84R25291 SCL-F
	By: Springer, Cook, Turner of Harris, Klick,	H.B. No. 3074
	Wray, et al.

	A BILL TO BE ENTITLED
	AN ACT
	relating to the provision of artificially administered nutrition
	and hydration and life-sustaining treatment.
	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
	SECTION 1.  Sections 166.002(2) and (10), Health and Safety
	Code, are amended 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.
	SECTION 2.  Section 166.003, Health and Safety Code, is
	amended to read as follows:
	Sec. 166.003.  WITNESSES. In any circumstance in which this
	chapter requires the execution of an advance directive or the
	issuance of a nonwritten advance directive to be witnessed:
	(1)  each witness must be a competent adult; and
	(2)  at least one of the witnesses must be a person who
	is not:
	(A)  a person designated by the declarant to make
	a health care or treatment decision;
	(B)  a person related to the declarant by blood or
	marriage;
	(C)  a person entitled to any part of the
	declarant's estate after the declarant's death under a will or
	codicil executed by the declarant or by operation of law;
	(D)  the attending physician;
	(E)  an employee of the attending physician;
	(F)  an employee of a health care facility in
	which the declarant is a patient if the employee is providing direct
	patient care to the declarant or is an officer, director, partner,
	or business office employee of the health care facility or of any
	parent organization of the health care facility; or
	(G)  a person who, at the time the written advance
	directive is executed or, if the directive is a nonwritten
	directive issued under this chapter, at the time the nonwritten
	directive is issued, has a claim against any part of the declarant's
	estate after the declarant's death.
	SECTION 3.  Section 166.032(c), Health and Safety Code, is
	amended to read as follows:
	(c)  A declarant may include in a directive directions other
	than those provided by Section 166.033 and may designate in a
	directive a person to make a health care or treatment decision for
	the declarant in the event the declarant becomes incompetent or
	otherwise mentally or physically incapable of communication.
	SECTION 4.  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 5.  Sections 166.046(b) and (e), Health and Safety
	Code, as amended by S.B. 219, Acts of the 84th Legislature, Regular
	Session, 2015, are amended to read as follows:
	(b)  The patient or the person responsible for the health
	care decisions of the individual who has made the decision
	regarding the directive or treatment decision:
	(1)  may be given a written description of the ethics or
	medical committee review process and any other policies and
	procedures related to this section adopted by the health care
	facility;
	(2)  shall be informed of the committee review process
	not less than 48 hours before the meeting called to discuss the
	patient's directive, unless the time period is waived by mutual
	agreement;
	(3)  at the time of being so informed, shall be
	provided:
	(A)  a copy of the appropriate statement set forth
	in Section 166.052; and
	(B)  a copy of the registry list of health care
	providers and referral groups that have volunteered their readiness
	to consider accepting transfer or to assist in locating a provider
	willing to accept transfer that is posted on the website maintained
	by the department under Section 166.053; and
	(4)  is entitled to:
	(A)  attend the meeting; [and]
	(B)  receive a written explanation of the decision
	reached during the review process;
	(C)  receive a copy of the portion of the
	patient's medical record related to the treatment received by the
	patient in the facility for the lesser of:
	(i)  the period of the patient's current
	admission to the facility; or
	(ii)  the preceding 30 calendar days; and
	(D)  receive a copy of all of the patient's
	reasonably available diagnostic results and reports related to the
	medical record provided under Paragraph (C).
	(e)  If the patient or 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 necessary to provide
	comfort, or any other health 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 10th day after both the written
	decision and the patient's medical record required under Subsection
	(b) are [is] provided to the patient or the 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)  be medically contraindicated such that the
	provision of the treatment seriously exacerbates life-threatening
	medical problems not outweighed by the benefit of the provision of
	the treatment;
	(3)  result in substantial irremediable physical pain
	not outweighed by the benefit of the provision of the treatment;
	(4)  be medically ineffective in prolonging life; or
	(5)  be contrary to the patient's or surrogate's
	clearly documented desire not to receive artificially administered
	nutrition or hydration.
