Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
PRIOR PRINTER'S NO. 81 PRINTER'S NO. 1073 THE GENERAL ASSEMBLY OF PENNSYLVANIA HOUSE BILL No. 96 Session of 2001 INTRODUCED BY FLEAGLE, NICKOL, MUNDY, CLARK, MANDERINO, VANCE, JOSEPHS, L. I. COHEN, BELFANTI, T. STEVENSON, BEBKO-JONES, MARSICO, FRANKEL, B. SMITH, BELARDI, RUBLEY, MAITLAND, DALEY, HERSHEY, CAPPABIANCA, GEIST, HALUSKA, M. BAKER, STERN, CORRIGAN, TIGUE, SCRIMENTI, SHANER, MAYERNIK, BARRAR, BASTIAN, BENNINGHOFF, CLYMER, DAILEY, FAIRCHILD, HENNESSEY, JADLOWIEC, R. MILLER, S. MILLER, NAILOR, PHILLIPS, SATHER, SOLOBAY, STABACK, WILT, ZUG, BROWNE, SEMMEL, STEELMAN, McCALL AND BOYES, JANUARY 23, 2001 AS REPORTED FROM COMMITTEE ON JUDICIARY, HOUSE OF REPRESENTATIVES, AS AMENDED, MARCH 13, 2001 AN ACT 1 2 3 4 5 6 7 8 9 Amending Title 20 (Decedents, Estates and Fiduciaries) of the Pennsylvania Consolidated Statutes, further providing for advance directives for health care definitions and emergency medical services; and providing for out-of-hospital nonresuscitation. The General Assembly of the Commonwealth of Pennsylvania hereby enacts as follows: Section 1. Title 20 of the Pennsylvania Consolidated Statutes is amended to 10 read: 11 § 5403. 12 The definition of "declarant" in section 5403 of Definitions. The following words and phrases when used in this chapter 13 shall have the meanings given to them in this section unless the 14 context clearly indicates otherwise: 15 * * * 1 2 "Declarant." A person who makes a declaration in accordance with this chapter. The _______________________________________ term includes an emancipated minor. 3 * * * 4 Section 2. 5 § 5413. 6 [(a) Section 5413 of Title 20 is amended to read: Emergency medical services. Care given prior to declaration taking effect.--Nothing 7 in this chapter shall be construed to make the provisions of a 8 declaration apply to care given to a patient by emergency 9 medical services personnel prior to the declaration's becoming 10 operative under sections 5405 (relating to when declaration 11 becomes operative) and 5408 (relating to duty of physician to 12 confirm terminal condition). 13 (b) Care given after declaration takes effect.--The 14 provisions of a declaration shall apply to care given to a 15 patient by emergency medical services personnel after the 16 declaration becomes operative under sections 5405 and 5408 only 17 if: 18 (1) an original declaration, signed by the declarant or 19 other authorized person, is presented to the emergency 20 medical services personnel. The emergency medical services 21 personnel must immediately notify the medical command 22 physician of the presence of the declaration; or 23 (2) the medical command physician, based on prior 24 notification by the attending physician or other health care 25 provider that a valid and operative declaration exists, 26 directs the emergency medical service personnel according to 27 the provisions of the declaration. 28 (c) Uncertainty regarding validity of declaration.-- 29 Emergency medical services personnel confronted with any 30 conflicting information regarding the patient's wishes for life- 20010H0096B1073 - 2 - 1 sustaining treatment shall act according to the accepted 2 treatment protocols and standards appropriate to their level of 3 certification.] 4 __________________________________________________________ (a) General rule.--An emergency medical services provider 5 _____________________________________________________________ shall, in the course of providing care to a declarant, at all 6 ___________________________________________________________ times comply with the instructions of an authorized medical 7 ____________________________________________________________ command physician to withhold or discontinue cardiopulmonary 8 ______________ resuscitation. 9 _____________________________________________________________ (b) Applicability.--This section is applicable only in those 10 _____________________________________________________________ instances where an out-of-hospital DNR order is not in effect 11 __________________________________________________________ under section 5404-A(a) (relating to orders, bracelets and 12 ___________ necklaces). 13 Section 3. Title 20 is amended by adding a chapter to read: 14 CHAPTER 54-A 15 OUT-OF-HOSPITAL NONRESUSCITATION 16 Sec. 17 5401-A. Short title of chapter. 18 5402-A. Legislative findings and intent. 19 5403-A. Definitions. 20 5404-A. Orders, bracelets and necklaces. 21 5405-A. Revocation. 22 5406-A. Liability. 23 5407-A. Effect on suicide and life insurance. 