By: Klick, et al. (Senate Sponsor - Springer) H.B. No. 3162
         (In the Senate - Received from the House May 9, 2023;
  May 11, 2023, read first time and referred to Committee on Health &
  Human Services; May 17, 2023, reported favorably by the following
  vote:  Yeas 9, Nays 0; May 17, 2023, sent to printer.)
Click here to see the committee vote
 
 
A BILL TO BE ENTITLED
 
AN ACT
 
  relating to advance directives, do-not-resuscitate orders, and
  health care treatment decisions made by or on behalf of certain
  patients, including a review of directives and decisions.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Subchapter B, Chapter 166, Health and Safety
  Code, is amended by adding Section 166.0445 to read as follows:
         Sec. 166.0445.  LIMITATION ON LIABILITY FOR PERFORMING
  CERTAIN MEDICAL PROCEDURES. (a) A physician or a health care
  professional acting under the direction of a physician is not
  subject to civil liability for participating in a medical procedure
  performed under Section 166.046(d-2).
         (b)  A physician or a health care professional acting under
  the direction of a physician is not subject to criminal liability
  for participating in a medical procedure performed under Section
  166.046(d-2) unless:
               (1)  the physician or health care professional in
  participating in the medical procedure acted with a specific
  malicious intent to cause the death of the patient and that conduct
  significantly hastened the patient's death; and
               (2)  the hastening of the patient's death is not
  attributable to the risks associated with the medical procedure.
         (c)  A physician or a health care professional acting under
  the direction of a physician has not engaged in unprofessional
  conduct by participating in a medical procedure performed under
  Section 166.046(d-2) unless the physician or health care
  professional in participating in the medical procedure acted with a
  specific malicious intent to harm the patient.
         SECTION 2.  The heading to Section 166.046, Health and
  Safety Code, is amended to read as follows:
         Sec. 166.046.  PROCEDURE IF NOT EFFECTUATING [A] DIRECTIVE
  OR TREATMENT DECISION FOR CERTAIN PATIENTS.
         SECTION 3.  Section 166.046, Health and Safety Code, is
  amended by amending Subsections (a), (b), (c), (d), (e), and (g) and
  adding Subsections (a-1), (a-2), (b-1), (b-2), (b-3), (d-1), (d-2),
  (d-3), and (i) to read as follows:
         (a)  This section applies only to health care and treatment
  for a patient who is determined to be incompetent or is otherwise
  mentally or physically incapable of communication.
         (a-1)  If an attending physician refuses to honor an [a
  patient's] advance directive of or [a] health care or treatment
  decision made by or on behalf of a patient to whom this section
  applies, the physician's refusal shall be reviewed by an ethics or
  medical committee. The attending physician may not be a member of
  that committee during the review. The patient shall be given
  life-sustaining treatment during the review.
         (a-2)  An ethics or medical committee that reviews a
  physician's refusal to honor an advance directive or health care or
  treatment decision under Subsection (a-1) shall consider the
  patient's well-being in conducting the review but may not make any
  judgment on the patient's quality of life. For purposes of this
  section, a decision by the committee based on any of the
  considerations described by Subdivisions (1) through (5) is not a
  judgment on the patient's quality of life. If the review requires
  the committee to determine whether life-sustaining treatment
  requested in the patient's advance directive or by the person
  responsible for the patient's health care decisions is medically
  inappropriate, the committee shall consider whether provision of
  the life-sustaining treatment:
               (1)  will prolong the natural process of dying or
  hasten the patient's death;
               (2)  will result in substantial, irremediable, and
  objectively measurable physical pain that is not outweighed by the
  benefit of providing the treatment;
               (3)  is medically contraindicated such that the
  provision of the treatment seriously exacerbates life-threatening
  medical problems not outweighed by the benefit of providing the
  treatment;
               (4)  is consistent with the prevailing standard of
  care; or
               (5)  is contrary to the patient's clearly documented
  desires.
