the legal guardian, proxy, or
	agent[, or physician];
	(8)  a separate section for execution of the document
	by at least one qualified relative of the person when the person
	does not have a legal guardian, proxy, or agent having a medical
	power of attorney and is incompetent or otherwise mentally or
	physically incapable of communication, including:
	(A)  a statement that the relative of the person
	is qualified to make a treatment decision under Section 166.088 to
	withhold or withdraw cardiopulmonary resuscitation and certain
	other designated treatments listed in Section 166.081(6)
	[life-sustaining treatment under Section 166.088] and, based on the
	known desires of the person or a determination of the best interest
	of the person, directs that one or more of the treatments listed in
	Section 166.081(6) [each listed life-sustaining treatment] should
	[not] be withheld or withdrawn on [initiated or continued in]
	behalf of the person; and
	(B)  places for the printed names and signatures
	of the witnesses and qualified relative of the person;
	(9)  a place for entry of the date of execution of the
	document;
	(10)  a statement that the document is in effect on the
	date of its execution and remains in effect until the death of the
	person or until the document is revoked;
	(11)  a statement that the document must accompany the
	person during transport;
	(12)  a statement regarding the proper disposition of
	the document or copies of the document, as the executive
	commissioner [board] determines appropriate; and
	(13)  a statement at the bottom of the document, with
	places for the signature of each person executing the document,
	that the document has been properly completed.
	(b-1)  Except as provided by Subsection (b-2), a written DNR
	order may be executed based on the oral instructions of a person,
	provided the order complies with Section 166.0855.
	(b-2)  A DNR order by a physician must be in writing and
	comply with the requirements of Section 166.0855.
	(c)  The executive commissioner [board] may, by rule and as
	recommended by the department, modify the standard form of the
	[out-of-hospital] DNR order described by Subsection (b) in order to
	accomplish the provisions and purposes of this subchapter.
	(d)  A photocopy or other complete facsimile of the original
	written [out-of-hospital] DNR order executed under this subchapter
	may be used for any purpose for which the original written order may
	be used under this subchapter.
	Sec. 166.084.  ISSUANCE OF [OUT-OF-HOSPITAL] DNR ORDER BY
	NONWRITTEN COMMUNICATION. (a) A competent person who is an adult
	may issue a [an out-of-hospital] DNR order by nonwritten
	communication.
	(b)  A declarant must issue the nonwritten [out-of-hospital]
	DNR order in the presence of the attending physician and two
	witnesses who qualify under Section 166.003, at least one of whom
	must be a witness who qualifies under Section 166.003(2).
	(c)  The attending physician and witnesses shall sign the
	[out-of-hospital] DNR order in the place of the document provided
	by Section 166.083(b)(7) and the attending physician shall sign the
	document in the place required by Section 166.083(b)(13). The
	physician shall make the fact of the existence of the
	[out-of-hospital] DNR order a part of the patient's [declarant's]
	medical record and the names of the witnesses shall be entered in
	the medical record.
	(d)  A [An out-of-hospital] DNR order issued in the manner
	provided by this section is valid and shall be honored by responding
	health care professionals as if executed in the manner provided by
	Section 166.082.
	Sec. 166.085.  EXECUTION OF [OUT-OF-HOSPITAL] DNR ORDER ON
	BEHALF OF [OR A] MINOR. (a) The following persons may execute a [an
	out-of-hospital] DNR order on behalf of a minor:
	(1)  the minor's parents;
	(2)  the minor's legal guardian; or
	(3)  the minor's managing conservator.
	(b)  A person listed under Subsection (a) may not execute a
	[an out-of-hospital] DNR order unless the minor has been diagnosed
	by a physician as suffering from a terminal or irreversible
	condition.
