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.