         (b)  The [patient or the] person responsible for the
  patient's 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 in writing [of the committee
  review process] not less than seven calendar days [48 hours] before
  the meeting called to discuss the patient's directive, unless the
  [time] period is waived by written mutual agreement, of:
                     (A)  the ethics or medical committee review
  process and any other related policies and procedures adopted by
  the health care facility, including any policy described by
  Subsection (b-1);
                     (B)  the rights described in Subdivisions
  (3)(A)-(D);
                     (C)  the date, time, and location of the meeting;
                     (D)  the work contact information of the
  facility's personnel who, in the event of a disagreement, will be
  responsible for overseeing the reasonable effort to transfer the
  patient to another physician or facility willing to comply with the
  directive; 
                     (E)  the factors the committee is required to
  consider under Subsection (a-2); and
                     (F)  the language in Section 166.0465;
               (2) [(3)]  at the time of being [so] informed under
  Subdivision (1), 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
               (3) [(4)]  is entitled to:
                     (A)  attend and participate in the meeting as
  scheduled by the committee;
                     (B)  receive during the meeting a written
  statement of the first name, first initial of the last name, and
  title of each committee member who will participate in the meeting;
                     (C)  subject to Subsection (b-1):
                           (i)  be accompanied at the meeting by the
  patient's spouse, parents, adult children, and not more than four
  additional individuals, including legal counsel, a physician, a
  health care professional, or a patient advocate, selected by the
  person responsible for the patient's health care decisions; and
                           (ii)  have an opportunity during the open
  portion of the meeting to either directly or through another
  individual attending the meeting:
                                 (a)  explain the justification for the
  health care or treatment request made by or on behalf of the
  patient;
                                 (b)  respond to information relating
  to the patient that is submitted or presented during the open
  portion of the meeting; and
                                 (c)  state any concerns of the person
  responsible for the patient's health care decisions regarding
  compliance with this section or Section 166.0465, including stating
  an opinion that one or more of the patient's disabilities are not
  relevant to the committee's determination of whether the medical or
  surgical intervention is medically appropriate;
                     (D)  receive a written notice [explanation] of:
                           (i)  the decision reached during the review
  process accompanied by an explanation of the decision, including,
  if applicable, the committee's reasoning for affirming that
  requested life-sustaining treatment is medically inappropriate;
                           (ii)  the patient's major medical conditions
  as identified by the committee, including any disability of the
  patient considered by the committee in reaching the decision,
  except the notice is not required to specify whether any medical
  condition qualifies as a disability;
                           (iii)  a statement that the committee has
  complied with Subsection (a-2) and Section 166.0465; and
                           (iv)  the health care facilities contacted
  before the meeting as part of the transfer efforts under Subsection
  (d) and, for each listed facility that denied the request to
  transfer the patient and provided a reason for the denial, the
  provided reason;
                     (E) [(C)]  receive a copy of or electronic access
  to 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
                     (F) [(D)]  receive a copy of or electronic access
  to all of the patient's reasonably available diagnostic results and
  reports related to the medical record provided under Paragraph (E)
  [(C)].
         (b-1)  A health care facility may adopt and implement a
  written policy for meetings held under this section that is
  reasonable and necessary to:
               (1)  facilitate information sharing and discussion of
  the patient's medical status and treatment requirements, including
  provisions related to attendance, confidentiality, and timing
  regarding any agenda item; and
               (2)  preserve the effectiveness of the meeting,
  including provisions disclosing that the meeting is not a legal
  proceeding and the committee will enter into an executive session
  for deliberations.
         (b-2)  Notwithstanding Subsection (b)(3), the following
  individuals may not attend or participate in the executive session
  of an ethics or medical committee under this section:
               (1)  the physicians or health care professionals
  providing health care and treatment to the patient; or
               (2)  the person responsible for the patient's health
  care decisions or any person attending the meeting under Subsection
  (b)(3)(C)(i).
         (b-3)  If the health care facility or person responsible for
  the patient's health care decisions intends to have legal counsel
  attend the meeting of the ethics or medical committee, the facility
  or person, as applicable, shall make a good faith effort to provide
  written notice of that intention not less than 48 hours before the
  meeting begins.
         (c)  The written notice [explanation] required by Subsection
  (b)(3)(D)(i) [Subsection (b)(4)(B)] must be included in the
  patient's medical record.
         (d)  After written notice is provided under Subsection
  (b)(1), [If] the patient's attending physician [, the patient, or
  the person responsible for the health care decisions of the
  individual does not agree with the decision reached during the
  review process under Subsection (b), the physician] shall make a
  reasonable effort to transfer the patient to a physician who is
  willing to comply with the directive. The health care [If the
  patient is a patient in a health care facility, the] facility's
  personnel shall assist the physician in arranging the patient's
  transfer to:
               (1)  another physician;
               (2)  an alternative care setting within that facility;
  or
               (3)  another facility.