	SECTION 8.  Subchapter C, Chapter 166, Health and Safety
	Code, is amended by adding Section 166.0855 to read as follows:
	Sec. 166.0855.  DNR ORDERS APPLICABLE. A DNR order is valid
	only if it is issued in compliance with:
	(1)  the directions of the patient, if competent, given
	orally or otherwise in the presence of a person authorized to make a
	treatment decision under Section 166.039;
	(2)  the directions in an advance directive enforceable
	in accordance with Section 166.005 or executed in accordance with
	Section 166.032, 166.034, or 166.035;
	(3)  the directions of the patient's legal guardian or
	agent under a medical power of attorney acting in compliance with
	Subchapter D;
	(4)  a treatment decision made in accordance with
	Section 166.039; or
	(5)  the reasonable medical judgment of the patient's
	attending physician that the patient's death is imminent within 24
	hours even if cardiopulmonary resuscitation is provided.
	SECTION 9.  Sections 166.086, 166.087, 166.088, 166.089,
	166.090, 166.091, 166.092, 166.093, 166.094, 166.095, 166.096, and
	166.097, Health and Safety Code, are amended to read as follows:
	Sec. 166.086.  DESIRE OF PERSON SUPERSEDES
	[OUT-OF-HOSPITAL] DNR ORDER. The desire of a competent person,
	including a competent minor, supersedes the effect of a [an
	out-of-hospital] DNR order executed or issued by or on behalf of the
	person when the desire is communicated to responding health care
	professionals as provided by this subchapter.
	Sec. 166.087.  PROCEDURE WHEN DECLARANT IS INCOMPETENT OR
	INCAPABLE OF COMMUNICATION. (a) This section applies when a person
	18 years of age or older has executed or issued a [an
	out-of-hospital] DNR order and subsequently becomes incompetent or
	otherwise mentally or physically incapable of communication.
	(b)  If the adult person has designated a person to make a
	treatment decision as authorized by Section 166.032(c), the
	attending physician and the designated person shall comply with the
	[out-of-hospital] DNR order.
	(c)  If the adult person has not designated a person to make a
	treatment decision as authorized by Section 166.032(c), the
	attending physician shall comply with the [out-of-hospital] DNR
	order unless the physician believes that the order does not reflect
	the person's present desire.
	Sec. 166.088.  PROCEDURE WHEN PERSON HAS NOT EXECUTED OR
	ISSUED [OUT-OF-HOSPITAL] DNR ORDER AND IS INCOMPETENT OR INCAPABLE
	OF COMMUNICATION. (a) If an adult person has not executed or
	issued a [an out-of-hospital] DNR order and is incompetent or
	otherwise mentally or physically incapable of communication, the
	attending physician and the person's legal guardian, proxy, or
	agent having a medical power of attorney may execute a [an
	out-of-hospital] DNR order on behalf of the person.
	(b)  If the person does not have a legal guardian, proxy, or
	agent under a medical power of attorney, the attending physician
	and at least one qualified relative from a category listed by
	Section 166.039(b), subject to the priority established under that
	subsection, may execute a [an out-of-hospital] DNR order in the
	same manner as a treatment decision made under Section 166.039(b).
	(c)  A decision to execute a [an out-of-hospital] DNR order
	made under Subsection (a) or (b) must be based on knowledge of what
	the person would desire, if known.
	(d)  A [An out-of-hospital] DNR order executed under
	Subsection (b) must be made in the presence of at least two
	witnesses who qualify under Section 166.003, at least one of whom
	must be a witness who qualifies under Section 166.003(2).
	(e)  The fact that an adult person has not executed or issued
	a [an out-of-hospital] DNR order does not create a presumption that
	the person does not want a treatment decision made to withhold or
	withdraw cardiopulmonary resuscitation and certain other
	designated treatments listed in Section 166.081(6)
	[life-sustaining treatment designated by the board].
	(f)  If there is not a qualified relative available to act
	for the person under Subsection (b), in order for a decision to be
	made to execute a DNR order under Subsection (a) or (b), the health
	care facility must file an application for temporary guardianship
	under Chapter 1251, Estates Code, for the appointment of a person
	who is not involved in the treatment of the patient or associated
	with or employed by the health care facility to serve as a temporary
	guardian for the patient for the limited purpose of making a
	decision about a [an out-of-hospital] DNR order [must be concurred
	in by another physician who is not involved in the treatment of the
	patient or who is a representative of the ethics or medical
	committee of the health care facility in which the person is a
	patient].
