88R3162 JG-D
	By: Johnson	S.B. No. 2039

	A BILL TO BE ENTITLED
	AN ACT
	relating to health care practitioner authority regarding certain
	do-not-resuscitate orders, including the use of electronic copies
	and photographs of out-of-hospital do-not-resuscitate orders.
	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
	SECTION 1.  Section 166.081(6), Health and Safety Code, is
	amended to read as follows:
	(6)  "Out-of-hospital DNR order":
	(A)  means a legally binding out-of-hospital
	do-not-resuscitate order, in the form specified by department rule
	under Section 166.083, prepared and signed as required by this
	subchapter [by the attending physician of a person], that documents
	the instructions of a person or the person's legally authorized
	representative and directs health care professionals acting in an
	out-of-hospital setting not to initiate or continue the following
	life-sustaining treatment:
	(i)  cardiopulmonary resuscitation;
	(ii)  advanced airway management;
	(iii)  artificial ventilation;
	(iv)  defibrillation;
	(v)  transcutaneous cardiac pacing; and
	(vi)  other life-sustaining treatment
	specified by department rule under Section 166.101(a); and
	(B)  does not include authorization to withhold
	medical interventions or therapies considered necessary to provide
	comfort care or to alleviate pain or to provide water or nutrition.
	SECTION 2.  Sections 166.082(b) and (c), Health and Safety
	Code, are amended to read as follows:
	(b)  Except as provided by this subsection, the declarant
	must sign the out-of-hospital DNR order in the presence of two
	witnesses who qualify under Section 166.003, at least one of whom
	must be a witness who qualifies under Section 166.003(2). The
	witnesses must sign the order.  The declarant's attending
	physician, or a physician assistant or an advanced practice
	registered nurse providing care to [of] the declarant, must sign
	the order and shall make the fact of the existence of the order and
	the reasons for execution of the order a part of the declarant's
	medical record. The declarant, in lieu of signing in the presence
	of witnesses, may sign the out-of-hospital DNR order and have the
	signature acknowledged before a notary public.
	(c)  If the person is incompetent but previously executed or
	issued a directive to physicians in accordance with Subchapter B,
	the physician, or a physician assistant or advanced practice
	registered nurse providing care to the person, may rely on the
	directive as the person's instructions to issue an out-of-hospital
	DNR order and shall place a copy of the directive in the person's
	medical record. The physician, physician assistant, or advanced
	practice registered nurse shall sign the order in lieu of the person
	signing under Subsection (b) and may use a digital or electronic
	signature authorized under Section 166.011.
	SECTION 3.  Sections 166.083(b) and (d), Health and Safety
	Code, are amended to read as follows:
	(b)  The standard form of an out-of-hospital DNR order
	specified by department rule must, at a minimum, contain the
	following:
	(1)  a distinctive single-page format that readily
	identifies the document as an out-of-hospital DNR order;
	(2)  a title that readily identifies the document as an
	out-of-hospital DNR order;
	(3)  the printed or typed name of the person who
	executed or issued the document or for whom the document was
	executed or issued;
	(4)  a statement that the physician, physician
	assistant, or advanced practice registered nurse signing the
	document is the person's attending physician, or a physician
	assistant or advanced practice registered nurse providing care to
	[of] the person, and that [the physician is directing] health care
	professionals acting in out-of-hospital settings, including a
	hospital emergency department, are directed not to initiate or
	continue certain life-sustaining treatment on behalf of the person,
	and a listing of those procedures not to be initiated or continued;
	(5)  a statement that the person understands that the
	person may revoke the out-of-hospital DNR order at any time by
	destroying the order and removing the DNR identification device, if
	any, or by communicating to health care professionals at the scene
	the person's desire to revoke the out-of-hospital DNR order;
	(6)  places for the printed names and signatures of the
	witnesses or the notary public's acknowledgment and for the printed
	name and signature of the person's attending physician, or a
	physician assistant or an advanced practice registered nurse
	providing care to [of] the person, and the professional's [medical]
	license number [of the attending physician];
	(7)  a separate section for execution of the document