         (d-1)  If another health care facility denies the patient's
  transfer request, the personnel of the health care facility
  assisting with the patient's transfer efforts under Subsection (d)
  shall make a good faith effort to inquire whether the facility that
  denied the patient's transfer request would be more likely to
  approve the transfer request if a medical procedure, as that term is
  defined in this section, is performed on the patient.
         (d-2)  If the patient's advance directive or the person
  responsible for the patient's health care decisions is requesting
  life-sustaining treatment that the attending physician has decided
  and the ethics or medical committee has affirmed is medically
  inappropriate:
               (1)  the attending physician or another physician
  responsible for the care of the patient shall perform on the patient
  each medical procedure that satisfies all of the following
  conditions:
                     (A)  in the attending physician's judgment, the
  medical procedure is reasonable and necessary to help effect the
  patient's transfer under Subsection (d);
                     (B)  an authorized representative for another
  health care facility with the ability to comply with the patient's
  advance directive or the health care or treatment decision made by
  or on behalf of the patient has expressed to the personnel described
  by Subsection (b)(1)(D) or the attending physician that the
  facility is more likely to accept the patient's transfer to the
  other facility if the medical procedure is performed on the
  patient;
                     (C)  in the medical judgment of the physician who
  would perform the medical procedure, performing the medical
  procedure is:
                           (i)  within the prevailing standard of
  medical care; and
                           (ii)  not medically contraindicated or
  medically inappropriate under the circumstances;
                     (D)  in the medical judgment of the physician who
  would perform the medical procedure, the physician has the training
  and experience to perform the medical procedure;
                     (E)  the physician who would perform the medical
  procedure has medical privileges at the facility where the patient
  is receiving care authorizing the physician to perform the medical
  procedure at the facility;
                     (F)  the facility where the patient is receiving
  care has determined the facility has the resources for the
  performance of the medical procedure at the facility; and
                     (G)  the person responsible for the patient's
  health care decisions provides consent on behalf of the patient for
  the medical procedure; and
               (2)  the person responsible for the patient's health
  care decisions is entitled to receive:
                     (A)  a delay notice:
                           (i)  if, at the time the written decision is
  provided as required by Subsection (b)(3)(D)(i), a medical
  procedure satisfies all of the conditions described by Subdivision
  (1); or
                           (ii)  if:
                                 (a)  at the time the written decision
  is provided as required by Subsection (b)(3)(D)(i), a medical
  procedure satisfies all of the conditions described by Subdivision
  (1) except Subdivision (1)(G); and
                                 (b)  the person responsible for the
  patient's health care decisions provides to the attending physician
  or another physician or health care professional providing direct
  care to the patient consent on behalf of the patient for the medical
  procedure within 24 hours of the request for consent;
                     (B)  a start notice:
                           (i)  if, at the time the written decision is
  provided as required by Subsection (b)(3)(D)(i), no medical
  procedure satisfies all of the conditions described by Subdivisions
  (1)(A) through (F); or
                           (ii)  if:
                                 (a)  at the time the written decision
  is provided as required by Subsection (b)(3)(D)(i), a medical
  procedure satisfies all of the conditions described by Subdivision
  (1) except Subdivision (1)(G); and
                                 (b)  the person responsible for the
  patient's health care decisions does not provide to the attending
  physician or another physician or health care professional
  providing direct care to the patient consent on behalf of the
  patient for the medical procedure within 24 hours of the request for
  consent; and
                     (C)  a start notice accompanied by a statement
  that one or more of the conditions described by Subdivisions (1)(A)
  through (G) are no longer satisfied if, after a delay notice is
  provided in accordance with Subdivision (2)(A) and before the
  medical procedure on which the delay notice is based is performed on
  the patient, one or more of those conditions are no longer
  satisfied.
         (d-3)  After the 25-day period described by Subsection (e)
  begins, the period may not be suspended or stopped for any reason.
  This subsection does not limit or affect a court's ability to order
  an extension of the period in accordance with Subsection (g).
  Subsection (d-2) does not require a medical procedure to be
  performed on the patient after the expiration of the 25-day period.