	(f-1)  The term of a temporary guardian appointed under a
	temporary guardianship created pursuant to Subsection (f) expires
	on the date a court enters an order finding that a qualified
	relative is available to make a decision about a DNR order. When the
	patient's legal guardian or a person listed in Subsection (b)
	becomes available, that person may make a treatment decision
	according to Subsection (a) or (b).
	(f-2)  If a qualified relative is not immediately available
	to make a treatment decision under Subsection (b), the attending
	physician or the attending physician's designee shall notify each
	qualified relative of the need for a qualified relative to make a
	treatment decision under this section by:
	(1)  personally delivering notice to the person; or
	(2)  providing written notice sent by certified mail,
	restricted delivery, return receipt requested, to the last known
	address of the person.
	(f-3)  A qualified relative is considered not available for
	the purposes of Subsection (f) only if 48 hours have elapsed since
	personal notice was provided under Subsection (f-2)(1), or 72 hours
	have elapsed since the return receipt for the written notice was
	received under Subsection (f-2)(2), and the qualified relative who
	was notified remains unavailable to make a treatment decision under
	this section.
	(g)  A person listed in Section 166.039(b) who wishes to
	challenge a decision made under this section must apply for
	temporary guardianship under Chapter 1251, Estates [Section 875,
	Texas Probate] Code. The court may waive applicable fees in that
	proceeding.
	Sec. 166.089.  COMPLIANCE WITH [OUT-OF-HOSPITAL] DNR ORDER.
	(a) When responding to a call for assistance in an out-of-hospital
	setting, health care professionals shall honor a [an
	out-of-hospital] DNR order in accordance with the statewide
	[out-of-hospital] DNR protocol and, where applicable, locally
	adopted [out-of-hospital] DNR protocols not in conflict with the
	statewide protocol if:
	(1)  the responding health care professionals discover
	an executed or issued [out-of-hospital] DNR order form on their
	arrival at the scene; and
	(2)  the responding health care professionals comply
	with this section.
	(b)  If the person is wearing a DNR identification device,
	the responding health care professionals must comply with Section
	166.090.
	(c)  The responding health care professionals must establish
	the identity of the person as the person who executed or issued the
	[out-of-hospital] DNR order or for whom the [out-of-hospital] DNR
	order was executed or issued.
	(d)  The responding health care professionals must determine
	that the [out-of-hospital] DNR order form appears to be valid in
	that it includes:
	(1)  written responses in the places designated on the
	form for the names, signatures, and other information required of
	persons executing or issuing, or witnessing or acknowledging as
	applicable, the execution or issuance of, the order;
	(2)  a date in the place designated on the form for the
	date the order was executed or issued; and
	(3)  the signature or digital or electronic signature
	of the declarant or persons executing or issuing the order and the
	attending physician in the appropriate places designated on the
	form for indicating that the order form has been properly
	completed.
	(e)  If the conditions prescribed by Subsections (a) through
	(d) are not determined to apply by the responding health care
	professionals at the scene, the [out-of-hospital] DNR order may not
	be honored and life-sustaining procedures otherwise required by law
	or local emergency medical services protocols shall be initiated or
	continued. Health care professionals acting in out-of-hospital
	settings are not required to accept or interpret a [an
	out-of-hospital] DNR order that does not meet the requirements of
	this subchapter.
	(f)  The [out-of-hospital] DNR order form or a copy of the
	form, when available, must accompany the person during transport.
	(g)  A record shall be made and maintained of the
	circumstances of each emergency medical services response in which
	a [an out-of-hospital] DNR order or DNR identification device is
	encountered, in accordance with the statewide [out-of-hospital]
	DNR protocol and any applicable local [out-of-hospital] DNR
	protocol not in conflict with the statewide protocol.
