Texas Senate Passes Bill Limiting When Clinicians May Write DNR Orders




Senator Perry

This week, the Texas Senate passed S.B. 11. This bill adds a new section 166.012 to the Health and Safety Code that specifies new procedures and requirements for do-not-resuscitate orders.



In short, the bill permits DNR orders to be written in only two situations:

1. With patient or surrogate consent

2. Without consent when death is imminent regardless of CPR but only if DNR is not contrary to the patient's prior instructions.



The bill sponsor observes that current Texas law is silent on requirements for the authorization, execution, or revocation of a DNR order in a hospital setting. It addresses only out-of-hospital DNR orders. Consequently. doctors can (and have) unilaterally written DNR orders for patients without discussion, let alone consent, from either the patient or a surrogate decision-maker. There was a hearing on July 21.  Healthcare providers oppose the bill.  It is supported by disability and right to life groups.



"(a) In this section, "DNR order" means an order instructing a health care professional not to attempt cardiopulmonary resuscitation or other life-sustaining treatment on a patient whose circulatory or respiratory function ceases."



"(b) This section applies to a DNR order used in a health care facility, including a hospital or an assisted living facility, or in hospice settings, including hospice services provided by a home and community support services agency. This section does not apply to an out-of-hospital DNR order as defined by Section 166.081.



"(c) A DNR order issued for a patient is valid only if the

order:

(1)  is issued in compliance with:

(A)  the written directions of a patient who was competent at the time the patient wrote the directions;

(B)  the oral directions of a competent patient delivered to or observed by two competent adult witnesses, at least one of whom must be a person not listed under Section 166.003(2);

(C)  the directions in an advance directive enforceable under Section 166.005 or executed in accordance with Section 166.032, 166.034, or 166.035;

(D)  the directions of a patient's legal guardian or agent under a medical power of attorney acting in accordance with Subchapter D; or

(E)  a treatment decision made in accordance with Section 166.039; or

(2)  is not contrary to the directions of a patient who was competent at the time the patient conveyed the directions and, in the reasonable medical judgment of the patient's attending physician:

(A)  the patient's death is imminent, regardless of the provision of cardiopulmonary resuscitation; and

(B)  the DNR order is medically appropriate."



"(d) If an individual described by Section 166.039(b)(1),

(2), or (3) arrives at the facility and notifies the facility of the individual's arrival after a DNR order is issued under Subsection (c)(2), the order must be disclosed to the individual in accordance with the priority established under Section 166.039(b)."



"(e) The facility may satisfy the notice requirement under

Subsection (d) by notifying one person in accordance with the priority established under Section 166.039(b). The facility is not required to notify additional persons beyond the first person notified."



"(f) A DNR order takes effect at the time the order is issued, provided the order is placed in the patient's medical record as soon as practicable."



"(g) On admission to a health care facility or on initial provision of hospice services, as applicable, the facility or service provider shall provide to the patient or person authorized to make treatment decisions on behalf of the patient notice of the policies of the facility or service provider regarding the rights of the patient and person authorized to make treatment decisions on behalf of the patient under this section."


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