         (e)  If the patient's advance directive [patient] or the
  person responsible for the patient's health care decisions [of the
  patient] is requesting life-sustaining treatment that the
  attending physician has decided and the ethics or medical committee
  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
  interventions [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 health care 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 25th calendar [10th] day after a start notice is
  [both the written decision and the patient's medical record
  required under Subsection (b) are] provided in accordance with
  Subsection (d-2)(2)(B) or (C) to [the patient or] the person
  responsible for the patient's health care decisions or a medical
  procedure for which a delay notice was provided in accordance with
  Subsection (d-2)(2)(A) is performed, whichever occurs first, [of
  the patient] unless ordered to extend the 25-day period [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 providing [the
  provision of] the treatment;
               (3)  result in substantial, irremediable, and
  objectively measurable physical pain not outweighed by the benefit
  of providing [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.
         (g)  At the request of [the patient or] the person
  responsible for the patient's health care decisions [of the
  patient], the appropriate district or county court shall extend the
  [time] period provided under Subsection (e) only if the court
  finds, by a preponderance of the evidence, that there is a
  reasonable expectation that a physician or health care facility
  that will honor the patient's directive will be found if the time
  extension is granted.
         (i)  In this section:
               (1)  "Delay notice" means a written notice that the
  first day of the 25-day period provided under Subsection (e), after
  which life-sustaining treatment may be withheld or withdrawn unless
  a court has granted an extension under Subsection (g), will be
  delayed until the calendar day after a medical procedure required
  by Subsection (d-2)(1) is performed unless, before the medical
  procedure is performed, the person receives written notice of an
  earlier first day because one or more conditions described by that
  subdivision are no longer satisfied.
               (2)  "Medical procedure" means only a tracheostomy or a
  percutaneous endoscopic gastrostomy.
               (3)  "Start notice" means a written notice that the
  25-day period provided under Subsection (e), after which
  life-sustaining treatment may be withheld or withdrawn unless a
  court has granted an extension under Subsection (g), will begin on
  the first calendar day after the date the notice is provided.
         SECTION 4.  Subchapter B, Chapter 166, Health and Safety
  Code, is amended by adding Section 166.0465 to read as follows:
         Sec. 166.0465.  ETHICS OR MEDICAL COMMITTEE DECISION RELATED
  TO PATIENT DISABILITY. (a) In this section, "disability" has the
  meaning assigned by the Americans with Disabilities Act of 1990 in
  42 U.S.C. Section 12102.
         (b)  During the review process under Section 166.046(b), the
  ethics or medical committee may not consider a patient's disability
  that existed before the patient's current admission unless the
  disability is relevant in determining whether the medical or
  surgical intervention is medically appropriate.
         SECTION 5.  Sections 166.052(a) and (b), Health and Safety
  Code, 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 for a patient
  who is determined to be incompetent or is otherwise mentally or
  physically incapable of communication, the statement required by
  Section 166.046(b)(2)(A) [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 the patient has
  requested through an advance directive or you have requested on
  behalf of the patient that life-sustaining treatment* be provided
  to [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, Texas Health and Safety
  Code.
         When an attending physician refuses to comply with an advance
  directive or other request for life-sustaining treatment for a
  patient who is determined to be incompetent or is otherwise
  mentally or physically incapable of communication 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 seven
  calendar days [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 seven calendar days
  [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 can be transferred to a willing
  provider for up to 25 calendar [10] days from the time you were
  given a written notice of the first day of the 25-day period or a
  medical procedure is performed that delayed the 25-day period and
  for which you received notice, whichever occurs first [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 25-day [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 25 calendar [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 25-day [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 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 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 a health care or treatment
  decision requesting the withholding or withdrawal of
  life-sustaining treatment for a patient who is determined to be
  incompetent or is otherwise mentally or physically incapable of
  communication, the statement required by Section 166.046(b)(2)(A)
  [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 the patient has
  requested through an advance directive or you have requested on
  behalf of the patient that [the withdrawal or withholding of]
  life-sustaining treatment* be withdrawn or withheld from [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, 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 seven
  calendar days [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 seven calendar days
  [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 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 6.  Subchapter B, Chapter 166, Health and Safety
  Code, is amended by adding Section 166.054 to read as follows:
         Sec. 166.054.  REPORTING REQUIREMENTS REGARDING ETHICS OR
  MEDICAL COMMITTEE PROCESSES. (a) Not later than the 180th day
  after the date written notice is provided under Section