	(h)  A [An out-of-hospital] DNR order executed or issued and
	documented or evidenced in the manner prescribed by this subchapter
	is valid and shall be honored by responding health care
	professionals in an out-of-hospital setting unless the person or
	persons found at the scene:
	(1)  identify themselves as the declarant or as the
	attending physician, legal guardian, qualified relative, or agent
	of the person having a medical power of attorney who executed or
	issued the [out-of-hospital] DNR order on behalf of the person; and
	(2)  request that cardiopulmonary resuscitation or
	certain other treatments listed in Section 166.081(6)
	[life-sustaining treatment designated by the board] be initiated or
	continued.
	(i)  If the policies of a health care facility preclude
	compliance with the [out-of-hospital] DNR order of a person or a [an
	out-of-hospital] DNR order issued by an attending physician on
	behalf of a person who is admitted to or a resident of the facility,
	or if the facility is unwilling to accept DNR identification
	devices as evidence of the existence of a [an out-of-hospital] DNR
	order, that facility shall take all reasonable steps to notify the
	person or, if the person is incompetent, the person's guardian or
	the person or persons having authority to make health care
	treatment decisions on behalf of the person, of the facility's
	policy and shall take all reasonable steps to effect the transfer of
	the person to the person's home or to a facility where the
	provisions of this subchapter can be carried out.
	Sec. 166.090.  DNR IDENTIFICATION DEVICE. (a) A person who
	has a valid [out-of-hospital] DNR order under this subchapter and
	has chosen to have all treatments listed in Section 166.081(6)
	withheld or withdrawn may wear a DNR identification device around
	the neck or on the wrist as prescribed by department [board] rule
	adopted under Section 166.101.
	(b)  The presence of a DNR identification device on the body
	of a person is conclusive evidence that the person has executed or
	issued a valid [out-of-hospital] DNR order or has a valid
	[out-of-hospital] DNR order executed or issued on the person's
	behalf. Responding health care professionals shall honor the DNR
	identification device as if a valid [out-of-hospital] DNR order
	form executed or issued by the person, which indicated the choice
	for all treatments listed in Section 166.081(6) to be withheld or
	withdrawn, were found in the possession of the person.
	Sec. 166.091.  DURATION OF [OUT-OF-HOSPITAL] DNR ORDER. A
	[An out-of-hospital] DNR order is effective until it is revoked as
	prescribed by Section 166.092.
	Sec. 166.092.  REVOCATION OF [OUT-OF-HOSPITAL] DNR ORDER.
	(a) A patient or other declarant, without regard to the patient's
	or other declarant's mental state or competency, or another person
	authorized to make a treatment decision in Section 166.039  may
	revoke a [an out-of-hospital] DNR order at any time [without regard
	to the declarant's mental state or competency]. An order may be
	revoked by[:
	[(1)     the declarant or someone in the declarant's
	presence and at the declarant's direction destroying the order form
	and removing the DNR identification device, if any;
	[(2)     a person who identifies himself or herself as the
	legal guardian, as a qualified relative, or as the agent of the
	declarant having a medical power of attorney who executed the
	out-of-hospital DNR order or another person in the person's
	presence and at the person's direction destroying the order form
	and removing the DNR identification device, if any;
	[(3)]  the patient or other declarant, or a person who
	identifies himself or herself as the legal guardian, a qualified
	relative, or the agent of the patient having a medical power of
	attorney, communicating orally or in another manner the person's
	[declarant's] intent to revoke the order[; or
	[(4)     a person who identifies himself or herself as the
	legal guardian, a qualified relative, or the agent of the declarant
	having a medical power of attorney who executed the out-of-hospital
	DNR order orally stating the person's intent to revoke the order].
