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  By: Deuell, Estes, Lucio S.B. No. 303
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to advance directives and health care and treatment
  decisions.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Section 166.002, Health and Safety Code, is
  amended by amending Subdivisions (2) and (10) and adding
  Subdivision (16) to read as follows:
               (2)  "Artificially administered [Artificial] nutrition
  and hydration" means the provision of nutrients or fluids by a tube
  inserted in a vein, under the skin in the subcutaneous tissues, or
  in the stomach (gastrointestinal tract).
               (10)  "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 [artificial] 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.
               (16)  "Surrogate" means a legal guardian, an agent
  under a medical power of attorney, or a person authorized under
  Section 166.039(b) to make a health care or treatment decision for
  an incompetent patient under this chapter.
         SECTION 2.  Subchapter A, Chapter 166, Health and Safety
  Code, is amended by adding Section 166.012 to read as follows:
         Sec. 166.012.  STATEMENT RELATING TO
  DO-NOT-ATTEMPT-RESUSCITATION ORDERS. (a)  In this section,
  "do-not-attempt-resuscitation order" or "DNAR order" means an
  order instructing health care professionals not to attempt
  cardiopulmonary resuscitation of the patient if circulatory or
  respiratory function ceases.
         (b)  Upon admission, a health care facility shall provide a
  patient or surrogate written notice of the facility's policies
  regarding the rights of the patient or surrogate under this
  section.
         (c)  Before placing a do-not-attempt-resuscitation (DNAR)
  order in a patient's medical record, the physician or the facility's
  personnel shall inform the patient or, if the patient is
  incompetent, make a reasonably diligent effort to contact or cause
  to be contacted the surrogate.  The facility shall establish a
  policy regarding the notification required under this section. The
  policy must authorize the notification to be given verbally by a
  physician or facility personnel.
         (d)  The DNAR order takes effect at the time it is written in
  the patient's chart or otherwise placed in the patient's medical
  record.
         (e)  If the patient or surrogate disagrees with the DNAR
  order being placed in or removed from the medical record, the
  patient or surrogate may request in writing and is entitled to a
  consultation or a review of the disagreement by the ethics or
  medical committee in the manner described by Section 166.046, with
  the patient or surrogate afforded all rights provided to the
  surrogate under that section, and with the physician afforded all
  protections from liability provided under Section 166.045(d).  The
  patient or surrogate may discontinue the process initiated under
  Section 166.046 by providing written notice to the ethics or
  medical committee.
         (f)  A DNAR order in the patient's medical record at the time
  a consultation or review is requested under Subsection (e) must be
  removed from the patient's medical record at that time.  A DNAR
  order may not be placed in the patient's medical record until the
  process initiated under Section 166.046 is concluded or
  discontinued at the request of the patient or surrogate.
         (g)  Subsection (c) does not apply to a DNAR order placed in
  the medical record of a patient:
               (1)  whose death, based on reasonable medical judgment,
  is imminent despite attempted resuscitation;
               (2)  for whom, based on reasonable medical judgment,
  resuscitation would be medically ineffective and there is
  insufficient time to contact the surrogate; or
               (3)  for whom the DNAR order is consistent with a
  patient's or surrogate's request or a patient's advance directive to
  not attempt resuscitation.
         (h)  Subsection (e) does not apply to a DNAR order placed in
  the medical record of a patient with respect to whom, based on
  reasonable medical judgment, death is imminent and resuscitation
  would be medically ineffective.
         (i)  This section does not create a cause of action or
  liability against a physician, health professional acting under the
  direction of a physician, or health care facility.
         (j)  A physician, health professional acting under the
  direction of a physician, or health care facility is not civilly or
  criminally liable or subject to review or disciplinary action by
  the appropriate licensing authority if the actor has complied with
  the procedures under this section and Section 166.046.
         (k)  This section does not affect the immunity from liability
  under Section 74.151, Civil Practice and Remedies Code.
         (l)  This section does not apply to an assisted living
  facility licensed under Chapter 247.
