85R7044 DMS-D
	By: Rodríguez	S.B. No. 919

	A BILL TO BE ENTITLED
	AN ACT
	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 [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 attending physician, 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, 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 [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.
	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, [or] the physician's designee,
	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, [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 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 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.  [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.  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 [an] attending physician or a physician
	assistant or advanced practice registered nurse of the decedent if
	the death occurred under [medical attendance for] the care of the
	person in connection with the [and] treatment of the condition or
	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.