	(b)  A [An oral] revocation of a DNR order under Subsection
	(a) [(a)(3) or (a)(4)] takes effect only when the patient or other
	declarant or a person who identifies himself or herself as the legal
	guardian, a qualified relative, or the agent of the patient
	[declarant] having a medical power of attorney [who executed the
	out-of-hospital DNR order] communicates the intent to revoke the
	order to the responding health care professionals or the attending
	physician [at the scene]. The responding health care professionals
	shall record the time, date, and place of the revocation in
	accordance with the statewide [out-of-hospital] DNR protocol and
	rules adopted by the executive commissioner [board] and any
	applicable local [out-of-hospital] DNR protocol. The attending
	physician or the physician's designee shall record in the person's
	medical record the time, date, and place of the revocation and, if
	different, the time, date, and place that the physician received
	notice of the revocation. The attending physician or the
	physician's designee shall also enter the word "VOID" on each page
	of the copy of the order in the person's medical record and enter
	and note the revocation in all relevant electronic medical records
	of the patient.
	(c)  Except as otherwise provided by this subchapter, a
	person is not civilly or criminally liable for failure to act on a
	revocation made under this section unless the person has actual
	knowledge of the revocation.
	(d)  If a licensed health care professional does not comply
	with a revocation under Subsection (a), the patient or other
	declarant, the legal guardian, a qualified relative, or an agent of
	the patient having medical power of attorney may bring an action to
	obtain an injunction to enforce the revocation from a court of
	competent jurisdiction.
	(e)  A person who seeks an injunction under Subsection (d)
	must:
	(1)  prove that the person is authorized to make a
	treatment decision on behalf of the patient under Section 166.039;
	and
	(2)  express a desire to revoke the DNR order.
	(f)  A court considering a request for an injunction under
	Subsection (d) may not require a person seeking an injunction under
	Subsection (d) to:
	(1)  pay the attorney's fees of an opposing party;
	(2)  provide expert testimony in support of the
	injunction; or
	(3)  establish irreparable harm.
	Sec. 166.093.  REEXECUTION OF [OUT-OF-HOSPITAL] DNR ORDER.
	A declarant may at any time reexecute or reissue a [an
	out-of-hospital] DNR order in accordance with the procedures
	prescribed by Section 166.082, including reexecution or reissuance
	after the declarant is diagnosed as having a terminal or
	irreversible condition.
	Sec. 166.094.  LIMITATION ON LIABILITY FOR WITHHOLDING OR
	WITHDRAWING CARDIOPULMONARY RESUSCITATION AND CERTAIN OTHER
	[LIFE-SUSTAINING] PROCEDURES. (a) A health care professional or
	health care facility or entity that in good faith causes
	cardiopulmonary resuscitation or certain other treatments listed
	in Section 166.081(6) [life-sustaining treatment designated by the
	board] to be withheld or withdrawn from a person in accordance with
	this subchapter is not civilly liable for that action.
	(b)  A health care professional or health care facility or
	entity that in good faith participates in withholding or
	withdrawing cardiopulmonary resuscitation or certain other
	treatments listed in Section 166.081(6) [life-sustaining treatment
	designated by the board] from a person in accordance with this
	subchapter is not civilly liable for that action.
	(c)  A health care professional or health care facility or
	entity that in good faith participates in withholding or
	withdrawing cardiopulmonary resuscitation or certain other
	treatments listed in Section 166.081(6) [life-sustaining treatment
	designated by the board] from a person in accordance with this
	subchapter is not criminally liable or guilty of unprofessional
	conduct as a result of that action.
	(d)  A health care professional or health care facility or
	entity that in good faith causes or participates in withholding or
	withdrawing cardiopulmonary resuscitation or certain other
	treatments listed in Section 166.081(6) [life-sustaining treatment
	designated by the board] from a person in accordance with this
	subchapter and rules adopted under this subchapter is not in
	violation of any other licensing or regulatory laws or rules of this
	state and is not subject to any disciplinary action or sanction by
	any licensing or regulatory agency of this state as a result of that
	action.
	Sec. 166.095.  LIMITATION ON LIABILITY FOR FAILURE TO
	EFFECTUATE [OUT-OF-HOSPITAL] DNR ORDER. (a) A health care
	professional or health care facility or entity that has no actual
	knowledge of a [an out-of-hospital] DNR order is not civilly or
	criminally liable for failing to act in accordance with the order.