24 5408-A. Order optional. 25 5409-A. Preservation of existing rights. 26 5410-A. Emergency medical services. 27 5411-A. Pregnancy. 28 5412-A. Penalties. 29 5413-A. Severability. 30 § 5401-A. 20010H0096B1073 Short title of chapter. - 3 - 1 This chapter shall be known and may be cited as the Do-Not- 2 Resuscitate Act. 3 § 5402-A. 4 5 Legislative findings and intent. The General Assembly finds and declares as follows: (1) Although cardiopulmonary resuscitation has saved the 6 lives of individuals about to experience sudden, unexpected 7 death, present medical data indicates that cardiopulmonary 8 resuscitation rarely leads to prolonged survival in 9 individuals with terminal illnesses in whom death is 10 11 expected. (2) In many circumstances, the performance of 12 cardiopulmonary resuscitation may cause infliction of 13 unwanted and unnecessary pain and suffering. 14 (3) Existing emergency medical services protocols may 15 require emergency medical services personnel to proceed to 16 cardiopulmonary resuscitation when an individual is found in 17 a cardiac or respiratory arrest even if the individual has 18 completed a living will or advance directive indicating that 19 the individual does not wish to receive cardiopulmonary 20 resuscitation. 21 (4) The administration of cardiopulmonary resuscitation 22 by emergency medical services personnel to an individual with 23 an out-of-hospital do-not-resuscitate order offends the 24 dignity of the individual and conflicts with standards of 25 accepted medical practice. 26 (5) This chapter provides clear direction to emergency 27 medical services personnel and other health care providers in 28 regard to the performance of cardiopulmonary resuscitation. 29 30 (6) Nothing in this chapter is intended to condone, authorize or approve mercy killing, euthanasia or aided 20010H0096B1073 - 4 - 1 suicide or to permit any affirmative or deliberate act or 2 omission to end life other than as defined in this chapter. 3 4 § 5403-A. Definitions. The following words and phrases when used in this chapter 5 shall have the meanings given to them in this section unless the 6 context clearly indicates otherwise: 7 8 9 10 "Attending physician." The physician who has primary responsibility for the treatment and care of the patient. "Bracelet." An out-of-hospital do-not-resuscitate bracelet. "Cardiopulmonary resuscitation." Cardiac compression, 11 invasive airway techniques, artificial ventilation, 12 defibrillation and other related procedures. 13 14 15 16 "Declarant." As defined in section 5403 (relating to definitions). "Declaration." As defined in section 5403 (relating to definitions). 17 "Department." The Department of Health of the Commonwealth. 18 "DNR." 19 "Emergency medical services provider." Do not resuscitate. A health care 20 provider recognized under the act of July 3, 1985 (P.L.164, 21 No.45), known as the Emergency Medical Services Act. The term 22 includes those individuals recognized under 42 Pa.C.S. § 8331.2 23 (relating to good Samaritan civil immunity for use of automated 24 external defibrillator). 25 "EMS." Emergency medical services. 26 "Health care provider." A person who is licensed or 27 certified by the laws of this Commonwealth to administer health 28 care in the ordinary course of business or practice of a 29 profession. The term includes personnel recognized under the act 30 of July 3, 1985 (P.L.164, No.45), known as the Emergency Medical 20010H0096B1073 - 5 - 1 Services Act. The term includes those individuals recognized 2 under 42 Pa.C.S. § 8331.2 (relating to good Samaritan civil 3 immunity for use of automated external defibrillator). 4 5 "Incompetent." The lack of sufficient capacity for a person to make or communicate decisions concerning himself. 6 "Invasive airway technique." 7 including endotracheal intubation. 8 "Life-sustaining treatment." 9 Any advanced airway technique, Any medical procedure or intervention that, when administered to a patient, will serve 10 only to prolong the process of dying or to maintain the patient 11 in a state of permanent unconsciousness. Life-sustaining 12 treatment shall include nutrition and hydration administered by 13 gastric tube or intravenously or any other artificial or 14 invasive means if the order of the patient so specifically 15 provides. 16 "Medical command physician." A licensed physician who is 17 authorized to give medical command under the act of July 3, 1985 18 (P.L.164, No.45), known as the Emergency Medical Services Act. 19 "Necklace." An out-of-hospital do-not-resuscitate necklace. 