         SECTION 3.  Section 166.033, Health and Safety Code, is
  amended to read as follows:
         Sec. 166.033.  FORM OF WRITTEN DIRECTIVE. A written
  directive may be in the following form:
  DIRECTIVE TO PHYSICIANS AND FAMILY OR SURROGATES
         Instructions for completing this document:
         This is an important legal document known as an Advance
  Directive. It is designed to help you communicate your wishes about
  medical treatment at some time in the future when you are unable to
  make your wishes known because of illness or injury. These wishes
  are usually based on personal values. In particular, you may want
  to consider what burdens or hardships of treatment you would be
  willing to accept for a particular amount of benefit obtained if you
  were seriously ill.
         You are encouraged to discuss your values and wishes with
  your family or chosen spokesperson, as well as your physician. Your
  physician, other health care provider, or medical institution may
  provide you with various resources to assist you in completing your
  advance directive. Brief definitions are listed below and may aid
  you in your discussions and advance planning. Initial the
  treatment choices that best reflect your personal preferences.
  Provide a copy of your directive to your physician, usual hospital,
  and family or spokesperson. Consider a periodic review of this
  document. By periodic review, you can best assure that the
  directive reflects your preferences.
         In addition to this advance directive, Texas law provides for
  two other types of directives that can be important during a serious
  illness. These are the Medical Power of Attorney and the
  Out-of-Hospital Do-Not-Resuscitate Order. You may wish to discuss
  these with your physician, family, hospital representative, or
  other advisers. You may also wish to complete a directive related
  to the donation of organs and tissues.
  DIRECTIVE
         I, __________, recognize that the best health care is based
  upon a partnership of trust and communication with my physician. My
  physician and I will make health care or treatment decisions
  together as long as I am of sound mind and able to make my wishes
  known. If there comes a time that I am unable to make medical
  decisions about myself because of illness or injury, I direct that
  the following treatment preferences be honored:
         If, in the judgment of my physician, I am suffering with a
  terminal condition from which I am expected to die within six
  months, even with available life-sustaining treatment provided in
  accordance with prevailing standards of medical care:
 
__________ I request that all treatments other than those needed to keep me comfortable be discontinued or withheld and my physician allow me to die as gently as possible;
 
OR
 
__________ I request that I be kept alive in this terminal condition using available life-sustaining treatment. (THIS SELECTION DOES NOT APPLY TO HOSPICE CARE.)
         If, in the judgment of my physician, I am suffering with an
  irreversible condition so that I cannot care for myself or make
  decisions for myself and am expected to die without life-sustaining
  treatment provided in accordance with prevailing standards of care:
 
__________ I request that all treatments other than those needed to keep me comfortable be discontinued or withheld and my physician allow me to die as gently as possible;
 
OR
 
__________ I request that I be kept alive in this irreversible condition using available life-sustaining treatment. (THIS SELECTION DOES NOT APPLY TO HOSPICE CARE.)
         Additional requests: (After discussion with your physician,
  you may wish to consider listing particular treatments in this
  space that you do or do not want in specific circumstances, such as
  artificially administered [artificial] nutrition and hydration 
  [fluids], intravenous antibiotics, etc. Be sure to state whether
  you do or do not want the particular treatment.)
 
 
 
         After signing this directive, if my representative or I elect
  hospice care, I understand and agree that only those treatments
  needed to keep me comfortable would be provided and I would not be
  given available life-sustaining treatments.
         If I do not have a Medical Power of Attorney, and I am unable
  to make my wishes known, I designate the following person(s) to make
  health care or treatment decisions with my physician compatible
  with my personal values:
  1.  __________
  2.  __________
         (If a Medical Power of Attorney has been executed, then an
  agent already has been named and you should not list additional
  names in this document.)
         If the above persons are not available, or if I have not
  designated a spokesperson, I understand that a spokesperson will be
  chosen for me following standards specified in the laws of Texas.
  If, in the judgment of my physician, my death is imminent within
  minutes to hours, even with the use of all available medical
  treatment provided within the prevailing standard of care, I
  acknowledge that all treatments may be withheld or removed except
  those needed to maintain my comfort. I understand that under Texas
  law this directive has no effect if I have been diagnosed as
  pregnant. This directive will remain in effect until I revoke it.
  No other person may do so.