	(b)  A health care professional or health care facility or
	entity is not subject to review and disciplinary action by the
	appropriate licensing board for failing to effectuate a [an
	out-of-hospital] DNR order if the decision was made in good faith.
	This subsection does not limit remedies available under other laws
	of this state.
	(c)  If an attending physician refuses to execute or comply
	with a [an out-of-hospital] DNR order, the physician shall inform
	the person, the legal guardian or qualified relatives of the
	person, or the agent of the person having a medical power of
	attorney and, if the person or another authorized to act on behalf
	of the person so directs, shall make a reasonable effort to transfer
	the person to another physician who is willing to execute or comply
	with a [an out-of-hospital] DNR order.
	Sec. 166.096.  HONORING [OUT-OF-HOSPITAL] DNR ORDER DOES NOT
	CONSTITUTE OFFENSE OF AIDING SUICIDE. A person does not commit an
	offense under Section 22.08, Penal Code, by withholding
	cardiopulmonary resuscitation or certain other treatments listed
	in Section 166.081(6) [life-sustaining treatment designated by the
	board] from a person in accordance with this subchapter.
	Sec. 166.097.  CRIMINAL PENALTY; PROSECUTION. (a) A person
	commits an offense if the person intentionally conceals, cancels,
	defaces, obliterates, or damages another person's
	[out-of-hospital] DNR order or DNR identification device without
	that person's consent or the consent of the person or persons
	authorized to execute or issue a [an out-of-hospital] DNR order on
	behalf of the person under this subchapter. An offense under this
	subsection is a Class A misdemeanor.
	(b)  A person is subject to prosecution for criminal homicide
	under Chapter 19, Penal Code, if the person, with the intent to
	cause cardiopulmonary resuscitation or certain other treatments
	listed in Section 166.081(6) [life-sustaining treatment designated
	by the board] to be withheld or withdrawn from another person
	contrary to the other person's desires, falsifies or forges a [an
	out-of-hospital] DNR order or intentionally conceals or withholds
	personal knowledge of a revocation and thereby directly causes
	cardiopulmonary resuscitation and certain other treatments listed
	in Section 166.081(6) [life-sustaining treatment designated by the
	board] to be withheld or withdrawn from the other person with the
	result that the other person's death is hastened.
	(c)  A health care professional commits an offense if the
	person knowingly executes a DNR order that is not in compliance with
	the provisions of this subchapter. An offense under this subsection
	is a felony of the third degree.
	SECTION 10.  Subchapter C, Chapter 166, Health and Safety
	Code, is amended by adding Section 166.0975 to read as follows:
	Sec. 166.0975.  DISCIPLINARY ACTION. The Texas Medical
	Board shall take disciplinary action under Chapter 164, Occupations
	Code, against a person who violates this chapter.
	SECTION 11.  Sections 166.098, 166.100, 166.101, and
	166.102, Health and Safety Code, are amended to read as follows:
	Sec. 166.098.  PREGNANT PERSONS. A person may not withhold
	or withdraw cardiopulmonary resuscitation or certain treatments
	listed in Section 166.081(6) [other life-sustaining treatment
	designated by the board] under this subchapter from a person known
	by the responding health care professionals to be pregnant.
	Sec. 166.100.  LEGAL RIGHT OR RESPONSIBILITY NOT AFFECTED.
	This subchapter does not impair or supersede any legal right or
	responsibility a patient or other person authorized to make a
	treatment decision under Section 166.039 may have under a
	constitution, other statute, regulation, or court decision to
	effect the withholding or withdrawing of cardiopulmonary
	resuscitation or certain other treatments listed in Section
	166.081(6) from himself or herself or the patient for whom the
	person has been authorized to make a treatment decision under
	Section 166.039 [life-sustaining treatment designated by the
	board].