20 "Order." 21 "Out-of-hospital do-not-resuscitate bracelet." An out-of-hospital do-not-resuscitate order. A bracelet in 22 the standard format set forth in section 5404-A (relating to 23 orders, bracelets and necklaces), supplied by the department and 24 issued by the attending physician, which may be worn, at the 25 patient's option, to notify emergency medical services providers 26 of the presence of an order. 27 "Out-of-hospital do-not-resuscitate necklace." A necklace in 28 the standard format set forth in section 5404-A (relating to 29 orders, bracelets and necklaces), supplied by the department and 30 issued by the attending physician, which may be worn, at the 20010H0096B1073 - 6 - 1 patient's option, to notify emergency medical services providers 2 of the presence of an order. 3 "Out-of-hospital do-not-resuscitate order." An order in the 4 standard format set forth in section 5404-A (relating to orders, 5 bracelets and necklaces), supplied by the department and issued 6 by the attending physician, directing emergency medical services 7 providers to withhold cardiopulmonary resuscitation from the 8 patient in the event of respiratory or cardiac arrest. 9 "Out-of-hospital do-not-resuscitate patient." 10 following: 11 (1) Any of the An individual: 12 (i) 13 (ii) who is in a terminal condition; and who, pursuant to section 5404-A(a) (relating to 14 orders, bracelets and necklaces), possesses and in any 15 manner displays or causes to be displayed for emergency 16 medical services providers an apparently valid order, 17 bracelet or necklace. 18 (2) 19 A declarant: (i) whose declaration has become operative under 20 section 5405(2) (relating to when declaration becomes 21 operative); and 22 (ii) who, pursuant to section 5404-A(a), possesses 23 and in any manner displays or causes to be displayed for 24 emergency medical services providers an apparently valid 25 order, bracelet or necklace. 26 "Patient." An out-of-hospital do-not-resuscitate patient. 27 "Permanently unconscious." A medical condition that has been 28 diagnosed in accordance with currently accepted medical 29 standards and with reasonable medical certainty as total and 30 irreversible loss of consciousness and capacity for interaction 20010H0096B1073 - 7 - 1 with the environment. The term includes, without limitation, a 2 persistent vegetative state or irreversible coma. 3 "Person." An individual, corporation, partnership, 4 association or Federal, State or local government or 5 governmental agency. 6 "Terminal condition." An incurable and irreversible medical 7 condition in an advanced state caused by injury, disease or 8 physical illness which will, in the opinion of the attending 9 physician, to a reasonable degree of medical certainty, result 10 in death regardless of the continued application of life- 11 sustaining treatment. 12 § 5404-A. 13 (a) Orders, bracelets and necklaces. Issuance.--An attending physician, upon the request of 14 an individual who is at least 18 years of age, has graduated 15 from high school or has married, or the individual's surrogate 16 if the surrogate is so authorized, shall issue to the individual 17 an order, and may issue at the request of the patient or the 18 patient's surrogate a bracelet or necklace supplied by the 19 department. The patient may, at the patient's option, wear the 20 bracelet or display the order or necklace to notify emergency 21 medical services providers of the patient's do-not-resuscitate 22 status. 23 (b) Format of order.--The department shall, with the advice 24 of the Pennsylvania Emergency Health Services Council and with 25 the assistance of the regional emergency medical services 26 councils, make available within 180 days of the effective date 27 of this subsection standard orders for issuance to patients by 28 attending physicians of this Commonwealth. The form of the order 29 shall contain, but not be limited to, the following: 30 20010H0096B1073 PENNSYLVANIA OUT-OF-HOSPITAL - 8 - 1 2 DO-NOT-RESUSCITATE ORDER Patient's full legal name: 3 I, the undersigned, state that I am the attending 4 physician of the patient named above. The above-named 5 patient has requested this order and I have made the 6 determination that this patient is in a terminal 7 condition and eligible for an order. 