Bill Text: TX SB919 | 2017-2018 | 85th Legislature | Introduced
NOTE: There are more recent revisions of this legislation. Read Latest Draft
Bill Title: Relating to the authority of an advanced practice registered nurse or physician assistant to sign a death certificate in limited situations.
Spectrum: Partisan Bill (Democrat 2-0)
Status: (Passed) 2017-06-01 - Effective immediately [SB919 Detail]
Download: Texas-2017-SB919-Introduced.html
Bill Title: Relating to the authority of an advanced practice registered nurse or physician assistant to sign a death certificate in limited situations.
Spectrum: Partisan Bill (Democrat 2-0)
Status: (Passed) 2017-06-01 - Effective immediately [SB919 Detail]
Download: Texas-2017-SB919-Introduced.html
85R7044 DMS-D | ||
By: Rodríguez | S.B. No. 919 |
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relating to the authority of an advanced practice registered nurse | ||
or physician assistant to sign a death certificate or | ||
out-of-hospital do-not-resuscitate order. | ||
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: | ||
SECTION 1. Section 166.081(6), Health and Safety Code, is | ||
amended to read as follows: | ||
(6) "Out-of-hospital DNR order": | ||
(A) means a legally binding out-of-hospital | ||
do-not-resuscitate order, in the form specified by department rule | ||
under Section 166.083, prepared and signed as required by this | ||
subchapter [ |
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the instructions of a person or the person's legally authorized | ||
representative and directs health care professionals acting in an | ||
out-of-hospital setting not to initiate or continue the following | ||
life-sustaining treatment: | ||
(i) cardiopulmonary resuscitation; | ||
(ii) advanced airway management; | ||
(iii) artificial ventilation; | ||
(iv) defibrillation; | ||
(v) transcutaneous cardiac pacing; and | ||
(vi) other life-sustaining treatment | ||
specified by department rule under Section 166.101(a); and | ||
(B) does not include authorization to withhold | ||
medical interventions or therapies considered necessary to provide | ||
comfort care or to alleviate pain or to provide water or nutrition. | ||
SECTION 2. Sections 166.082(b) and (c), Health and Safety | ||
Code, are amended to read as follows: | ||
(b) Except as provided by this subsection, the declarant | ||
must sign the out-of-hospital DNR order in the presence of two | ||
witnesses who qualify under Section 166.003, at least one of whom | ||
must be a witness who qualifies under Section 166.003(2). The | ||
witnesses must sign the order. The attending physician, a | ||
physician assistant, or an advanced practice registered nurse | ||
providing care to [ |
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make the fact of the existence of the order and the reasons for | ||
execution of the order a part of the declarant's medical record. | ||
The declarant, in lieu of signing in the presence of witnesses, may | ||
sign the out-of-hospital DNR order and have the signature | ||
acknowledged before a notary public. | ||
(c) If the person is incompetent but previously executed or | ||
issued a directive to physicians in accordance with Subchapter B, | ||
the physician, a physician assistant, or an advanced practice | ||
registered nurse providing care to the person may rely on the | ||
directive as the person's instructions to issue an out-of-hospital | ||
DNR order and shall place a copy of the directive in the person's | ||
medical record. The physician, the physician assistant, or the | ||
advanced practice registered nurse shall sign the order in lieu of | ||
the person signing under Subsection (b) and may use a digital or | ||
electronic signature authorized under Section 166.011. | ||
SECTION 3. Section 166.083(b), Health and Safety Code, is | ||
amended to read as follows: | ||
(b) The standard form of an out-of-hospital DNR order | ||
specified by department rule must, at a minimum, contain the | ||
following: | ||
(1) a distinctive single-page format that readily | ||
identifies the document as an out-of-hospital DNR order; | ||
(2) a title that readily identifies the document as an | ||
out-of-hospital DNR order; | ||
(3) the printed or typed name of the person; | ||
(4) a statement that the physician, physician | ||
assistant, or advanced practice registered nurse signing the | ||
document is the person's attending physician or a physician | ||
assistant or advanced practice registered nurse of the person and | ||
that the physician, physician assistant, or advanced practice | ||
registered nurse is directing health care professionals acting in | ||
out-of-hospital settings, including a hospital emergency | ||
department, not to initiate or continue certain life-sustaining | ||
treatment on behalf of the person, and a listing of those procedures | ||
not to be initiated or continued; | ||
(5) a statement that the person understands that the | ||
person may revoke the out-of-hospital DNR order at any time by | ||
destroying the order and removing the DNR identification device, if | ||