	Sec. 166.101.  DUTIES OF DEPARTMENT AND EXECUTIVE
	COMMISSIONER [BOARD]. (a) The executive commissioner [board]
	shall, on the recommendation of the department, adopt all
	reasonable and necessary rules to carry out the provisions and
	purposes of this subchapter, including rules:
	(1)  adopting a statewide [out-of-hospital] DNR order
	protocol that sets out standard procedures for the withholding or
	withdrawing of cardiopulmonary resuscitation and certain other
	treatments listed in Section 166.081(6) [life-sustaining
	treatment] by health care professionals that addresses each of the
	methods for executing the DNR order described in Section 166.082,
	subject to Sections 166.084, 166.085, and 166.092 [acting in
	out-of-hospital settings];
	(2)  [designating life-sustaining treatment that may
	be included in an out-of-hospital DNR order, including all
	procedures listed in Sections 166.081(6)(A)(i) through (v); and
	[(3)]  governing recordkeeping in circumstances in
	which a [an out-of-hospital] DNR order or DNR identification device
	is encountered by responding health care professionals; and
	(3)  explicitly specifying that a DNR order may be
	issued by a physician only in compliance with the methods for
	executing the DNR order described in Section 166.082, subject to
	Sections 166.084, 166.085, and 166.0855.
	(b)  The rules adopted [by the board] under Subsection (a)
	are not effective until approved by the Texas Medical [State] Board
	[of Medical Examiners].
	(c)  Local emergency medical services authorities may adopt
	local [out-of-hospital] DNR order protocols if the local protocols
	do not conflict with the statewide [out-of-hospital] DNR order
	protocol adopted by the executive commissioner [board].
	(d)  The executive commissioner [board] by rule shall
	specify a distinctive standard design for a necklace and a bracelet
	DNR identification device that signifies, when worn by a person,
	that the possessor has executed or issued a valid [out-of-hospital]
	DNR order under this subchapter or is a person for whom a valid
	[out-of-hospital] DNR order has been executed or issued.
	(e)  The department shall report to the executive
	commissioner [board] from time to time regarding issues identified
	in emergency medical services responses in which a [an
	out-of-hospital] DNR order or DNR identification device is
	encountered. The report may contain recommendations to the
	executive commissioner [board] for necessary modifications to the
	form of the standard [out-of-hospital] DNR order or the designated
	[life-sustaining] procedures listed in the standard
	[out-of-hospital] DNR order, the statewide [out-of-hospital] DNR
	order protocol, or the DNR identification devices.
	Sec. 166.102.  DUTY OF [PHYSICIAN'S DNR ORDER MAY BE HONORED
	BY HEALTH CARE PERSONNEL OTHER THAN] EMERGENCY MEDICAL SERVICES
	PERSONNEL RESPONDING TO CALL. [(a) Except as provided by
	Subsection (b), a licensed nurse or person providing health care
	services in an out-of-hospital setting may honor a physician's
	do-not-resuscitate order.
	[(b)]  When responding to a call for assistance, emergency
	medical services personnel:
	(1)  shall honor only a properly executed or issued
	[out-of-hospital] DNR order or prescribed DNR identification
	device in accordance with this subchapter; and
	(2)  have no duty to review, examine, interpret, or
	honor a person's other written directive, including a written
	directive in the form prescribed by Section 166.033.
	SECTION 12.  Subchapter C, Chapter 166, Health and Safety
	Code, is amended by adding Section 166.103 to read as follows:
	Sec. 166.103.  APPLICABILITY OF SUBCHAPTER. This subchapter
	applies to facilities licensed under Chapter 142.
	SECTION 13.  Not later than December 1, 2015, the executive
	commissioner of the Health and Human Services Commission shall
	adopt the rules required by Section 166.101(a), Health and Safety
	Code, as amended by this Act.
	SECTION 14.  (a)  Except as provided by Subsection (b) of
	this section, the changes in law made by this Act apply to a
	do-not-resuscitate order on or after the effective date of this
	Act, regardless of whether the order was issued before, on, or after
	the effective date of this Act.
	(b)  Section 166.083, Health and Safety Code, as amended by
	this Act, and Section 166.0855, Health and Safety Code, as added by
	this Act, apply only to a do-not-resuscitate order that is issued on
	or after the effective date of this Act.
	SECTION 15.  This Act takes effect September 1, 2015.