88R11055 LRM-F
 
  By: Springer S.B. No. 1724
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to advance directives and health care treatment decisions
  made by or on behalf of patients, including a review of those
  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
  REQUIRED MEDICAL PROCEDURE. (a) A physician or health care
  professional acting under the direction of a physician is not
  subject to civil liability for conducting a medical procedure
  required under Section 166.046(d-1).
         (b)  A physician or health care professional acting under the
  direction of a physician is not subject to criminal liability for
  conducting a medical procedure required under Section 166.046(d-1)
  unless:
               (1)  the physician or health care professional in
  conducting the medical procedure acted with a specific intent to
  cause the death of the patient and that conduct 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 health care professional acting under the
  direction of a physician has not engaged in unprofessional conduct
  by conducting a medical procedure required under Section
  166.046(d-1) unless the physician or health care professional fails
  to exercise reasonable medical judgment in conducting the medical
  procedure. For purposes of this subsection, the standard of care
  that a physician or health care professional must exercise is the
  degree of care a physician or health care professional of ordinary
  prudence and skill would have exercised under the same or similar
  circumstances in the same or a similar community.
         SECTION 2.  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), and (d-1) to read as
  follows:
         (a)  This section applies only to the treatment and care of a
  qualified patient who is declared incompetent or otherwise mentally
  or physically incapable of communication.
         (a-1)  If an attending physician refuses to honor a patient's
  advance directive or a health care or treatment decision made by or
  on behalf of a patient, the physician's refusal shall be reviewed by
  an ethics or medical committee. The attending physician may not be
  a member of that committee. 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 a patient's advance directive or
  health care treatment decision under Subsection (a-1) shall
  consider the patient's well-being in conducting the review. If the
  review requires the committee to make a determination on whether
  life-sustaining treatment requested in a 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 cause harm or undesirable side effects
  without a proportionate benefit to the patient;
               (3)  will exacerbate life-threatening medical problems
  that outweigh the treatment benefits;
               (4)  will result in substantial irremediable physical
  pain or other measurable suffering that outweigh the treatment
  benefits;
               (5)  without regard to any judgment on the patient's
  quality of life, will be medically ineffective at:
                     (A)  improving the patient's current condition;
  or
                     (B)  reducing the patient's current medical
  support level;
               (6)  is consistent with the prevailing standard of
  care; or
               (7)  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 or, for
  a patient for whom a review is conducted under Subsection (a-1) and
  who did not designate a person to make health care or treatment
  decisions or who does not have a legal guardian or agent under a
  medical power of attorney, a person in the priority order described
  by Section 166.039(b):
               (1)  must [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 attendance and
  confidentiality 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 name, title, and work contact information
  of the facility's personnel who, in the event of a disagreement
  described by Subsection (d-1), will be responsible for overseeing
  the transfer of the patient to another physician or facility that is
  willing to comply with the directive; and
                     (E)  the factors the committee is required to
  consider under Subsection (a-2);
               (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;
                     (B)  receive before or during the meeting a
  written statement of the full name and title of each committee
  member who will participate in the meeting;
                     (C)  subject to Subsection (b-2):
                           (i)  be accompanied at the meeting by up to
  10 individuals selected by the patient or surrogate, including
  legal counsel, physicians, health care professionals, or patient
  advocates; and
                           (ii)  have an opportunity during the meeting
  to either directly or through another individual:
                                 (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 meeting;
  and
                                 (c)  state any concerns the patient or
  surrogate has regarding compliance with this section or Section
  166.0465;
                     (D)  receive a written notice [explanation] of:
                           (i)  the decision reached during the review
  process;
                           (ii)  an explanation of the decision,
  including, if applicable, the committee's reasoning for affirming
  that 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;
                           (iii)  a statement that the committee has
  complied with Subsection (a-2) and Section 166.0465; and
                           (iv)  a list of the health care facilities
  contacted before the meeting as part of the transfer efforts made
  under Subsection (d) and, for each facility on the list that denied
  the request to transfer the patient, any reason provided by the
  facility for denying the request;
                     (E) [(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
                     (F) [(D)]  receive a copy of 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 attendance and confidentiality 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; and
               (2)  preserve the effectiveness of the meeting.
         (b-2)  Notwithstanding Subsection (b)(3), the following
  individuals may not participate in the deliberations of an ethics
  or medical committee under this section:
               (1)  the physicians or health care professionals
  providing treatment and care to the patient; or
               (2)  the patient, the person entitled to written notice
  of the meeting under Subsection (b)(1), or any person attending
  under Subsection (b)(3)(C).
