88R3544 LRM-D
	By: Hinojosa	H.B. No. 647

	A BILL TO BE ENTITLED
	AN ACT
	relating to an advance directive and do-not-resuscitate order of a
	pregnant woman and information provided for an advance directive.
	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
	SECTION 1.  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
	three [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, and the Health Care
	Facility 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.)
	Pregnancy directive:
	If I am pregnant, my decision concerning life-sustaining
	treatment is modified as follows:
	________________________________________________________________
	________________________________________________________________
	________________________________________________________________
	(THIS SECTION IS OPTIONAL, IS COMPLETED ONLY FOR A PERSON OF
	CHILD-BEARING AGE, AND DOES NOT AFFECT THE VALIDITY OF THIS FORM IF
	LEFT BLANK.)
	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 nutrition and hydration, 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 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
	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 hydration. 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 2.  Section 166.049, Health and Safety Code, is
	amended to read as follows:
	Sec. 166.049.  PREGNANT PERSONS [PATIENTS]. A person of
	child-bearing age may specify in an advance directive the person
	executes the effect the person's pregnancy has on the advance
	directive [A person may not withdraw or withhold life-sustaining
	treatment under this subchapter from a pregnant patient].
	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 signing the
	document is the attending physician of the person and that the
	physician 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)  a statement that if the person is of child-bearing
	age, the person may specify in the form the effect the person's
	pregnancy has on the out-of-hospital DNR order;
	(7)  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;
	(8) [(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 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 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;
	(9) [(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;
	(10) [(9)]  a place for entry of the date of execution
	of the document;
	(11) [(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;
	(12) [(11)]  a statement that the document must
	accompany the person during transport;
	(13) [(12)]  a statement regarding the proper
	disposition of the document or copies of the document, as the
	executive commissioner determines appropriate; and
	(14) [(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.  Section 166.084(c), Health and Safety Code, is
	amended to read as follows:
	(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)(8) [166.083(b)(7)] and the attending physician
	shall sign the document in the place required by Section
	166.083(b)(14) [166.083(b)(13)]. The physician 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.  Section 166.098, Health and Safety Code, is
	amended to read as follows:
	Sec. 166.098.  PREGNANT PERSONS. A person of child-bearing
	age may specify in an out-of-hospital DNR order executed by the
	person the effect the person's pregnancy has on the order [A person
	may not withhold cardiopulmonary resuscitation or certain other
	life-sustaining treatment designated by department rule under this
	subchapter from a person known by the responding health care
	professionals to be pregnant].
	SECTION 6.  This Act takes effect September 1, 2023.