PRIOR PRINTER'S NO. 2734 PRINTER'S NO. 3998
No. 2085 Session of 1998
INTRODUCED BY FLEAGLE, WAUGH, VANCE, TANGRETTI, GEIST, HERSHEY,
MUNDY, MILLER, LAUGHLIN, DEMPSEY, EGOLF, COY, M. COHEN,
BELFANTI, STEELMAN, McGILL, PESCI, SATHER, TRELLO, ROSS,
SAYLOR AND WILT, JANUARY 12, 1998
AS REPORTED FROM COMMITTEE ON HEALTH AND HUMAN SERVICES, HOUSE
OF REPRESENTATIVES, AS AMENDED, OCTOBER 6, 1998
AN ACT
1 Amending Title 20 (Decedents, Estates and Fiduciaries) of the
2 Pennsylvania Consolidated Statutes, further providing for
3 advance directives for emergency medical service health care; <--
4 AND MAKING AN APPROPRIATION.
5 The General Assembly of the Commonwealth of Pennsylvania
6 hereby enacts as follows:
7 Section 1. Sections 5403, 5407, 5410(b), 5411, 5413 and 5415
8 of Title 20 of the Pennsylvania Consolidated Statutes are
9 amended to read:
10 § 5403. Definitions.
11 The following words and phrases when used in this chapter
12 shall have the meanings given to them in this section unless the
13 context clearly indicates otherwise:
14 "Attending physician." The physician who has primary
15 responsibility for the treatment and care of the declarant.
16 "Declarant." A person who makes a declaration in accordance
17 with this chapter.
1 "Declaration." A written document voluntarily executed by
2 the declarant in accordance with this chapter.
3 "Emergency medical service provider." A health care provider
4 recognized under the act of July 3, 1985 (P.L.164, No.45), known
5 as the Emergency Medical Services Act.
6 "Emergency medical services do-not-resuscitate bracelet" or
7 "EMS-DNR bracelet." A bracelet in the standard format set forth
8 in section 5413 (relating to emergency medical services),
9 supplied by the Department of Health and issued by the attending
10 physician, which may be worn, at the declarant's option, to
11 notify emergency medical service providers of the presence of a
12 do-not-resuscitate order.
13 "Emergency medical services do-not-resuscitate card" or "EMS-
14 DNR card." A wallet-sized card in the standard format set forth
15 in section 5413 (relating to emergency medical services),
16 supplied by the Department of Health and issued by the attending
17 physician, which may be displayed, at the declarant's option, to
18 notify emergency medical service providers of the presence of a
19 do-not-resuscitate order.
20 "Emergency medical services do-not-resuscitate order" or
21 "EMS-DNR order." An order in the standard format set forth in
22 section 5413 (relating to emergency medical services), supplied
23 by the Department of Health and issued by the attending
24 physician, directing emergency medical service providers to
25 withhold cardiopulmonary resuscitation (cardiac compression,
26 endotracheal intubation, artificial ventilation, defibrillation
27 and other related procedures) from the declarant in the event of
28 respiratory or cardiac arrest.
29 "Health care provider." A person who is licensed or
30 certified by the laws of this Commonwealth to administer health
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1 care in the ordinary course of business or practice of a
2 profession. The term includes personnel recognized under the act
3 of July 3, 1985 (P.L.164, No.45), known as the Emergency Medical
4 Services Act.
5 "Incompetent." The lack of sufficient capacity for a person
6 to make or communicate decisions concerning himself.
7 "Life-sustaining treatment." Any medical procedure or
8 intervention that, when administered to a qualified patient,
9 will serve only to prolong the process of dying or to maintain
10 the patient in a state of permanent unconsciousness. Life-
11 sustaining treatment shall include nutrition and hydration
12 administered by gastric tube or intravenously or any other
13 artificial or invasive means if the declaration of the qualified
14 patient so specifically provides.
15 ["Medical command physician." A licensed physician who is
16 authorized to give medical command under the act of July 3, 1985
17 (P.L.164, No.45), known as the Emergency Medical Services Act.]
18 "Permanently unconscious." A medical condition that has been
19 diagnosed in accordance with currently accepted medical
20 standards and with reasonable medical certainty as total and
21 irreversible loss of consciousness and capacity for interaction
22 with the environment. The term includes, without limitation, a
23 persistent vegetative state or irreversible coma.
24 "Person." An individual, corporation, partnership,
25 association or Federal, State or local government or
26 governmental agency.
27 "Qualified patient." A person who has executed a declaration
28 and who has been determined to be in a terminal condition or to
29 be permanently unconscious.