any, or by communicating to health care professionals at the scene | ||
the person's desire to revoke the out-of-hospital DNR order; | ||
(6) places for the printed names and signatures of the | ||
witnesses or the notary public's acknowledgment and for the printed | ||
name and signature of the attending physician, the physician | ||
assistant, or the advanced practice registered nurse of the person | ||
and the professional's [ |
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(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, [ |
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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, | ||
[ |
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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, [ |
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registered nurse; | ||
(8) a separate section for execution of the document | ||
by at least one qualified relative of the person when the person | ||
does not have a legal guardian, proxy, or agent having a medical | ||
power of attorney and is incompetent or otherwise mentally or | ||
physically incapable of communication, including: | ||
(A) a statement that the relative of the person | ||
is qualified to make a treatment decision to withhold | ||
cardiopulmonary resuscitation and certain other designated | ||
life-sustaining treatment under Section 166.088 and, based on the | ||
known desires of the person or a determination of the best interest | ||
of the person, directs that each listed life-sustaining treatment | ||
should not be initiated or continued in behalf of the person; and | ||
(B) places for the printed names and signatures | ||
of the witnesses and qualified relative of the person; | ||
(9) a place for entry of the date of execution of the | ||
document; | ||
(10) a statement that the document is in effect on the | ||
date of its execution and remains in effect until the death of the | ||
person or until the document is revoked; | ||
(11) a statement that the document must accompany the | ||
person during transport; | ||
(12) a statement regarding the proper disposition of | ||
the document or copies of the document, as the executive | ||
commissioner determines appropriate; and | ||
(13) a statement at the bottom of the document, with | ||
places for the signature of each person executing the document, | ||
that the document has been properly completed. | ||
SECTION 4. Sections 166.084(b) and (c), Health and Safety | ||
Code, are amended to read as follows: | ||
(b) A declarant must issue the nonwritten out-of-hospital | ||
DNR order in the presence of the person's attending physician or a | ||
physician assistant or advanced practice registered nurse of the | ||
person and two witnesses who qualify under Section 166.003, at | ||
least one of whom must be a witness who qualifies under Section | ||
166.003(2). | ||
(c) The attending physician, the physician assistant, or | ||
the advanced practice registered nurse and witnesses shall sign the | ||
out-of-hospital DNR order in the place of the document provided by | ||
Section 166.083(b)(7) and the attending physician, the physician | ||
assistant, or the advanced practice registered nurse shall sign the | ||
document in the place required by Section 166.083(b)(13). The | ||
physician, physician assistant, or advanced practice registered | ||
nurse shall make the fact of the existence of the out-of-hospital | ||
DNR order a part of the declarant's medical record and the names of | ||
the witnesses shall be entered in the medical record. | ||
SECTION 5. Sections 166.087(b) and (c), Health and Safety | ||
Code, are amended to read as follows: | ||
(b) If the adult person has designated a person to make a | ||
treatment decision as authorized by Section 166.032(c), the | ||
person's attending physician or a physician assistant or advanced | ||
practice registered nurse of the person and the designated person | ||
shall comply with the out-of-hospital DNR order. | ||
(c) If the adult person has not designated a person to make a | ||
treatment decision as authorized by Section 166.032(c), the | ||
person's attending physician or a physician assistant or advanced | ||
practice registered nurse of the person shall comply with the | ||
out-of-hospital DNR order unless the physician, physician | ||
assistant, or advanced practice registered nurse believes that the | ||
order does not reflect the person's present desire. | ||
SECTION 6. Sections 166.088(a), (b), and (f), Health and | ||
Safety Code, are amended to read as follows: | ||
(a) If an adult person has not executed or issued an | ||
out-of-hospital DNR order and is incompetent or otherwise mentally | ||
or physically incapable of communication, the person's attending | ||
physician or a physician assistant or advanced practice registered | ||
nurse of the person and the person's legal guardian, proxy, or agent | ||
having a medical power of attorney may execute an out-of-hospital | ||
DNR order on behalf of the person. | ||
(b) If the person does not have a legal guardian, proxy, or | ||
