85R7044 DMS-D
 
  By: Rodríguez S.B. No. 919
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to the authority of an advanced practice registered nurse
  or physician assistant to sign a death certificate or
  out-of-hospital do-not-resuscitate order.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Section 166.081(6), Health and Safety Code, is
  amended to read as follows:
               (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
  under Section 166.083, prepared and signed as required by this
  subchapter [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 acting in an
  out-of-hospital setting not to initiate or continue the following
  life-sustaining treatment:
                           (i)  cardiopulmonary resuscitation;
                           (ii)  advanced airway management;
                           (iii)  artificial ventilation;
                           (iv)  defibrillation;
                           (v)  transcutaneous cardiac pacing; and
                           (vi)  other life-sustaining treatment
  specified by department rule under Section 166.101(a); and
                     (B)  does not include authorization to withhold
  medical interventions or therapies considered necessary to provide
  comfort care or to alleviate pain or to provide water or nutrition.
         SECTION 2.  Sections 166.082(b) and (c), Health and Safety
  Code, are amended to read as follows:
         (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, a
  physician assistant, or an advanced practice registered nurse
  providing care to [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, a physician assistant, or an advanced practice
  registered nurse providing care to the person may rely on the
  directive as the person's instructions to issue an out-of-hospital
  DNR order and shall place a copy of the directive in the person's
  medical record. The physician, the physician assistant, or the
  advanced practice registered nurse shall sign the order in lieu of
  the person signing under Subsection (b) and may use a digital or
  electronic signature authorized under Section 166.011.
         SECTION 3.  Section 166.083(b), Health and Safety Code, is
  amended to read as follows:
         (b)  The standard form of an out-of-hospital DNR order
  specified by department rule must, at a minimum, contain the
  following:
               (1)  a distinctive single-page format that readily
  identifies the document as an out-of-hospital DNR order;
               (2)  a title that readily identifies the document as an
  out-of-hospital DNR order;
               (3)  the printed or typed name of the person;
               (4)  a statement that the physician, physician
  assistant, or advanced practice registered nurse signing the
  document is the person's attending physician or a physician
  assistant or advanced practice registered nurse of the person and
  that the physician, physician assistant, or advanced practice
  registered nurse is directing health care professionals acting in
  out-of-hospital settings, including a hospital emergency
  department, not to initiate or continue certain life-sustaining
  treatment on behalf of the person, and a listing of those procedures
  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, the physician
  assistant, or the advanced practice registered nurse of the person
  and the professional's [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, the physician assistant, or the advanced practice
  registered nurse attesting to the issuance of 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, the person by nonwritten means of communication,
  [or] the physician, the physician assistant, or the advanced
  practice registered nurse directs that each listed life-sustaining
  treatment should not be 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,
  agent, [or] physician, physician assistant, or advanced practice
  registered nurse;
               (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 to withhold
  cardiopulmonary resuscitation and certain other designated
  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 each listed life-sustaining treatment
  should not be 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 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.
         SECTION 4.  Sections 166.084(b) and (c), Health and Safety
  Code, are amended to read as follows:
         (b)  A declarant must issue the nonwritten out-of-hospital
  DNR order in the presence of the person's attending physician or a
  physician assistant or advanced practice registered nurse of the
  person 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, the physician assistant, or
  the advanced practice registered nurse 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, the physician
  assistant, or the advanced practice registered nurse shall sign the
  document in the place required by Section 166.083(b)(13). The
  physician, physician assistant, or advanced practice registered
  nurse shall make the fact of the existence of the out-of-hospital
  DNR order a part of the declarant's medical record and the names of
  the witnesses shall be entered in the medical record.
         SECTION 5.  Sections 166.087(b) and (c), Health and Safety
  Code, are amended to read as follows:
         (b)  If the adult person has designated a person to make a
  treatment decision as authorized by Section 166.032(c), the
  person's attending physician or a physician assistant or advanced
  practice registered nurse of the person 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
  person's attending physician or a physician assistant or advanced
  practice registered nurse of the person shall comply with the
  out-of-hospital DNR order unless the physician, physician
  assistant, or advanced practice registered nurse believes that the
  order does not reflect the person's present desire.
         SECTION 6.  Sections 166.088(a), (b), and (f), Health and
  Safety Code, are amended to read as follows:
         (a)  If an adult person has not executed or issued an
  out-of-hospital DNR order and is incompetent or otherwise mentally
  or physically incapable of communication, the person's attending
  physician or a physician assistant or advanced practice registered
  nurse of the person and the person's legal guardian, proxy, or agent
  having a medical power of attorney may execute 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 person's attending
  physician or a physician assistant or advanced practice registered
  nurse of the person 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 an out-of-hospital
  DNR order in the same manner as a treatment decision made under
  Section 166.039(b).
         (f)  If there is not a qualified relative available to act
  for the person under Subsection (b), an out-of-hospital DNR order
  must be concurred in by another physician, physician assistant, or
  advanced practice registered nurse 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.