30 "Terminal condition." An incurable and irreversible medical
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1 condition in an advanced state caused by injury, disease or
2 physical illness which will, in the opinion of the attending
3 physician, to a reasonable degree of medical certainty, result
4 in death regardless of the continued application of life-
5 sustaining treatment.
6 § 5407. Liability.
7 (a) General rule.--No physician, emergency medical service
8 provider or other health care provider who, consistent with this
9 chapter, causes or participates in the initiating, continuing,
10 withholding or withdrawal of life-sustaining treatment from a
11 qualified patient who is incompetent shall, as a result thereof,
12 be subject to criminal or civil liability or be found to have
13 committed an act of unprofessional conduct if the attending
14 physician has followed the declarant's wishes as expressed
15 earlier by the declarant in the form of a declaration and/or
16 EMS-DNR order executed pursuant to this chapter.
17 (b) Absence of declaration or EMS-DNR order, bracelet or
18 card.--The absence of a declaration or EMS-DNR order, bracelet
19 or card by a patient shall not give rise to any presumption as
20 to the intent of the patient to consent to or to refuse the
21 initiation, continuation or termination of life-sustaining
22 treatment.
23 § 5410. Effect on suicide and life insurance.
24 * * *
25 (b) Life insurance.--The making of or failure to make a
26 declaration or EMS-DNR order in accordance with this chapter
27 shall not affect in any manner the sale, procurement or issuance
28 of any policy of life insurance nor shall it be deemed to modify
29 the terms of an existing policy of life insurance. No policy of
30 life insurance shall be legally impaired or invalidated in any
19980H2085B3998 - 4 -
1 manner by the withholding or withdrawal of life-sustaining
2 treatment from an insured patient, notwithstanding any term of
3 the policy to the contrary.
4 § 5411. Declaration optional.
5 No physician or other health care provider and no health care
6 service plan, health maintenance organization, insurer issuing
7 disability insurance, self-insured employee welfare benefit
8 plan, nonprofit hospital plan or Federal, State or local
9 government sponsored or operated program shall:
10 (1) require any person to execute a declaration or EMS-
11 DNR order as a condition for being insured for or receiving
12 health care services; or
13 (2) charge any person a different rate or fee whether or
14 not the person executes or has executed a declaration.
15 § 5413. Emergency medical services.
16 (a) Care given prior to declaration taking effect.--Nothing
17 in this chapter shall be construed to make the provisions of a
18 declaration apply to care given to a patient by emergency
19 medical services personnel prior to the declaration's becoming
20 operative under sections 5405 (relating to when declaration
21 becomes operative) and 5408 (relating to duty of physician to
22 confirm terminal condition).
23 [(b) Care given after declaration takes effect.--The
24 provisions of a declaration shall apply to care given to a
25 patient by emergency medical services personnel after the
26 declaration becomes operative under sections 5405 and 5408 only
27 if:
28 (1) an original declaration, signed by the declarant or
29 other authorized person, is presented to the emergency
30 medical services personnel. The emergency medical services
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1 personnel must immediately notify the medical command
2 physician of the presence of the declaration; or
3 (2) the medical command physician, based on prior
4 notification by the attending physician or other health care
5 provider that a valid and operative declaration exists,
6 directs the emergency medical service personnel according to
7 the provisions of the declaration.
8 (c) Uncertainty regarding validity of declaration.--
9 Emergency medical services personnel confronted with any
10 conflicting information regarding the patient's wishes for life-
11 sustaining treatment shall act according to the accepted
12 treatment protocols and standards appropriate to their level of
13 certification.]
14 (b) EMS-DNR orders, bracelets and cards.--The attending
15 physician who makes the determination pursuant to section
16 5405(2) (relating to when declaration becomes operative) shall,
17 if appropriate based on the declaration, issue to the declarant
18 an emergency medical services do-not-resuscitate order, and may
19 issue at the request of the declarant or his surrogate an EMS-
20 DNR bracelet and/or card supplied by the Department of Health.
21 The declarant may, at the declarant's option, wear the bracelet
22 and/or display the order or card to notify emergency medical
23 service providers of the declarant's do-not-resuscitate status.