agent under a medical power of attorney, the person's attending | ||
physician or a physician assistant or advanced practice registered | ||
nurse of the person and at least one qualified relative from a | ||
category listed by Section 166.039(b), subject to the priority | ||
established under that subsection, may execute an out-of-hospital | ||
DNR order in the same manner as a treatment decision made under | ||
Section 166.039(b). | ||
(f) If there is not a qualified relative available to act | ||
for the person under Subsection (b), an out-of-hospital DNR order | ||
must be concurred in by another physician, physician assistant, or | ||
advanced practice registered nurse who is not involved in the | ||
treatment of the patient or who is a representative of the ethics or | ||
medical committee of the health care facility in which the person is | ||
a patient. | ||
SECTION 7. Sections 166.089(d), (h), and (i), Health and | ||
Safety Code, are amended to read as follows: | ||
(d) The responding health care professionals must determine | ||
that the out-of-hospital DNR order form appears to be valid in that | ||
it includes: | ||
(1) written responses in the places designated on the | ||
form for the names, signatures, and other information required of | ||
persons executing or issuing, or witnessing or acknowledging as | ||
applicable, the execution or issuance of, the order; | ||
(2) a date in the place designated on the form for the | ||
date the order was executed or issued; and | ||
(3) the signature or digital or electronic signature | ||
of the declarant or persons executing or issuing the order and the | ||
attending physician, a physician assistant, or an advanced practice | ||
registered nurse in the appropriate places designated on the form | ||
for indicating that the order form has been properly completed. | ||
(h) An out-of-hospital DNR order executed or issued and | ||
documented or evidenced in the manner prescribed by this subchapter | ||
is valid and shall be honored by responding health care | ||
professionals unless the person or persons found at the scene: | ||
(1) identify themselves as the declarant or as the | ||
person's attending physician or a physician assistant or advanced | ||
practice registered nurse of the person, legal guardian, qualified | ||
relative, or agent of the person having a medical power of attorney | ||
who executed or issued the out-of-hospital DNR order on behalf of | ||
the person; and | ||
(2) request that cardiopulmonary resuscitation or | ||
certain other life-sustaining treatment designated by department | ||
rule be initiated or continued. | ||
(i) If the policies of a health care facility preclude | ||
compliance with the out-of-hospital DNR order of a person or an | ||
out-of-hospital DNR order issued by an attending physician, a | ||
physician assistant, or an advanced practice registered nurse on | ||
behalf of a person who is admitted to or a resident of the facility, | ||
or if the facility is unwilling to accept DNR identification | ||
devices as evidence of the existence of an out-of-hospital DNR | ||
order, that facility shall take all reasonable steps to notify the | ||
person or, if the person is incompetent, the person's guardian or | ||
the person or persons having authority to make health care | ||
treatment decisions on behalf of the person, of the facility's | ||
policy and shall take all reasonable steps to effect the transfer of | ||
the person to the person's home or to a facility where the | ||
provisions of this subchapter can be carried out. | ||
SECTION 8. Section 166.092(b), Health and Safety Code, is | ||
amended to read as follows: | ||
(b) An oral revocation under Subsection (a)(3) or (a)(4) | ||
takes effect only when the declarant or a person who identifies | ||
himself or herself as the legal guardian, a qualified relative, or | ||
the agent of the declarant having a medical power of attorney who | ||
executed the out-of-hospital DNR order communicates the intent to | ||
revoke the order to the responding health care professionals or the | ||
person's attending physician or the physician assistant or advanced | ||
practice registered nurse of the person at the scene. The | ||
responding health care professionals shall record the time, date, | ||
and place of the revocation in accordance with the statewide | ||
out-of-hospital DNR protocol and rules adopted by the executive | ||
commissioner and any applicable local out-of-hospital DNR | ||
protocol. The attending physician, [ |
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the physician assistant, or the advanced practice registered nurse | ||
shall record in the person's medical record the time, date, and | ||
place of the revocation and, if different, the time, date, and place | ||
that the physician, physician assistant, or advanced practice | ||
registered nurse received notice of the revocation. The attending | ||
physician, [ |
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or the advanced practice registered nurse shall also enter the word | ||
"VOID" on each page of the copy of the order in the person's medical | ||