  166.046(b)(1), a health care facility shall prepare and submit to
  the commission a report that contains the following information:
               (1)  the number of days that elapsed from the patient's
  admission to the facility to the date notice was provided under
  Section 166.046(b)(1);
               (2)  whether the ethics or medical committee met to
  review the case under Section 166.046 and, if the committee did
  meet, the number of days that elapsed from the date notice was
  provided under Section 166.046(b)(1) to the date the meeting was
  held;
               (3)  whether the patient was:
                     (A)  transferred to a physician within the same
  facility who was willing to comply with the patient's advance
  directive or a health care or treatment decision made by or on
  behalf of the patient;
                     (B)  transferred to a different health care
  facility; or
                     (C)  discharged from the facility to a private
  residence or other setting that is not a health care facility;
               (4)  whether the patient died while receiving
  life-sustaining treatment at the facility;
               (5)  whether life-sustaining treatment was withheld or
  withdrawn from the patient at the facility after expiration of the
  time period described by Section 166.046(e) and, if so, the
  disposition of the patient after the withholding or withdrawal of
  life-sustaining treatment at the facility, as selected from the
  following categories:
                     (A)  the patient died at the facility;
                     (B)  the patient is currently a patient at the
  facility;
                     (C)  the patient was transferred to a different
  health care facility; or
                     (D)  the patient was discharged from the facility
  to a private residence or other setting that is not a health care
  facility;
               (6)  the age group of the patient selected from the
  following categories:
                     (A)  17 years of age or younger;
                     (B)  18 years of age or older and younger than 66
  years of age; or
                     (C)  66 years of age or older;
               (7)  the health insurance coverage status of the
  patient selected from the following categories:
                     (A)  private health insurance coverage;
                     (B)  public health plan coverage; or
                     (C)  uninsured;
               (8)  the patient's sex;
               (9)  the patient's race;
               (10)  whether the facility was notified of and able to
  reasonably verify any public disclosure of the contact information
  for the facility's personnel, physicians or health care
  professionals who provide care at the facility, or members of the
  ethics or medical committee in connection with the patient's stay
  at the facility; and
               (11)  whether the facility was notified of and able to
  reasonably verify any public disclosure by facility personnel of
  the contact information for the patient's immediate family members
  or the person responsible for the patient's health care decisions
  in connection with the patient's stay at the facility.
         (b)  The commission shall ensure information provided in
  each report submitted by a health care facility under Subsection
  (a) is kept confidential and not disclosed in any manner, except as
  provided by this section.
         (c)  Not later than April 1 of each year, the commission
  shall prepare and publish on the commission's Internet website a
  report that contains:
               (1)  aggregate information compiled from the reports
  submitted to the commission under Subsection (a) during the
  preceding year on:
                     (A)  the total number of written notices provided
  under Section 166.046(b)(1);
                     (B)  the average number of days described by
  Subsection (a)(1);
                     (C)  the total number of meetings held by ethics
  or medical committees to review cases under Section 166.046;
                     (D)  the average number of days described by
  Subsection (a)(2);
                     (E)  the total number of patients described by
  Subsections (a)(3)(A), (B), and (C);
                     (F)  the total number of patients described by
  Subsection (a)(4);
                     (G)  the total number of patients for whom
  life-sustaining treatment was withheld or withdrawn after
  expiration of the time period described by Section 166.046(e);
                     (H)  the total number of cases for which the
  facility was notified of and able to reasonably verify the public
  disclosure of the contact information for the facility's personnel,
  physicians or health care professionals who provide care at the
  facility, or members of the ethics or medical committee in
  connection with the patient's stay at the facility; and
                     (I)  the total number of cases for which the
  facility was notified of and able to reasonably verify the public
  disclosure by facility personnel of contact information for the
  patient's immediate family members or person responsible for the
  patient's health care decisions in connection with the patient's
  stay at the facility; and
               (2)  if the total number of reports submitted under
  Subsection (a) for the preceding year is 10 or more, aggregate
  information compiled from those reports on the total number of
  patients categorized by:
                     (A)  sex;
                     (B)  race;
                     (C)  age group, based on the categories described
  by Subsection (a)(6);
                     (D)  health insurance coverage status, based on
  the categories described by Subsection (a)(7); and
                     (E)  for patients for whom life-sustaining
  treatment was withheld or withdrawn at the facility after
  expiration of the period described by Section 166.046(e), the total
  number of patients described by each of the following:
                           (i)  Subsection (a)(5)(A);
                           (ii)  Subsection (a)(5)(B);
                           (iii)  Subsection (a)(5)(C); and
                           (iv)  Subsection (a)(5)(D).