	by the legal guardian of the person, the person's proxy, an agent of
	the person having a medical power of attorney, [or] the attending
	physician, the physician assistant, or the advanced practice
	registered nurse attesting to the issuance of an out-of-hospital
	DNR order by nonwritten means of communication or acting in
	accordance with a previously executed or previously issued
	directive to physicians under Section 166.082(c) that includes the
	following:
	(A)  a statement that the legal guardian, the
	proxy, the agent, the person by nonwritten means of communication,
	[or] the physician, the physician assistant, or the advanced
	practice registered nurse directs that each listed life-sustaining
	treatment should not be initiated or continued in behalf of the
	person; and
	(B)  places for the printed names and signatures
	of the witnesses and, as applicable, the legal guardian, proxy,
	agent, [or] physician, physician assistant, or advanced practice
	registered nurse;
	(8)  a separate section for execution of the document
	by at least one qualified relative of the person when the person
	does not have a legal guardian, proxy, or agent having a medical
	power of attorney and is incompetent or otherwise mentally or
	physically incapable of communication, including:
	(A)  a statement that the relative of the person
	is qualified to make a treatment decision to withhold
	cardiopulmonary resuscitation and certain other designated
	life-sustaining treatment under Section 166.088 and, based on the
	known desires of the person or a determination of the best interest
	of the person, directs that each listed life-sustaining treatment
	should not be initiated or continued in behalf of the person; and
	(B)  places for the printed names and signatures
	of the witnesses and qualified relative of the person;
	(9)  a place for entry of the date of execution of the
	document;
	(10)  a statement that the document is in effect on the
	date of its execution and remains in effect until the death of the
	person or until the document is revoked;
	(11)  a statement that the document must accompany the
	person during transport;
	(12)  a statement regarding the proper disposition of
	the document or copies of the document, as the executive
	commissioner determines appropriate; and
	(13)  a statement at the bottom of the document, with
	places for the signature of each person executing the document,
	that the document has been properly completed.
	(d)  A photocopy or other complete facsimile, including an
	electronic copy or photograph, of the original written
	out-of-hospital DNR order executed under this subchapter may be
	used for any purpose for which the original written order may be
	used under this subchapter.
	SECTION 4.  Sections 166.084(b) and (c), Health and Safety
	Code, are amended to read as follows:
	(b)  A declarant must issue the nonwritten out-of-hospital
	DNR order in the presence of the declarant's attending physician,
	or a physician assistant or advanced practice registered nurse
	providing care to the declarant, and two witnesses who qualify
	under Section 166.003, at least one of whom must be a witness who
	qualifies under Section 166.003(2).
	(c)  The attending physician, the physician assistant, or
	the advanced practice registered nurse and witnesses shall sign the
	out-of-hospital DNR order in the place of the document provided by
	Section 166.083(b)(7) and the attending physician, the physician
	assistant, or the advanced practice registered nurse shall sign the
	document in the place required by Section 166.083(b)(13). The
	physician, physician assistant, or advanced practice registered
	nurse shall make the fact of the existence of the out-of-hospital
	DNR order a part of the declarant's medical record and the names of
	the witnesses shall be entered in the medical record.
	SECTION 5.  Sections 166.087(b) and (c), Health and Safety
	Code, are amended to read as follows:
	(b)  If the adult person has designated a person to make a
	treatment decision as authorized by Section 166.032(c), the adult
	person's attending physician, or a physician assistant or advanced
	practice registered nurse providing care to the person, and the
	designated person shall comply with the out-of-hospital DNR order.
	(c)  If the adult person has not designated a person to make a
	treatment decision as authorized by Section 166.032(c), the
	person's attending physician, or a physician assistant or advanced
	practice registered nurse providing care to the person, shall
	comply with the out-of-hospital DNR order unless the physician,
	physician assistant, or advanced practice registered nurse
	believes that the order does not reflect the person's present
	desire.