record. | ||
SECTION 9. Section 166.095(c), Health and Safety Code, is | ||
amended to read as follows: | ||
(c) If a person's [ |
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assistant or advanced practice registered nurse of the person | ||
refuses to execute or comply with an out-of-hospital DNR order, the | ||
physician, physician assistant, or advanced practice registered | ||
nurse shall inform the person, the legal guardian or qualified | ||
relatives of the person, or the agent of the person having a medical | ||
power of attorney and, if the person or another authorized to act on | ||
behalf of the person so directs, shall make a reasonable effort to | ||
transfer the person to another physician, physician assistant, or | ||
advanced practice registered nurse who is willing to execute or | ||
comply with an out-of-hospital DNR order. | ||
SECTION 10. The heading to Section 166.102, Health and | ||
Safety Code, is amended to read as follows: | ||
Sec. 166.102. [ |
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HEALTH CARE PERSONNEL OTHER THAN EMERGENCY MEDICAL SERVICES | ||
PERSONNEL. | ||
SECTION 11. Section 166.102(a), Health and Safety Code, is | ||
amended to read as follows: | ||
(a) Except as provided by Subsection (b), a licensed nurse | ||
or person providing health care services in an out-of-hospital | ||
setting may honor a physician's, physician assistant's, or advanced | ||
practice registered nurse's do-not-resuscitate order. | ||
SECTION 12. Sections 193.005(a), (b), and (c), Health and | ||
Safety Code, are amended to read as follows: | ||
(a) A person required to file a death certificate or fetal | ||
death certificate shall obtain the required medical certification | ||
from the decedent's [ |
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assistant or advanced practice registered nurse of the decedent if | ||
the death occurred under [ |
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person in connection with the [ |
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disease process that contributed to the death. | ||
(b) The attending physician, physician assistant, or | ||
advanced practice registered nurse shall complete the medical | ||
certification not later than five days after receiving the death | ||
certificate. | ||
(c) An associate physician, the chief medical officer of the | ||
institution where the death occurred, a physician assistant or | ||
advanced practice registered nurse at the institution where the | ||
death occurred, or the physician who performed an autopsy on the | ||
decedent may complete the medical certification if: | ||
(1) the attending physician, the physician assistant, | ||
or the advanced practice registered nurse described by Subsection | ||
(a) is unavailable; | ||
(2) the attending physician, the physician assistant, | ||
or the advanced practice registered nurse described by Subsection | ||
(a) approves; and | ||
(3) the person completing the medical certification | ||
has access to the medical history of the case and the death is due to | ||
natural causes. | ||
SECTION 13. Section 671.001(d), Health and Safety Code, is | ||
amended to read as follows: | ||
(d) A registered nurse, including an advanced practice | ||
registered nurse, or physician assistant may determine and | ||
pronounce a person dead in situations other than those described by | ||
Subsection (b) if permitted by written policies of a licensed | ||
health care facility, institution, or entity providing services to | ||
that person. Those policies must include physician assistants who | ||
are credentialed or otherwise permitted to practice at the | ||
facility, institution, or entity. If the facility, institution, or | ||
entity has an organized nursing staff and an organized medical | ||
staff or medical consultant, the nursing staff and medical staff or | ||
consultant shall jointly develop and approve those policies. The | ||
executive commissioner of the Health and Human Services Commission | ||
shall adopt rules to govern policies for facilities, institutions, | ||
or entities that do not have organized nursing staffs and organized | ||
medical staffs or medical consultants. | ||
SECTION 14. Section 671.002(a), Health and Safety Code, is | ||
amended to read as follows: | ||
(a) A physician who determines death in accordance with | ||
Section 671.001(b) or a registered nurse, including an advanced | ||
practice registered nurse, or physician assistant who determines | ||
death in accordance with Section 671.001(d) is not liable for civil | ||
damages or subject to criminal prosecution for the physician's, | ||
registered nurse's, or physician assistant's actions or the actions | ||
of others based on the determination of death. | ||
SECTION 15. This Act takes effect immediately if it | ||
receives a vote of two-thirds of all the members elected to each | ||
house, as provided by Section 39, Article III, Texas Constitution. | ||
If this Act does not receive the vote necessary for immediate | ||
effect, this Act takes effect September 1, 2017. |