         Signed __________ Date __________ City, County, State of
  Residence __________
         Two competent adult witnesses must sign below, acknowledging
  the signature of the declarant. The witness designated as Witness 1
  may not be a person designated to make a health care or treatment
  decision for the patient and may not be related to the patient by
  blood or marriage. This witness may not be entitled to any part of
  the estate and may not have a claim against the estate of the
  patient. This witness may not be the attending physician or an
  employee of the attending physician. If this witness is an employee
  of a health care facility in which the patient is being cared for,
  this witness may not be involved in providing direct patient care to
  the patient. This witness may not be an officer, director, partner,
  or business office employee of a health care facility in which the
  patient is being cared for or of any parent organization of the
  health care facility.
         Witness 1 __________ Witness 2 __________
         Definitions:
         "Artificially administered [Artificial] nutrition and
  hydration" means the provision of nutrients or fluids by a tube
  inserted in a vein, under the skin in the subcutaneous tissues, or
  in the stomach (gastrointestinal tract).
         "Irreversible condition" means a condition, injury, or
  illness:
               (1)  that may be treated, but is never cured or
  eliminated;
               (2)  that leaves a person unable to care for or make
  decisions for the person's own self; and
               (3)  that, without life-sustaining treatment provided
  in accordance with the prevailing standard of medical care, is
  fatal.
         Explanation: Many serious illnesses such as cancer, failure
  of major organs (kidney, heart, liver, or lung), and serious brain
  disease such as Alzheimer's dementia may be considered irreversible
  early on. There is no cure, but the patient may be kept alive for
  prolonged periods of time if the patient receives life-sustaining
  treatments. Late in the course of the same illness, the disease may
  be considered terminal when, even with treatment, the patient is
  expected to die. You may wish to consider which burdens of
  treatment you would be willing to accept in an effort to achieve a
  particular outcome. This is a very personal decision that you may
  wish to discuss with your physician, family, or other important
  persons in your life.
         "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 [artificial] hydration
  [and nutrition]. The term does not include the administration of
  pain management medication, the performance of a medical procedure
  necessary to provide comfort care, or any other medical care
  provided to alleviate a patient's pain.
         "Terminal condition" means an incurable condition caused by
  injury, disease, or illness that according to reasonable medical
  judgment will produce death within six months, even with available
  life-sustaining treatment provided in accordance with the
  prevailing standard of medical care.
         Explanation: Many serious illnesses may be considered
  irreversible early in the course of the illness, but they may not be
  considered terminal until the disease is fairly advanced. In
  thinking about terminal illness and its treatment, you again may
  wish to consider the relative benefits and burdens of treatment and
  discuss your wishes with your physician, family, or other important
  persons in your life.
         SECTION 4.  Section 166.039, Health and Safety Code, is
  amended by adding Subsections (a-1) and (b-1) and amending
  Subsections (e) and (f) to read as follows:
         (a-1)  In making the decision described by Subsection (a),
  the attending physician may consult with a physician who previously
  treated the patient if the previous physician:
               (1)  is known and available, regardless of whether the
  previous physician has discontinued providing care for the patient
  or does not have privileges at the treating facility;
               (2)  had a conversation with the patient on end-of-life
  issues at a time when the patient was competent and capable of
  communication; and
               (3)  documented the conversation described by
  Subdivision (2) in the patient's medical record.
         (b-1)  The attending physician and the health care
  facility's personnel shall make a reasonably diligent effort to
  contact or cause to be contacted the persons listed in Subsection
  (b) in the order of priority under Subsection (b) until one of the
  persons is contacted or the list is exhausted regarding making a
  health care or treatment decision for the patient.
         (e)  If the patient does not have a legal guardian or agent
  under a medical power of attorney and a person listed in Subsection
  (b) is not available, a health care or treatment decision made under
  Subsection (b) must be concurred with [in] by another physician who
  is not involved in the treatment of the patient or who is a
  representative of an ethics or medical committee of the health care
  facility in which the person is a patient.
         (f)  The fact that an adult [qualified] patient has not
  executed or issued a directive does not create a presumption
  regarding the provision, withholding, or withdrawal of [that the
  patient does not want a treatment decision to be made to withhold or
  withdraw] life-sustaining treatment.