         (d)  If the commission receives fewer than 10 reports under
  Subsection (a) for inclusion in an annual report required under
  Subsection (c), the commission shall include in the next annual
  report prepared after the commission receives 10 or more reports
  the aggregate information for all years for which the information
  was not included in a preceding annual report. The commission shall
  include in the next annual report a statement that identifies each
  year during which an underlying report was submitted to the
  commission under Subsection (a).
         (e)  The annual report required by Subsection (c) or (d) may
  not include any information that could be used alone or in
  combination with other reasonably available information to
  identify any individual, entity, or facility.
         (f)  The executive commissioner shall adopt rules to:
               (1)  establish a standard form for the reporting
  requirements of this section; and
               (2)  protect and aggregate any information the
  commission receives under this section.
         (g)  Information collected as required by this section or
  submitted to the commission under this section:
               (1)  is not admissible in a civil or criminal
  proceeding in which a physician, health care professional acting
  under the direction of a physician, or health care facility is a
  defendant;
               (2)  may not be used in relation to any disciplinary
  action by a licensing or regulatory agency with oversight over a
  physician, health care professional acting under the direction of a
  physician, or health care facility; and
               (3)  is not public information or subject to disclosure
  under Chapter 552, Government Code, except as permitted by Section
  552.008, Government Code.
         SECTION 7.  Sections 166.203(a), (b), and (c), Health and
  Safety Code, are amended to read as follows:
         (a)  A DNR order issued for a patient is valid only if [the
  patient's attending physician issues the order,] the order is
  dated[,] and [the order]:
               (1)  is issued by a physician providing direct care to
  the patient in compliance with:
                     (A)  the written and dated directions of a patient
  who was competent at the time the patient wrote the directions;
                     (B)  the oral directions of a competent patient
  delivered to or observed by two competent adult witnesses, at least
  one of whom must be a person not listed under Section 166.003(2)(E)
  or (F);
                     (C)  the directions in an advance directive
  enforceable under Section 166.005 or executed in accordance with
  Section 166.032, 166.034, [or] 166.035, 166.082, 166.084, or
  166.085;
                     (D)  the directions of a patient's:
                           (i)  legal guardian;
                           (ii) [or] agent under a medical power of
  attorney acting in accordance with Subchapter D; or
                           (iii)  proxy as designated and authorized by
  a directive executed in accordance with Subchapter B to make a
  treatment decision for the patient if the patient becomes
  incompetent or otherwise mentally or physically incapable of
  communication; or
                     (E)  a treatment decision made in accordance with
  Section 166.039; [or]
               (2)  is issued by the patient's attending physician
  and:
                     (A)  the order is not contrary to the directions
  of a patient who was competent at the time the patient conveyed the
  directions; and
                     (B)  [,] in the reasonable medical judgment of the
  patient's attending physician:
                           (i) [(A)]  the patient's death is imminent,
  within minutes to hours, regardless of the provision of
  cardiopulmonary resuscitation; and
                           (ii) [(B)]  the DNR order is medically
  appropriate; or
               (3)  is issued by the patient's attending physician:
                     (A)  for a patient who is incompetent or otherwise
  mentally or physically incapable of communication; and
                     (B)  in compliance with a decision:
                           (i)  agreed on by the attending physician
  and the person responsible for the patient's health care decisions;
  and
                           (ii)  concurred in by another physician who
  is not involved in the direct 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.
         (b)  The DNR order takes effect at the time the order is
  issued, provided the order is placed in the patient's medical
  record as soon as practicable and may be issued and entered in a
  format acceptable under the policies of the health care facility or
  hospital.
         (c)  Unless notice is provided in accordance with Section
  166.204(a), before [Before] placing in a patient's medical record a
  DNR order issued under Subsection (a)(2), a [the] physician,
  physician assistant, nurse, or other person acting on behalf of a
  health care facility or hospital shall:
               (1)  inform the patient of the order's issuance; or
               (2)  if the patient is incompetent, make a reasonably
  diligent effort to contact or cause to be contacted and inform of
  the order's issuance:
                     (A)  the patient's known agent under a medical
  power of attorney or legal guardian; or
                     (B)  for a patient who does not have a known agent
  under a medical power of attorney or legal guardian, a person
  described by Section 166.039(b)(1), (2), or (3).