8 I direct any and all emergency medical services 9 personnel, commencing on the effective date of this 10 order, to withhold cardiopulmonary resuscitation (cardiac 11 compression, invasive airway techniques, artificial 12 ventilation, defibrillation and other related procedures) 13 from the patient in the event of the patient's 14 respiratory or cardiac arrest. I further direct such 15 personnel to provide to the patient other medical 16 interventions, such as intravenous fluids, oxygen or 17 other therapies necessary to provide comfort care or to 18 alleviate pain, unless directed otherwise by the patient 19 or the emergency medical services provider's authorized 20 medical command physician. 21 Signature of attending physician: 22 Printed name of attending physician: 23 Dated: 24 Attending physician's emergency telephone number: 25 Signature of patient (if capable of making informed 26 decisions): 27 I, the undersigned, hereby direct that in the event 28 of my cardiac and/or respiratory arrest, efforts at 29 cardiopulmonary resuscitation not be initiated. I 30 understand that I may revoke these directions at any time 20010H0096B1073 - 9 - 1 by giving verbal instructions to the emergency medical 2 services providers, by physical cancellation or 3 destruction of this form or my bracelet or necklace, or 4 by simply not displaying this form or the bracelet or 5 necklace for my EMS caregivers. 6 Signature of surrogate (if patient is incapable of 7 making informed decisions): 8 I, the undersigned, hereby certify that I am 9 authorized to execute this order on the patient's behalf 10 by virtue of having been designated as the patient's 11 surrogate and/or by virtue of my relationship to the 12 patient (specify relationship: _________________). I 13 hereby direct that in the event of the patient's cardiac 14 and/or respiratory arrest, efforts at cardiopulmonary 15 resuscitation not be initiated. 16 (c) Format of bracelet.--The department shall, with the 17 advice of the Pennsylvania Emergency Health Services Council and 18 with the assistance of the regional emergency medical services 19 councils, make available within 180 days of the effective date 20 of this subsection standard bracelets for issuance to patients 21 by attending physicians. The bracelets shall be uniform in 22 design and shall, at a minimum, on the face clearly indicate 23 OUT-OF-HOSPITAL DNR and the name of the patient and attending 24 physician, as well as the dated signature of the attending 25 physician. 26 (d) Format of necklace.--The department shall, with the 27 advice of the Pennsylvania Emergency Health Services Council and 28 with the assistance of the regional emergency medical services 29 councils, make available within 180 days of the effective date 30 of this subsection standard necklaces for issuance to patients 20010H0096B1073 - 10 - 1 by attending physicians. The necklaces shall be uniform in 2 design and shall, at a minimum, on the face clearly indicate 3 OUT-OF-HOSPITAL DNR and the name of the patient and attending 4 physician, as well as the dated signature of the attending 5 physician. 6 § 5405-A. 7 (a) 8 9 10 11 Revocation. Patient.--If a patient has obtained an order, only the patient may revoke the patient's DNR status. (b) Surrogate.--If a surrogate has obtained an order, the patient or the surrogate may revoke the patient's status. (c) Manner.--Revocation under this section may be done at 12 any time without regard to the patient's physical or mental 13 condition and in any manner, including verbally or by destroying 14 or not displaying the order, bracelet or necklace. 15 § 5406-A. 16 (a) Liability. General rule.--No physician, emergency medical services 17 provider or other health care provider who, consistent with this 18 chapter, causes or participates in the initiating, continuing, 19 withholding or withdrawal of life-sustaining treatment or 20 cardiopulmonary resuscitation from a patient shall, as a result 21 of such action, be subject to criminal or civil liability or be 22 found to have committed an act of unprofessional conduct if the 23 attending physician, health care provider or emergency medical 24 services provider has followed the patient's EXPRESSED wishes as 25 expressed earlier by the patient in the form of a declaration 26 or, order OR REVOCATION, executed pursuant to this chapter. 27 (b) Absence of order, bracelet or necklace.--The absence of 28 an order, bracelet or necklace by a patient shall not give rise 29 to any presumption as to the intent of the patient to consent to 30 or to refuse the initiation, continuation or termination of 20010H0096B1073 - 11 - < < 1 life-sustaining treatment. 2 § 5407-A. 3 (a) Effect on suicide and life insurance. Criminal effect.