	SECTION 6.  Sections 166.052(a) and (b), Health and Safety
	Code, as amended by S.B. 219, Acts of the 84th Legislature, Regular
	Session, 2015, are amended to read as follows:
	(a)  In cases in which the attending physician refuses to
	honor an advance directive or health care or treatment decision
	requesting the provision of life-sustaining treatment, the
	statement required by Section 166.046(b)(3)(A) shall be in
	substantially the following form:
	When There Is A Disagreement About Medical Treatment: The
	Physician Recommends 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 refuses to comply with an advance
	directive or other request for life-sustaining treatment because of
	the physician's judgment that the treatment would be medically
	inappropriate, the case will be reviewed by an ethics or medical
	committee. Life-sustaining treatment will be provided through the
	review.
	You will receive notification of this review at least 48
	hours before a meeting of the committee related to your case. You
	are entitled to attend the meeting. With your agreement, the
	meeting may be held sooner than 48 hours, if possible.
	You are entitled to receive a written explanation of the
	decision reached during the review process.
	If after this review process both the attending physician and
	the ethics or medical committee conclude that life-sustaining
	treatment is 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,
	licensed physicians, 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 Health Services.
	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 until the patient [he or she] can be transferred to a
	willing provider for up to 10 days from the time you were given both
	the committee's written decision that life-sustaining treatment is
	not appropriate and the patient's medical record. The patient will
	continue to be given after the 10-day period treatment to enhance
	pain management and reduce suffering, including artificially
	administered nutrition and hydration, unless, based on reasonable
	medical judgment, providing artificially administered nutrition
	and hydration would hasten the patient's death, be medically
	contraindicated such that the provision of the treatment seriously
	exacerbates life-threatening medical problems not outweighed by
	the benefit of the provision of the treatment, result in
	substantial irremediable physical pain not outweighed by the
	benefit of the provision of the treatment, be medically ineffective
	in prolonging life, or be contrary to the patient's or surrogate's
	clearly documented desires.
	4.  If a transfer can be arranged, the patient will be
	responsible for the costs of the transfer.
	5.  If a provider cannot be found willing to give the
	requested treatment within 10 days, life-sustaining treatment may
	be withdrawn unless a court of law has granted an extension.
	6.  You may ask the appropriate district or county court to
	extend the 10-day period if the court finds that there is a
	reasonable expectation that you may find a physician or health care
	facility willing to provide life-sustaining treatment [will be
	found] if the extension is granted. Patient medical records will be
	provided to the patient or surrogate in accordance with Section
	241.154, Texas Health and Safety Code.
	*"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 refuses to
	comply with an advance directive or treatment decision requesting
	the withholding or withdrawal of life-sustaining treatment, the
	statement required by Section 166.046(b)(3)(A) shall be in
	substantially the following form:
	When There Is A Disagreement About Medical Treatment: The
	Physician Recommends Life-Sustaining Treatment That You Wish To
	Stop
	You have been given this information because you have
	requested the withdrawal or withholding of life-sustaining
	treatment* 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 refuses to comply with an advance
	directive or other request for withdrawal or withholding of
	life-sustaining treatment for any reason, the case will be reviewed
	by an ethics or medical committee. Life-sustaining treatment will
	be provided through the review.
	You will receive notification of this review at least 48
	hours before a meeting of the committee related to your case. You
	are entitled to attend the meeting. With your agreement, the
	meeting may be held sooner than 48 hours, if possible.
	You are entitled to receive a written explanation of the
	decision reached during the review process.
	If you or the attending physician do not agree with the
	decision reached during the review process, and the attending
	physician still refuses to comply with your request to withhold or
	withdraw life-sustaining treatment, then the following procedure
	will occur:
	1.  The physician, with the help of the health care facility,
	will assist you in trying to find a physician and facility willing
	to withdraw or withhold the life-sustaining treatment.
	2.  You are being given a list of health care providers,
	licensed physicians, 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 Health Services.
	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 7.  Not later than March 1, 2016, the executive
	commissioner of the Health and Human Services Commission shall
	adopt all rules necessary to implement this Act.
	SECTION 8.  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,
	2016. A review, consultation, disagreement, or other action
	relating to a health care or treatment decision made before April 1,
	2016, is governed by the law in effect immediately before the
	effective date of this Act, and that law is continued in effect for
	that purpose.
	SECTION 9.  This Act takes effect September 1, 2015.