	SECTION 6.  Sections 166.088(a), (b), and (f), Health and
	Safety Code, are amended to read as follows:
	(a)  If an adult person has not executed or issued an
	out-of-hospital DNR order and is incompetent or otherwise mentally
	or physically incapable of communication, the person's attending
	physician, or a physician assistant or advanced practice registered
	nurse providing care to the person, and the person's legal
	guardian, proxy, or agent having a medical power of attorney may
	execute an out-of-hospital DNR order on behalf of the person.
	(b)  If the person does not have a legal guardian, proxy, or
	agent under a medical power of attorney, the person's attending
	physician, or a physician assistant or advanced practice registered
	nurse providing care to the person, and at least one qualified
	relative from a category listed by Section 166.039(b), subject to
	the priority established under that subsection, may execute an
	out-of-hospital DNR order in the same manner as a treatment
	decision made under Section 166.039(b).
	(f)  If there is not a qualified relative available to act
	for the person under Subsection (b), an out-of-hospital DNR order
	must be concurred in by another physician, physician assistant, or
	advanced practice registered nurse who is not involved in the
	treatment of the patient or who is a representative of the ethics or
	medical committee of the health care facility in which the person is
	a patient.
	SECTION 7.  Sections 166.089(d), (h), and (i), Health and
	Safety Code, are amended to read as follows:
	(d)  The responding health care professionals must determine
	that the out-of-hospital DNR order form appears to be valid in that
	it includes:
	(1)  written responses in the places designated on the
	form for the names, signatures, and other information required of
	persons executing or issuing, or witnessing or acknowledging as
	applicable, the execution or issuance of, the order;
	(2)  a date in the place designated on the form for the
	date the order was executed or issued; and
	(3)  the signature or digital or electronic signature
	of the declarant or persons executing or issuing the order and the
	attending physician, a physician assistant, or an advanced practice
	registered nurse in the appropriate places designated on the form
	for indicating that the order form has been properly completed.
	(h)  An out-of-hospital DNR order executed or issued and
	documented or evidenced in the manner prescribed by this subchapter
	is valid and shall be honored by responding health care
	professionals unless the person or persons found at the scene:
	(1)  identify themselves as the declarant or as the
	attending physician of the person who executed or issued the
	out-of-hospital DNR order or for whom the out-of-hospital DNR order
	was executed or issued, a physician assistant or advanced practice
	registered nurse providing care to the person, or the legal
	guardian, qualified relative, or agent of the person having a
	medical power of attorney who executed or issued the
	out-of-hospital DNR order on behalf of the person; and
	(2)  request that cardiopulmonary resuscitation or
	certain other life-sustaining treatment designated by department
	rule be initiated or continued.
	(i)  If the policies of a health care facility preclude
	compliance with the out-of-hospital DNR order of a person or an
	out-of-hospital DNR order issued by an attending physician, a
	physician assistant, or an advanced practice registered nurse on
	behalf of a person who is admitted to or a resident of the facility,
	or if the facility is unwilling to accept DNR identification
	devices as evidence of the existence of an out-of-hospital DNR
	order, that facility shall take all reasonable steps to notify the
	person or, if the person is incompetent, the person's guardian or
	the person or persons designated as having authority to make health
	care treatment decisions on behalf of the person for whom the order
	was executed or issued, of the facility's policy and shall take all
	reasonable steps to effect the transfer of the person to the
	person's home or to a facility where the provisions of this
	subchapter can be carried out.