         (c)  The written notices [explanation] required by
  Subsections (b)(3)(D)(i) and (ii) [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. 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)  In this subsection, "medical procedure" means only a
  tracheostomy or a percutaneous endoscopic gastrostomy. If the
  person responsible for a patient's health care decisions does not
  agree with the decision reached during the review process under
  Subsection (b), the attending physician or another physician
  responsible for the care of the patient shall perform on the patient
  each medical procedure that satisfies the following conditions:
               (1)  in the physician's judgment, the medical procedure
  is reasonable and necessary to help effect the patient's transfer
  under Subsection (d);
               (2)  based on the physician's discussion with the
  facility, performing the medical procedure will increase the
  likelihood of effecting the patient's transfer under Subsection (d)
  to a health care facility that is willing to consider accepting or
  able to accept the patient;
               (3)  in the physician's medical judgment, performing
  the medical procedure is:
                     (A)  within the prevailing standard of medical
  care; and
                     (B)  not medically contraindicated or medically
  inappropriate under the circumstances;
               (4)  the physician has the training and experience to
  perform the medical procedure;
               (5)  if the patient is receiving care in a health care
  facility, the physician has been granted privileges by the facility
  that authorize the physician to perform the medical procedure at
  the facility;
               (6)  the health care facility at which the medical
  procedure will be performed has the resources for the performance
  of the procedure; and
               (7)  the person responsible for the health care
  decisions of the patient provides consent on behalf of the patient
  for the medical procedure.
         (e)  If the patient's advance directive [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 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 21st business [10th] day after both the written decision
  and the patient's medical record required under Subsection (b) are
  provided to [the patient or] the person responsible for the health
  care decisions of the patient unless ordered to extend the time [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.
         (g)  At the request of [the patient or] the person
  responsible for the 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.
         SECTION 3.  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 (42
  U.S.C. Section 12101 et seq.).
         (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 life-sustaining
  treatment is medically appropriate.
         SECTION 4.  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, 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 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, 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 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 21 business [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 that [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 21 business [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 that [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 treatment decision requesting
  the withholding or withdrawal of life-sustaining treatment, 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 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, 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 5.  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 department a report that contains information on:
               (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 a patient;
                     (B)  transferred to a different 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;
               (5)  whether life-sustaining treatment was withheld or
  withdrawn from the patient after expiration of the time described
  by Section 166.046(e);
               (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; and
               (9)  the patient's race.
         (b)  The department 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 department
  shall prepare and publish on the department's Internet website a
  report that contains:
               (1)  aggregate information compiled from the reports
  submitted to the department 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); and
                     (G)  the total number of patients for whom
  life-sustaining treatment was withheld or withdrawn after
  expiration of the time described by Section 166.046(e); 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); and
                     (D)  health insurance coverage status, based on
  the categories described by Subsection (a)(7).
         (d)  If the department receives fewer than 10 reports under
  Subsection (a) for inclusion in an annual report required under
  Subsection (c), the department shall include in the next annual
  report prepared after the department receives 10 or more reports
  the aggregate information for all years for which the information
  was not included in a preceding annual report. The department shall
  include in the next annual report a statement that identifies each
  year during which an underlying report was submitted to the
  department 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
  department receives under this section.
         (g)  Information submitted to the department 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.
         SECTION 6.  Section 166.202(a), Health and Safety Code, is
  amended to read as follows:
         (a)  This subchapter applies to a DNR order issued for a
  patient admitted to [in] a health care facility or hospital.
         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,
  regardless of the provision of cardiopulmonary resuscitation; and
                           (ii) [(B)]  the DNR order is medically
  appropriate.
         (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 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-1), 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 Subsection (a) and adding Subsection (a-1) to
  read as follows:
         (a)  If a physician issues a DNR order under Section
  166.203(a)(2), a physician, a physician assistant, a nurse, or
  another person acting on behalf of a health care facility or
  hospital shall provide notice of the order to the appropriate
  persons in accordance with Subsection (a-1) or Section 166.203(c).
         (a-1)  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).
         SECTION 9.  Sections 166.205(a) and (b), Health and Safety
  Code, are amended 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)  the 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)(2), and the person
  responsible for making health care or treatment decisions on behalf
  of the patient 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).
         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:
               (1)  [intentionally] 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)  A person does not commit an offense under Subsection (a)
  if the person's 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 having authority to make health care
  treatment decisions on behalf of the patient.
         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, 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, a treatment decision
  may be concurred by another physician who is not involved in the
  treatment of the patient.
         (c)  Any medical treatment consented to under Subsection (a)
  or (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.