PRIOR PRINTER'S NO. 81 PRINTER'S NO. 1073
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 Amending Title 20 (Decedents, Estates and Fiduciaries) of the
2 Pennsylvania Consolidated Statutes, further providing for
3 advance directives for health care definitions and emergency
4 medical services; and providing for out-of-hospital
5 nonresuscitation.
6 The General Assembly of the Commonwealth of Pennsylvania
7 hereby enacts as follows:
8 Section 1. The definition of "declarant" in section 5403 of
9 Title 20 of the Pennsylvania Consolidated Statutes is amended to
10 read:
11 § 5403. Definitions.
12 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 "Declarant." A person who makes a declaration in accordance
2 with this chapter. The term includes an emancipated minor.
3 * * *
4 Section 2. Section 5413 of Title 20 is amended to read:
5 § 5413. Emergency medical services.
6 [(a) 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-
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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. Short title of chapter.
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1 This chapter shall be known and may be cited as the Do-Not-
2 Resuscitate Act.
3 § 5402-A. Legislative findings and intent.
4 The General Assembly finds and declares as follows:
5 (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 expected.
11 (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 (6) Nothing in this chapter is intended to condone,
30 authorize or approve mercy killing, euthanasia or aided
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1 suicide or to permit any affirmative or deliberate act or
2 omission to end life other than as defined in this chapter.
3 § 5403-A. Definitions.
4 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 "Attending physician." The physician who has primary
8 responsibility for the treatment and care of the patient.
9 "Bracelet." An out-of-hospital do-not-resuscitate bracelet.
10 "Cardiopulmonary resuscitation." Cardiac compression,
11 invasive airway techniques, artificial ventilation,
12 defibrillation and other related procedures.
13 "Declarant." As defined in section 5403 (relating to
14 definitions).
15 "Declaration." As defined in section 5403 (relating to
16 definitions).
17 "Department." The Department of Health of the Commonwealth.
18 "DNR." Do not resuscitate.
19 "Emergency medical services provider." 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
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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 "Incompetent." The lack of sufficient capacity for a person
5 to make or communicate decisions concerning himself.
6 "Invasive airway technique." Any advanced airway technique,
7 including endotracheal intubation.
8 "Life-sustaining treatment." Any medical procedure or
9 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." An out-of-hospital do-not-resuscitate order.
21 "Out-of-hospital do-not-resuscitate bracelet." 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
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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." Any of the
10 following:
11 (1) An individual:
12 (i) who is in a terminal condition; and
13 (ii) 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) A declarant:
19 (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
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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. Orders, bracelets and necklaces.
13 (a) 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 PENNSYLVANIA OUT-OF-HOSPITAL
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1 DO-NOT-RESUSCITATE ORDER
2 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
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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
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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. Revocation.
7 (a) Patient.--If a patient has obtained an order, only the
8 patient may revoke the patient's DNR status.
9 (b) Surrogate.--If a surrogate has obtained an order, the
10 patient or the surrogate may revoke the patient's status.
11 (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. Liability.
16 (a) 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
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1 life-sustaining treatment.
2 § 5407-A. Effect on suicide and life insurance.
3 (a) 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. Order optional.
17 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) charge any person a different rate or fee whether or
26 not the person executes or has executed an order.
27 § 5409-A. Preservation of existing rights.
28 The provisions of this chapter shall not impair or supersede
29 any existing rights or responsibilities not addressed in this
30 chapter.
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1 § 5410-A. Emergency medical services.
2 (a) 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) Effect of order, bracelet or necklace.--
8 (1) Emergency medical services providers are authorized
9 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) As used in this subsection, the term "comply" means:
21 (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 (c) Uncertainty regarding validity or applicability of
30 order, bracelet or necklace.--
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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. Pregnancy.
22 (a) 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 (1) will not maintain the pregnant patient in such a way
30 as to permit the continuing development and live birth of the
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1 unborn child;
2 (2) will be physically harmful to the pregnant patient;
3 or
4 (3) would cause pain to the pregnant patient which
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 (c) Payment of expenses by Commonwealth.--
10 (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. Penalties.
25 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
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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.
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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.
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