         SECTION 5.  Subsection (c), Section 166.045, Health and
  Safety Code, is amended to read as follows:
         (c)  If an attending physician disagrees with and refuses to
  comply with a patient's directive or a health care or treatment
  decision of a patient or of a surrogate made on behalf of an
  incompetent patient, and the attending physician does not wish to
  follow the procedure established under Section 166.046,
  life-sustaining treatment shall be provided to the patient, but
  only until a reasonable opportunity has been afforded for the
  transfer of the patient to another physician or health care
  facility willing to comply with the health care [directive] or
  treatment decision.
         SECTION 6.  The heading to Section 166.046, Health and
  Safety Code, is amended to read as follows:
         Sec. 166.046.  PROCEDURE IF PHYSICIAN DISAGREES WITH AND
  REFUSES TO COMPLY WITH HEALTH CARE [NOT EFFECTUATING A DIRECTIVE]
  OR TREATMENT DECISION.
         SECTION 7.  Section 166.046, Health and Safety Code, is
  amended by amending Subsections (a), (b), (c), (d), (e), (e-1),
  (g), and (h) and adding Subsections (a-1), (a-2), (a-3), (a-4),
  (a-5), (a-6), (a-7), (a-8), and (b-1) to read as follows:
         (a)  If an attending physician disagrees with and refuses to
  comply with [honor] a patient's advance directive or a health care
  or treatment decision [made by or on behalf] of a patient or of a
  surrogate made on behalf of an incompetent patient, the
  disagreement and the physician's refusal shall be reviewed by an
  ethics or medical committee under this section.  The ethics or
  medical committee of a facility other than a nursing home licensed
  under Chapter 242 may not include any health care provider involved
  in the direct care of a patient whose treatment the committee
  reviews or a subcommittee of such an ethics or medical committee.
         (a-1)  If the patient has been diagnosed with a terminal
  condition, the ethics or medical committee shall determine if,
  based on reasonable medical judgment, the treatment requested by
  the patient or, if the patient is incompetent, by the surrogate
  would:
               (1)  hasten the patient's death;
               (2)  seriously exacerbate other major medical problems
  not outweighed by the benefit of the provision of the treatment;
               (3)  result in substantial irremediable physical pain
  or discomfort not outweighed by the benefit of the provision of the
  treatment; or
               (4)  be medically ineffective in prolonging the
  patient's life.
         (a-2)  If the patient has been diagnosed with an irreversible
  nonterminal condition, the ethics or medical committee may sustain
  the decision to withdraw life-sustaining treatment requested by the
  patient or, if the patient is incompetent, by the surrogate only if,
  based on reasonable medical judgment, the treatment would:
               (1)  threaten the patient's life;
               (2)  seriously exacerbate other major medical problems
  not outweighed by the benefit of the provision of the treatment;
               (3)  result in substantial irremediable physical pain
  or discomfort not outweighed by the benefit of the provision of the
  treatment; or
               (4)  be medically ineffective in prolonging the
  patient's life.
         (a-3)  In all deliberations under this section, the ethics or
  medical committee should strive to honor the values of each unique
  patient. All patients will be treated equally without regard to
  permanent physical or mental disabilities, age, gender, religion,
  ethnic background, or financial or insurance status.  The committee
  should make the same decision about whether or not a requested
  treatment is medically appropriate for individuals with or without
  a permanent disability, advanced age, gender, religious or cultural
  differences, or financial circumstances.
         (a-4)  The fact that life-sustaining treatment is delivered
  in an intensive care unit is not itself sufficient to justify the
  refusal to provide that treatment. This section does not authorize
  withholding or withdrawing pain management medication, medical
  procedures considered necessary to provide comfort care, or any
  other medical care provided to alleviate a patient's pain.
         (a-5)  [The attending physician may not be a member of that
  committee.] The patient shall be given life-sustaining treatment
  pending [during] the ethics or medical committee's review.
         (a-6)  When an ethics or medical committee review has been
  initiated under this chapter, the ethics or medical committee
  shall:
               (1)  inform the patient or surrogate that the patient
  or surrogate may discontinue the process under this section by
  providing written notice to the ethics or medical committee;
               (2)  appoint a patient liaison familiar with
  end-of-life issues and hospice care options to assist the patient
  or surrogate throughout the process described by this section; and
               (3)  appoint one or more representatives of the ethics
  or medical committee to conduct an advisory ethics consultation
  with the patient or surrogate, the outcome of which must be
  documented in the patient's medical record by a representative of
  the committee.