         SECTION 7.  Sections 166.089(d), (h), and (i), Health and
  Safety Code, are amended to read as follows:
         (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, a physician assistant, or an advanced practice
  registered nurse in the appropriate places designated on the form
  for indicating that the order form has been properly completed.
         (h)  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 unless the person or persons found at the scene:
               (1)  identify themselves as the declarant or as the
  person's attending physician or a physician assistant or advanced
  practice registered nurse of the person, 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 life-sustaining treatment designated by department
  rule 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 an
  out-of-hospital DNR order issued by an attending physician, a
  physician assistant, or an advanced practice registered nurse 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 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.
         SECTION 8.  Section 166.092(b), Health and Safety Code, is
  amended to read as follows:
         (b)  An oral revocation under Subsection (a)(3) or (a)(4)
  takes effect only when the declarant or 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 communicates the intent to
  revoke the order to the responding health care professionals or the
  person's attending physician or the physician assistant or advanced
  practice registered nurse of the person 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 and any applicable local out-of-hospital DNR
  protocol.  The attending physician, [or] the physician's designee,
  the physician assistant, or the advanced practice registered nurse
  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, physician assistant, or advanced practice
  registered nurse received notice of the revocation.  The attending
  physician, [or] the physician's designee, the physician assistant,
  or the advanced practice registered nurse shall also enter the word
  "VOID" on each page of the copy of the order in the person's medical
  record.
         SECTION 9.  Section 166.095(c), Health and Safety Code, is
  amended to read as follows:
         (c)  If a person's [an] attending physician or a physician
  assistant or advanced practice registered nurse of the person
  refuses to execute or comply with an out-of-hospital DNR order, the
  physician, physician assistant, or advanced practice registered
  nurse 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, physician assistant, or
  advanced practice registered nurse who is willing to execute or
  comply with an out-of-hospital DNR order.
         SECTION 10.  The heading to Section 166.102, Health and
  Safety Code, is amended to read as follows:
         Sec. 166.102.  [PHYSICIAN'S] DNR ORDER MAY BE HONORED BY
  HEALTH CARE PERSONNEL OTHER THAN EMERGENCY MEDICAL SERVICES
  PERSONNEL.
         SECTION 11.  Section 166.102(a), Health and Safety Code, is
  amended to read as follows:
         (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, physician assistant's, or advanced
  practice registered nurse's do-not-resuscitate order.
         SECTION 12.  Sections 193.005(a), (b), and (c), Health and
  Safety Code, are amended to read as follows:
         (a)  A person required to file a death certificate or fetal
  death certificate shall obtain the required medical certification
  from the decedent's [an] attending physician or a physician
  assistant or advanced practice registered nurse of the decedent if
  the death occurred under [medical attendance for] the care of the
  person in connection with the [and] treatment of the condition or
  disease process that contributed to the death.
         (b)  The attending physician, physician assistant, or
  advanced practice registered nurse shall complete the medical
  certification not later than five days after receiving the death
  certificate.
         (c)  An associate physician, the chief medical officer of the
  institution where the death occurred, a physician assistant or
  advanced practice registered nurse at the institution where the
  death occurred, or the physician who performed an autopsy on the
  decedent may complete the medical certification if:
               (1)  the attending physician, the physician assistant,
  or the advanced practice registered nurse described by Subsection
  (a) is unavailable;
               (2)  the attending physician, the physician assistant,
  or the advanced practice registered nurse described by Subsection
  (a) approves; and
               (3)  the person completing the medical certification
  has access to the medical history of the case and the death is due to
  natural causes.
         SECTION 13.  Section 671.001(d), Health and Safety Code, is
  amended to read as follows:
         (d)  A registered nurse, including an advanced practice
  registered nurse, or physician assistant may determine and
  pronounce a person dead in situations other than those described by
  Subsection (b) if permitted by written policies of a licensed
  health care facility, institution, or entity providing services to
  that person.  Those policies must include physician assistants who
  are credentialed or otherwise permitted to practice at the
  facility, institution, or entity.  If the facility, institution, or
  entity has an organized nursing staff and an organized medical
  staff or medical consultant, the nursing staff and medical staff or
  consultant shall jointly develop and approve those policies.  The
  executive commissioner of the Health and Human Services Commission
  shall adopt rules to govern policies for facilities, institutions,
  or entities that do not have organized nursing staffs and organized
  medical staffs or medical consultants.
         SECTION 14.  Section 671.002(a), Health and Safety Code, is
  amended to read as follows:
         (a)  A physician who determines death in accordance with
  Section 671.001(b) or a registered nurse, including an advanced
  practice registered nurse, or physician assistant who determines
  death in accordance with Section 671.001(d) is not liable for civil
  damages or subject to criminal prosecution for the physician's,
  registered nurse's, or physician assistant's actions or the actions
  of others based on the determination of death.
         SECTION 15.  This Act takes effect immediately if it
  receives a vote of two-thirds of all the members elected to each
  house, as provided by Section 39, Article III, Texas Constitution.  
  If this Act does not receive the vote necessary for immediate
  effect, this Act takes effect September 1, 2017.