	SECTION 8.  Section 166.092(b), Health and Safety Code, is
	amended to read as follows:
	(b)  An oral revocation under Subsection (a)(3) or (a)(4)
	takes effect only when the declarant or a person who identifies
	himself or herself as the legal guardian, a qualified relative, or
	the agent of the declarant having a medical power of attorney who
	executed the out-of-hospital DNR order communicates the intent to
	revoke the order to the responding health care professionals or the
	declarant's attending physician, or the physician assistant or
	advanced practice registered nurse providing care to the declarant,
	at the scene.  The responding health care professionals shall
	record the time, date, and place of the revocation in accordance
	with the statewide out-of-hospital DNR protocol and rules adopted
	by the executive commissioner and any applicable local
	out-of-hospital DNR protocol.  The attending physician, [or] the
	physician's designee, the physician assistant, or the advanced
	practice registered nurse shall record in the declarant's
	[person's] medical record the time, date, and place of the
	revocation and, if different, the time, date, and place that the
	physician, physician assistant, or advanced practice registered
	nurse received notice of the revocation.  The attending physician,
	[or] the physician's designee, the physician assistant, or the
	advanced practice registered nurse shall also enter the word "VOID"
	on each page of the copy of the order in the declarant's [person's]
	medical record.
	SECTION 9.  Section 166.095(c), Health and Safety Code, is
	amended to read as follows:
	(c)  If a person's [an] attending physician, or a physician
	assistant or advanced practice registered nurse providing care to
	the person, refuses to execute or comply with an out-of-hospital
	DNR order, the physician, physician assistant, or advanced practice
	registered nurse shall inform the person, the legal guardian or
	qualified relatives of the person, or the agent of the person having
	a medical power of attorney and, if the person or another authorized
	to act on behalf of the person so directs, shall make a reasonable
	effort to transfer the person to another physician, physician
	assistant, or advanced practice registered nurse who is willing to
	execute or comply with an out-of-hospital DNR order.
	SECTION 10.  The heading to Section 166.102, Health and
	Safety Code, is amended to read as follows:
	Sec. 166.102.  [PHYSICIAN'S] DNR ORDER MAY BE HONORED BY
	HEALTH CARE PERSONNEL OTHER THAN EMERGENCY MEDICAL SERVICES
	PERSONNEL.
	SECTION 11.  Section 166.102(a), Health and Safety Code, is
	amended to read as follows:
	(a)  Except as provided by Subsection (b), a licensed nurse
	or person providing health care services in an out-of-hospital
	setting may honor a physician's, physician assistant's, or advanced
	practice registered nurse's do-not-resuscitate order.
	SECTION 12.  Section 166.203(a), Health and Safety Code, is
	amended to read as follows:
	(a)  A DNR order issued for a patient is valid only if the
	patient's attending physician, or a physician assistant or advanced
	practice registered nurse providing care to the patient, issues the
	order, the order is dated, and the order:
	(1)  is issued 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;
	(D)  the directions of a patient's legal guardian
	or agent under a medical power of attorney acting in accordance with
	Subchapter D; or
	(E)  a treatment decision made in accordance with
	Section 166.039; or
	(2)  is not contrary to the directions of a patient who
	was competent at the time the patient conveyed the directions and,
	in the reasonable medical judgment of the patient's attending
	physician:
	(A)  the patient's death is imminent, regardless
	of the provision of cardiopulmonary resuscitation; and
	(B)  the DNR order is medically appropriate.
	SECTION 13.  Sections 166.205(a), (b), and (c), Health and
	Safety Code, are amended to read as follows:
	(a)  A physician, physician assistant, or advanced practice
	registered nurse 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)  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)  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).
	(b)  A person providing direct care to a patient under the
	supervision of a physician, physician assistant, or advanced
	practice registered nurse shall notify the physician, physician
	assistant, or advanced practice registered nurse of the request to
	revoke a DNR order under Subsection (a).
	(c)  A patient's attending physician, or a physician
	assistant or advanced practice registered nurse providing care to
	the patient, may at any time revoke a DNR order issued under Section
	166.203(a)(2).
	SECTION 14.  Section 166.083(d), Health and Safety Code, as
	amended by this Act, is intended to clarify rather than change
	existing law.
	SECTION 15.  This Act takes effect immediately if it
	receives a vote of two-thirds of all the members elected to each
	house, as provided by Section 39, Article III, Texas Constitution.
	If this Act does not receive the vote necessary for immediate
	effect, this Act takes effect September 1, 2023.