         (a-7)  If a disagreement over a health care or treatment
  decision persists following the consultation described in
  Subsection (a-6)(3), the ethics or medical committee shall hold a
  meeting to review the disagreement.
         (a-8)  The ethics or medical committee in holding a review
  required under this section, including a review following a
  consultation described by Subsection (a-6)(3), shall advise the
  patient or surrogate that the patient's attending physician may
  present medical facts at the meeting. The patient's attending
  physician may attend and present facts but may not participate as a
  member of the committee in the case being evaluated.
         (b)  When a meeting of the ethics or medical committee is
  required under this section [The patient or the person responsible
  for the health care decisions of the individual who has made the
  decision regarding the directive or treatment decision]:
               (1)  not later than the seventh calendar day before the
  scheduled date of the meeting required under this section, unless
  the time period is waived by mutual agreement, the committee shall
  provide to the patient or surrogate:
                     (A)  [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;
                     (B)  notice that the patient or surrogate is
  entitled to receive the continued assistance of a patient liaison
  to assist the patient or surrogate throughout the process described
  in this section;
                     (C)  notice that the patient or surrogate may seek
  a second opinion at the patient's or surrogate's expense from other
  medical professionals regarding the patient's medical status and
  treatment requirements and communicate the resulting information
  to the members of the committee for consideration before the
  meeting;
                     (D) [(2)     shall be informed of the committee
  review process not less than 48 hours before the meeting called to
  discuss the patient's directive, unless the time period is waived
  by mutual agreement;
               [(3)     at the time of being so informed, shall be
  provided:
                     [(A)]  a copy of the appropriate statement set
  forth in Section 166.052; and
                     (E) [(B)]  a copy of the registry list of health
  care providers, health care facilities, and referral groups that,
  in compliance with any state laws prohibiting barratry, 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 [Texas Health
  Care Information Council] under Section 166.053; and
               (2)  if requested in writing, the patient or surrogate
  is entitled to receive from the facility:
                     (A)  not later than 72 hours after the request is
  made, a free copy of the portion of the patient's medical record
  related to the current admission to the facility or the treatment
  received by the patient during the preceding 30 calendar days in the
  facility, whichever is shorter, together with any reasonably
  available diagnostic results and reports; and
                     (B)  not later than the fifth calendar day after
  the date of the request or at another time specified by mutual
  agreement, a free copy of the remainder of the patient's medical
  record, if any, related to the current admission to the facility.
         (b-1)  The patient or surrogate[; and
               [(4)]  is entitled to:
               (1) [(A)]  attend and participate in the meeting of the
  ethics or medical committee, excluding the committee's
  deliberations;
               (2)  be accompanied at the meeting by up to five
  persons, or more persons at the committee's discretion, for
  support, subject to the facility's reasonable written attendance
  policy as necessary to:
                     (A)  facilitate information sharing and
  discussion of the patient's medical status and treatment
  requirements; and
                     (B)  preserve the order and decorum of the
  meeting; and
               (3) [(B)]  receive a written explanation of the
  decision reached during the review process.
         (c)  The written explanation required by Subsection (b-1)(3) 
  [(b)(2)(B)] must be included in the patient's medical record.
         (d)  If the attending physician, the patient, or the
  surrogate [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 and the
  facility shall make a reasonably diligent [reasonable] effort to
  transfer the patient to a physician of the patient's or surrogate's
  choice who is willing to accept the patient [comply with the
  directive].  The [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.
         (e)  If the patient or surrogate [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 [review process] 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
  considered necessary to provide comfort care, or any other medical
  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 calendar [10th] day after the written decision
  required under Subsection (b-1) [(b)] is provided to the patient or
  the surrogate [person responsible for the health care decisions of
  the patient] unless ordered to 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)  seriously exacerbate other major medical problems
  not outweighed by the benefit of the provision of the treatment;
               (3)  result in substantial irremediable physical pain
  or discomfort not outweighed by the benefit of the provision of the
  treatment; or
               (4)  be medically ineffective in prolonging the
  patient's life.
