85R7044 DMS-D     By: Coleman H.B. No. 3857       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.