         SECTION 8.  Section 166.204, Health and Safety Code, is
  amended by amending Subsections (a), (b), and (c) and adding
  Subsection (a-1) to read as follows:
         (a)  If an individual arrives at a health care facility or
  hospital that is treating a patient for whom a DNR order is issued
  under Section 166.203(a)(2) and the individual notifies a
  physician, physician assistant, or nurse providing direct care to
  the patient of the individual's arrival, the physician, physician
  assistant, or nurse who has actual knowledge of the order shall,
  unless notice has been provided in accordance with Section
  166.203(c), disclose the order to the individual, provided the
  individual is:
               (1)  the patient's known agent under a medical power of
  attorney or legal guardian; or
               (2)  for a patient who does not have a known agent under
  a medical power of attorney or legal guardian, a person described by
  Section 166.039(b)(1), (2), or (3).
         (a-1)  For a patient who was incompetent at the time notice
  otherwise would have been provided to the patient under Section
  166.203(c)(1) and if a physician providing direct care to the
  patient later determines that, based on the physician's reasonable
  medical judgment, the patient has become competent, a physician,
  physician assistant, or nurse providing direct care to the patient
  shall disclose the order to the patient, provided that the
  physician, physician assistant, or nurse has actual knowledge:
               (1)  of the order; and
               (2)  that a physician providing direct care to the
  patient has determined that the patient has become competent.
         (b)  Failure to comply with Subsection (a) or (a-1) or
  Section 166.203(c) does not affect the validity of a DNR order
  issued under this subchapter.
         (c)  Any person, including a health care facility or
  hospital, [who makes a good faith effort to comply with Subsection
  (a) of this section or Section 166.203(c) and contemporaneously
  records the person's effort to comply with Subsection (a) of this
  section or Section 166.203(c) in the patient's medical record] is
  not civilly or criminally liable or subject to disciplinary action
  from the appropriate licensing authority for any act or omission
  related to providing notice under Subsection (a) or (a-1) of this
  section or Section 166.203(c) if the person:
               (1)  makes a good faith effort to comply with
  Subsection (a) or (a-1) or Section 166.203(c) and contemporaneously
  records in the patient's medical record the person's effort to
  comply with those provisions; or
               (2)  makes a good faith determination that the
  circumstances that would require the person to perform an act under
  Subsection (a) or (a-1) or Section 166.203(c) are not met.
         SECTION 9.  Section 166.205, Health and Safety Code, is
  amended by amending Subsections (a), (b), and (c) and adding
  Subsection (c-1) to read as follows:
         (a)  A physician providing direct care to a patient for whom
  a DNR order is issued shall revoke the patient's DNR order if [the
  patient or, as applicable, the patient's agent under a medical
  power of attorney or the patient's legal guardian if the patient is
  incompetent]:
               (1)  an advance directive that serves as the basis of
  the DNR order is properly revoked in accordance with this
  chapter; [effectively revokes an advance directive, in accordance
  with Section 166.042, for which a DNR order is issued under Section
  166.203(a); or]
               (2)  the patient expresses to any person providing
  direct care to the patient a revocation of consent to or intent to
  revoke a DNR order issued under Section 166.203(a); or
               (3)  the DNR order was issued under Section
  166.203(a)(1)(D) or (E) or Section 166.203(a)(3), and the person
  responsible for the patient's health care decisions expresses to
  any person providing direct care to the patient a revocation of
  consent to or intent to revoke the DNR order.
         (b)  A person providing direct care to a patient under the
  supervision of a physician shall notify the physician of the
  request to revoke a DNR order or of the revocation of an advance
  directive under Subsection (a).
         (c)  A patient's attending physician may at any time revoke a
  DNR order issued under:
               (1)  Section 166.203(a)(1)(A), (B), or (C), provided
  that:
                     (A)  the order is for a patient who is incompetent
  or otherwise mentally or physically incapable of communication; and
                     (B)  the decision to revoke the order is:
                           (i)  agreed on by the attending physician
  and the person responsible for the patient's health care decisions;
  and
                           (ii)  concurred in by another physician who
  is not involved in the direct 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;
               (2)  Section 166.203(a)(1)(E), provided that the
  order's issuance was based on a treatment decision made in
  accordance with Section 166.039(e);
               (3)  Section 166.203(a)(2); or
               (4)  Section 166.203(a)(3).
         (c-1)  A patient's attending physician shall revoke a DNR
  order issued for the patient under Section 166.203(a)(2) if, in the
  attending physician's reasonable medical judgment, the condition
  described by Section 166.203(a)(2)(B)(i) is no longer satisfied.