         (e-1)  If during a previous admission to a facility the [a
  patient's] attending physician and the ethics or medical committee
  [review process under Subsection (b) have] determined that
  life-sustaining treatment is inappropriate, a subsequent committee
  review is not required if [and] the patient is readmitted to the
  same facility for the same condition within six months from the date
  of the previous decision, provided that the [reached during the
  review process conducted upon the previous admission, Subsections
  (b) through (e) need not be followed if the patient's] attending
  physician and a consulting physician who is a member of the ethics
  or medical committee of the facility document on the patient's
  readmission that the patient's condition [either has not improved
  or] has deteriorated since the previous review [process] was
  conducted.
         (g)  On motion [At the request] of the patient or surrogate 
  [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 the patient or surrogate may find a
  physician or health care facility that will honor the patient's or
  surrogate's health care or treatment decision [directive will be
  found] if the time extension is granted.
         (h)  This section may not be construed to impose an
  obligation on a facility or a home and community support services
  agency licensed under Chapter 142, an assisted living facility
  licensed under Chapter 247, or a similar organization that is
  beyond the scope of the services or resources of the facility, [or]
  agency, or organization. This section does not apply to hospice
  services provided by a home and community support services agency
  licensed under Chapter 142 or services provided by an assisted
  living facility licensed under Chapter 247.
         SECTION 8.  Subsections (a) and (b), Section 166.052, Health
  and Safety Code, are amended to read as follows:
         (a)  In cases in which the attending physician disagrees with
  and refuses to comply with a health care [honor an advance
  directive] or treatment decision requesting the provision of
  life-sustaining treatment, the statement required by Section
  166.046(b)(1)(D) [166.046(b)(2)(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 of the Texas Health and Safety Code.
         When an attending physician disagrees with and refuses to
  comply with a [an advance directive or other] request for
  life-sustaining treatment because of the physician's medical 
  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.
         As the patient or the patient's decision-maker, you [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.
         The committee will appoint a patient liaison to assist you
  through this process. You are entitled to attend the meeting,
  address the committee, and be accompanied by up to five persons, or
  more persons at the committee's discretion, to support you, subject
  to the facility's reasonable written attendance policy to
  facilitate information sharing and discussion of the patient's
  medical status and treatment requirements and preserve the order
  and decorum of the meeting. On written request, you are also
  entitled to receive:
               (1)  not later than 72 hours after the request is made,
  a free copy of the portion of the patient's medical record related
  to the current admission to the facility or the treatment received
  during the preceding 30 calendar days in the facility, whichever is
  shorter, together with any reasonably available diagnostic results
  and reports; and
               (2)  not later than the fifth calendar day following
  the request or at another time specified by mutual agreement, a free
  copy of the remainder of the medical record, if any, related to the
  current admission to the facility.
         As the patient or the patient's decision-maker, you are free
  to seek a second opinion at the patient's or your expense from other
  medical professionals regarding the patient's medical status and
  treatment requirements and communicate the resulting information
  to the members of the ethics or medical committee for consideration
  before the meeting.
         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,
  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 [Texas] Health Services [Care Information
  Council]. 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 and treatment to enhance pain management and reduce
  suffering, including artificially administered nutrition and
  hydration, until the patient [he or she] can be transferred to a
  willing provider for up to 21 calendar [10] days from the time you
  were given the committee's written decision that life-sustaining
  treatment is not medically appropriate.
         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 calendar [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 the 21-day [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 [will be
  found] if the extension is granted.
         *"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 [artificial] 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 disagrees with
  and refuses to comply with a health care [an advance directive] or
  treatment decision requesting the withholding or withdrawal of
  life-sustaining treatment, the statement required by Section
  166.046(b)(1)(D) [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 of the Texas Health and Safety Code.
         When an attending physician disagrees with and refuses to
  comply with a [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.
         As the patient or the patient's decision-maker, you [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 will be appointed a patient liaison familiar with
  end-of-life issues and hospice care options to assist you
  throughout this process. A representative of the ethics or medical
  committee will also conduct an advisory consultation with you.