--The withholding or withdrawal of life- 4 sustaining treatment from a patient in accordance with the 5 provisions of this chapter shall not, for any purpose, 6 constitute suicide or homicide. 7 (b) Life insurance.--The making of or failure to make an 8 order in accordance with this chapter shall not affect in any 9 manner the sale, procurement or issuance of any policy of life 10 insurance nor shall it be deemed to modify the terms of an 11 existing policy of life insurance. No policy of life insurance 12 shall be legally impaired or invalidated in any manner by the 13 withholding or withdrawal of life-sustaining treatment from an 14 insured patient, notwithstanding any term of the policy to the 15 contrary. 16 § 5408-A. 17 Order optional. No physician or other health care provider and no health care 18 service plan, health maintenance organization, insurer issuing 19 disability insurance, self-insured employee welfare benefit 20 plan, nonprofit hospital plan or Federal, State or local 21 government sponsored or operated program may: 22 (1) require any person to execute an order as a 23 condition for being insured for or receiving health care 24 services; or 25 (2) 26 27 28 charge any person a different rate or fee whether or not the person executes or has executed an order. § 5409-A. Preservation of existing rights. The provisions of this chapter shall not impair or supersede 29 any existing rights or responsibilities not addressed in this 30 chapter. 20010H0096B1073 - 12 - 1 § 5410-A. 2 (a) Emergency medical services. Medical command instructions.--Notwithstanding the 3 absence of an order, bracelet or necklace pursuant to this 4 section, emergency medical services providers shall at all times 5 comply with the instructions of an authorized medical command 6 physician to withhold or discontinue resuscitation. 7 (b) 8 9 Effect of order, bracelet or necklace.-(1) Emergency medical services providers are authorized to, and shall, comply with an order if made aware of the 10 order by examining a bracelet, a necklace or the order 11 itself. 12 (2) Emergency medical services providers shall provide 13 other medical interventions necessary and appropriate to 14 provide comfort and alleviate pain, including intravenous 15 fluids, medications, oxygen and any other intervention 16 appropriate to the level of the certification of the 17 provider, unless otherwise directed by the patient or the 18 emergency medical services provider's authorized medical 19 command physician. 20 (3) 21 As used in this subsection, the term "comply" means: (i) to withhold cardiopulmonary resuscitation from 22 the patient in the event of respiratory or cardiac 23 arrest; or 24 (ii) to discontinue and cease cardiopulmonary 25 resuscitation in the event the emergency medical services 26 provider is presented with an order or discovers a 27 necklace or bracelet after initiating cardiopulmonary 28 resuscitation. 29 30 (c) Uncertainty regarding validity or applicability of order, bracelet or necklace.-- 20010H0096B1073 - 13 - 1 (1) Emergency medical services providers who in good 2 faith are uncertain about the validity or applicability of an 3 order, bracelet or necklace shall render care in accordance 4 with their level of certification. 5 (2) Emergency medical services providers who act under 6 paragraph (1) shall not be subject to civil or criminal 7 liability or administrative sanction for failure to comply 8 with an order under this section. 9 (d) Recognition of other states' orders.--Emergency medical 10 services or out-of-hospital DNR orders, bracelets or necklaces 11 valid in states other than this Commonwealth shall be recognized 12 in this Commonwealth to the extent that these orders, bracelets 13 or necklaces are consistent with the laws of this Commonwealth. 14 Emergency medical services providers shall act in accordance 15 with the provisions of this section when encountering a patient 16 with an apparently valid EMS or out-of-hospital DNR form, 17 bracelet or necklace issued by another state. Emergency medical 18 services providers acting in good faith under this section shall 19 be entitled to the same immunities and protections that would 20 otherwise be applicable. 21 § 5411-A. 22 (a) Pregnancy. General rule.--Notwithstanding the existence of an order 23 or direction to the contrary, life-sustaining treatment, 24 cardiopulmonary resuscitation, nutrition and hydration must be 25 provided to a pregnant patient unless, to a reasonable degree of 26 medical certainty as certified on the patient's medical record 27 by the attending physician and an obstetrician who has examined 28 the patient, life-sustaining treatment, nutrition and hydration: 29 30 (1) will not maintain the pregnant patient in such a way as to permit the continuing development and live birth of the 20010H0096B1073 - 14 - 1 unborn child; 2 3 (2) will be physically harmful to the pregnant patient; (3) would cause pain to the pregnant patient which or 4 5 cannot be alleviated by medication. 