         SECTION 10.  Sections 166.206(a) and (b), Health and Safety
  Code, are amended to read as follows:
         (a)  If a [an attending] physician, health care facility, or
  hospital does not wish to execute or comply with a DNR order or the
  patient's instructions concerning the provision of cardiopulmonary
  resuscitation, the physician, facility, or hospital shall inform
  the patient, the legal guardian or qualified relatives of the
  patient, or the agent of the patient under a medical power of
  attorney of the benefits and burdens of cardiopulmonary
  resuscitation.
         (b)  If, after receiving notice under Subsection (a), the
  patient or another person authorized to act on behalf of the patient
  and the [attending] physician, health care facility, or hospital
  remain in disagreement, the physician, facility, or hospital shall
  make a reasonable effort to transfer the patient to another
  physician, facility, or hospital willing to execute or comply with
  a DNR order or the patient's instructions concerning the provision
  of cardiopulmonary resuscitation.
         SECTION 11.  Section 166.209, Health and Safety Code, is
  amended to read as follows:
         Sec. 166.209.  ENFORCEMENT. (a) Subject to Sections
  166.205(d), 166.207, and 166.208 and Subsection (c), a [A]
  physician, physician assistant, nurse, or other person commits an
  offense if, with the specific intent to violate this subchapter,
  the person intentionally:
               (1)  conceals, cancels, effectuates, or falsifies
  another person's DNR order in violation of this subchapter; or
               (2)  [if the person intentionally] conceals or
  withholds personal knowledge of another person's revocation of a
  DNR order in violation of this subchapter.
         (a-1)  An offense under Subsection (a) [this subsection] is a
  Class A misdemeanor.  This section [subsection] does not preclude
  prosecution for any other applicable offense.
         (b)  Subject to Sections 166.205(d), 166.207, and 166.208, a
  [A] physician, health care professional, health care facility,
  hospital, or entity is subject to review and disciplinary action by
  the appropriate licensing authority for intentionally:
               (1)  failing to effectuate a DNR order in violation of
  this subchapter; or
               (2)  issuing a DNR order in violation of this
  subchapter.
         (c)  Subsection (a) does not apply to a person whose act or
  omission was based on a reasonable belief that the act or omission
  was in compliance with the wishes of the patient or the person
  responsible for the patient's health care decisions.
         SECTION 12.  Section 313.004, Health and Safety Code, is
  amended by amending Subsections (a) and (c) and adding Subsection
  (a-1) to read as follows:
         (a)  If an adult patient of a home and community support
  services agency or in a hospital or nursing home, or an adult inmate
  of a county or municipal jail, is comatose, incapacitated, or
  otherwise mentally or physically incapable of communication and
  does not have a legal guardian or an agent under a medical power of
  attorney who is reasonably available after a reasonably diligent
  inquiry, an adult surrogate from the following list, in order of
  priority, who has decision-making capacity, is reasonably
  available after a reasonably diligent inquiry, and is willing to
  consent to medical treatment on behalf of the patient may consent to
  medical treatment on behalf of the patient:
               (1)  the patient's spouse;
               (2)  the patient's [an adult child of the patient who
  has the waiver and consent of all other qualified] adult children
  [of the patient to act as the sole decision-maker];
               (3)  [a majority of] the patient's parents [reasonably
  available adult children]; or
               (4)  the patient's nearest living relative [parents; or
               [(5)  the individual clearly identified to act for the
  patient by the patient before the patient became incapacitated, the
  patient's nearest living relative, or a member of the clergy].
         (a-1)  If the patient does not have a legal guardian, an
  agent under a medical power of attorney, or a person listed in
  Subsection (a) who is reasonably available after a reasonably
  diligent inquiry, another physician who is not involved in the
  medical treatment of the patient may concur with the treatment.
         (c)  Any medical treatment consented to under Subsection (a)
  or concurred with under Subsection (a-1) must be based on knowledge
  of what the patient would desire, if known.
         SECTION 13.  Chapter 166, Health and Safety Code, as amended
  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 the effective date of this Act. A review, consultation,
  disagreement, or other action relating to a health care or
  treatment decision made before the effective date of this Act is
  governed by the law in effect immediately before the effective date
  of this Act, and the former law is continued in effect for that
  purpose.
         SECTION 14.  Section 166.209, Health and Safety Code, as
  amended by this Act, applies only to conduct that occurs on or after
  the effective date of this Act. Conduct that occurs before the
  effective date of this Act is governed by the law in effect on the
  date the conduct occurred, and the former law is continued in effect
  for that purpose.
         SECTION 15.  This Act takes effect September 1, 2023.
 
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