         On written request you are entitled to receive:
               (1)  not later than 72 hours after the request is made,
  a free copy of the portion of the patient's medical record related
  to the current admission to the facility or the treatment received
  by the patient during the preceding 30 calendar days in the
  facility, whichever is shorter, together with any reasonably
  available diagnostic results and reports; and
               (2)  not later than the fifth calendar day following
  the date of the request or at another time specified by mutual
  agreement, a free copy of the remainder of the medical record, if
  any, related to the current admission to the facility.
         As the patient or the patient's decision-maker, you are free
  to seek a second opinion at the patient's or your expense from other
  medical professionals regarding the patient's medical status and
  treatment requests and communicate the resulting information to the
  members of the ethics or medical committee for consideration before
  the meeting.
         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 disagrees with and 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 accept the patient [withdraw or withhold the life-sustaining
  treatment].
         2.  You are being given a list of health care providers,
  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 [Texas] Health Services [Care Information
  Council]. 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 [artificial] 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 9.  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)  On submission of a health care
  facility's application to renew its license, a facility in which
  one or more meetings of an ethics or medical committee are held
  under this chapter shall file a report with the department that
  contains aggregate information regarding the number of cases
  initiated by an ethics or medical committee under Section 166.046
  and the disposition of those cases by the facility.
         (b)  Aggregate data submitted to the department under this
  section may include only the following:
               (1)  the total number of patients for whom a review by
  the ethics or medical committee was initiated under Section
  166.046(b);
               (2)  the number of patients under Subdivision (1) who
  were transferred to:
                     (A)  another physician within the same facility;
  or
                     (B)  a different facility;
               (3)  the number of patients under Subdivision (1) who
  were discharged to home;
               (4)  the number of patients under Subdivision (1) for
  whom treatment was withheld or withdrawn pursuant to surrogate
  consent:
                     (A)  before the decision was rendered following a
  review under Section 166.046(b);
                     (B)  after the decision was rendered following a
  review under Section 166.046(b); or
                     (C)  during or after the 21-day period described
  by Section 166.046(e);
               (5)  the average length of stay before a review meeting
  is held under Section 166.046(b); and
               (6)  the number of patients under Subdivision (1) who
  died while still receiving life-sustaining treatment:
                     (A)  before the review meeting under Section
  166.046(b);
                     (B)  during the 21-day period; or
                     (C)  during extension of the 21-day period, if
  any.
         (c)  The report required by this section may not contain any
  data specific to an individual patient or physician.
         (d)  The department shall adopt rules to:
               (1)  establish a standard form for the reporting
  requirements of this section; and
               (2)  post on the department's Internet website the data
  submitted under Subsection (b) in the format provided by rule.
         (e)  Data collected as required by, or 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; and
               (2)  may not be used in relation to any disciplinary
  action by a licensing board or other body with professional or
  administrative oversight over a physician, health care
  professional acting under the direction of a physician, or health
  care facility.
         SECTION 10.  Subsections (a) and (c), Section 166.082,
  Health and Safety Code, are amended to read as follows:
         (a)  A competent adult [person] may at any time execute a
  written out-of-hospital DNR order directing health care
  professionals acting in an out-of-hospital setting to withhold
  cardiopulmonary resuscitation and certain other life-sustaining
  treatment designated by the board.
         (c)  If the person is incompetent but previously executed or
  issued a directive to physicians in accordance with Subchapter B
  requesting that all treatment, other than treatment necessary for
  keeping the person comfortable, be discontinued or withheld, the
  physician 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 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 11.  Subsection (d), Section 166.152, Health and
  Safety Code, is amended to read as follows:
         (d)  The principal's attending physician shall make
  reasonable efforts to inform the principal of any proposed
  treatment or of any proposal to withdraw or withhold treatment
  before implementing an agent's health care or treatment decision
  [advance directive].
         SECTION 12.  Not later than March 1, 2014, the executive
  commissioner of the Health and Human Services Commission shall
  adopt the rules necessary to implement the changes in law made by
  this Act to Chapter 166, Health and Safety Code.
         SECTION 13.  The change in law made 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 April 1,
  2014. A review, consultation, disagreement, or other action
  relating to a health care or treatment decision made before April 1,
  2014, 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.  This Act takes effect September 1, 2013.