6 (b) Pregnancy test.--Nothing in this section shall require a 7 physician to perform a pregnancy test unless the physician has 8 reason to believe that the patient may be pregnant. 9 10 (c) Payment of expenses by Commonwealth.-(1) In the event that treatment, cardiopulmonary 11 resuscitation, nutrition or hydration are provided to a 12 pregnant patient, notwithstanding the existence of an order 13 or direction to the contrary, the Commonwealth shall pay all 14 usual, customary and reasonable expenses directly and 15 indirectly incurred by the pregnant patient to whom such 16 treatment, nutrition and hydration are provided. 17 (2) The Commonwealth shall have the right of subrogation 18 against all moneys paid by any third-party health insurer on 19 behalf of the pregnant patient. 20 (3) The expenditures incurred on behalf of the pregnant 21 patient shall constitute a grant and no lien shall be placed 22 upon the property of the pregnant patient, her estate or her 23 heirs. 24 § 5412-A. 25 Penalties. Any person who intentionally conceals, cancels, defaces, 26 obliterates or damages the order, bracelet or necklace of 27 another without the consent of the patient commits a felony of 28 the third degree. Any person who falsifies or forges the order, 29 bracelet or necklace of another, or conceals or withholds 30 personal knowledge of a revocation as provided in section 5405-A 20010H0096B1073 - 15 - 1 (relating to revocation), with the intent to cause a withholding 2 or withdrawal of life-sustaining treatment contrary to the 3 wishes of the patient and, because of such an act, directly 4 causes life-sustaining treatment to be withheld or withdrawn and 5 death to be hastened shall be subject to prosecution for 6 criminal homicide as provided in 18 Pa.C.S. Ch. 25 (relating to 7 criminal homicide). Any person who intentionally, by undue 8 influence, fraud or duress, causes a person to execute an order 9 pursuant to this chapter commits a felony of the third degree. 10 § 5413-A. Severability. 11 The provisions of this chapter are severable, and, if any 12 word, phrase, clause, sentence, section or provision of this 13 chapter is for any reason held to be unconstitutional, the 14 decision of the court shall not affect or impair any of the 15 remaining provisions of this chapter. It is hereby declared as 16 the legislative intent that this chapter would have been adopted 17 had such unconstitutional word, phrase, clause, sentence, 18 section or provision thereof not been included herein. 19 Section 4. The Department of Health shall, with the advice 20 of the Pennsylvania Emergency Health Services Council and with 21 the assistance of the regional emergency medical services 22 councils, develop and make available to health care providers 23 recognized under the act of July 3, 1985 (P.L.164, No.45), known 24 as the Emergency Medical Services Act, including those 25 individuals recognized under 42 Pa.C.S. § 8331.2, within 180 26 days of the effective date of this act, educational materials 27 relating to the implementation of the provisions of this act. 28 The department shall also cause the requirements of this act to 29 be included as part of the curricula for health care providers 30 recognized under the Emergency Medical Services Act. 20010H0096B1073 - 16 - 1 Section 5. The Department of Health may contract with any 2 public or private entity to facilitate all or part of its 3 responsibilities under 20 Pa.C.S. Ch. 54 or 54-A. 4 Section 6. The Department of Health, upon the conclusion of 5 at least one public hearing, shall publish interim regulations 6 in the Pennsylvania Bulletin within 120 days of the effective 7 date of this act. The interim regulations shall not be subject 8 to the act of July 31, 1968 (P.L.769, No.240), referred to as 9 the Commonwealth Documents Law, or to the act of June 25, 1982 10 (P.L.633, No.181), known as the Regulatory Review Act. The 11 interim regulations shall be effective until final regulations 12 are promulgated by the department. Final regulations shall be 13 promulgated no later than 18 months following the effective date 14 of this act. 15 Section 7. This act shall take effect in 60 days. L15L20DMS/20010H0096B1073 - 17 -