24 (c) Revocation of EMS-DNR order.--The declarant or the
25 declarant's surrogate may revoke the declarant's EMS-DNR status
26 at any time without regard to the declarant's physical or mental
27 condition and in any manner, including verbally or by destroying
28 or not displaying the order, bracelet or card. Revocation of the
29 declaration shall also serve to revoke the EMS-DNR order, though
30 emergency medical service providers shall not be subject to
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1 civil or criminal liability or administrative sanction for
2 failure to verify the declaration prior to complying with the
3 EMS-DNR order.
4 (d) Effect of EMS-DNR order, bracelet or card.--Emergency
5 medical service providers are hereby authorized to and shall
6 comply, subject to subsection (e), with an approved Department
7 of Health-issued EMS-DNR order if made aware of such by
8 examining an EMS-DNR bracelet, card or the order itself. Such
9 providers shall have no duty to examine the underlying
10 declaration. "Compliance" for purposes of this subsection shall
11 mean the withholding of cardiopulmonary resuscitation (cardiac
12 compression, endotracheal intubation INVASIVE AIRWAY TECHNIQUES, <--
13 artificial ventilation, defibrillation and other related
14 procedures) from the declarant in the event of respiratory or
15 cardiac arrest. "Compliance" shall also mean the discontinuance
16 and cessation of such resuscitative measures in the event the
17 emergency medical service provider is presented with an EMS-DNR
18 order, card and/or bracelet after initiating such resusciative
19 measures. Emergency medical service providers shall provide
20 other medical interventions necessary and appropriate to provide
21 comfort and alleviate pain, including intravenous fluids,
22 medications and, oxygen AND ANY OTHER INTERVENTION APPROPRIATE <--
23 TO THE LEVEL OF THE CERTIFICATION OF THE PROVIDER, unless
24 otherwise directed by the declarant or the declarant's
25 surrogate.
26 (e) Unwillingness of emergency medical service provider to
27 comply.--Emergency medical services providers who cannot in good
28 conscience comply with an EMS-DNR order shall make a good faith
29 effort to proceed under section 5409 (relating to unwillingness
30 to comply; transfer of declarant) and, so long as such good
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1 faith effort is made, shall not be subject to civil or criminal
2 liability or administrative sanction for failure to comply with
3 an EMS-DNR order. Emergency medical service providers unable to
4 comply with an EMS-DNR order under this subsection shall not be
5 subject to discipline, termination, demotion or other
6 retribution by their employer or the EMS organization with which
7 they are affiliated solely for their actions under this
8 subsection.
9 (f) Uncertainty regarding validity of order, bracelet or
10 card.--Emergency medical service providers who in good faith are
11 uncertain about the validity of an EMS-DNR order, bracelet or
12 card shall render care in accordance with their level of
13 certification. Such providers shall not be subject to civil or
14 criminal liability or administrative sanction for failure to
15 comply with an EMS-DNR order under this subsection.
16 (g) Format of EMS-DNR order.--The Department of Health
17 shall, with the advice of the Pennsylvania Emergency Health
18 Services Council and with the assistance of the regional
19 emergency medical services councils, make available within 180
20 days of the effective date of this subsection standard EMS-DNR
21 orders for issuance to declarants by attending physicians of
22 this Commonwealth. The form of the order shall contain, but not
23 be limited to, the following:
24 PENNSYLVANIA EMERGENCY MEDICAL SERVICES
25 DO-NOT-RESUSCITATE ORDER
26 Patient's full legal name:
27 I, the undersigned, state that I am the attending
28 physician of the patient named above. The above-named
29 patient has executed an advance directive for health care
30 and I have made the determination that this patient is
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1 INCOMPETENT AND in a terminal condition or in a state of <--
2 permanent unconsciousness and that their declaration is
3 now operative.
4 I direct any and all emergency medical service
5 personnel, commencing on the effective date of this
6 order, to withhold cardiopulmonary resuscitation (cardiac
7 compression, endotracheal intubation INVASIVE AIRWAY <--
8 TECHNIQUES, artificial ventilation, defibrillation and
9 other related procedures) from the declarant in the event
10 of the declarant's respiratory or cardiac arrest. I
11 further direct such personnel to provide to the patient
12 other medical interventions, such as intravenous fluids,
13 oxygen or other therapies necessary to provide comfort
14 care or to alleviate pain, unless directed otherwise by
15 the declarant or the declarant's lawful surrogate.
16 Signature of attending physician:
17 Printed name of attending physician:
18 Dated:
19 Attending physician's emergency telephone number:
20 Signature of patient (if capable of making informed
21 decisions):
22 I, the undersigned, hereby direct that in the event
23 of my cardiac and/or respiratory arrest, efforts at
24 cardiopulmonary resuscitation not be initiated. I
25 understand that I may revoke these directions at any time
26 by giving verbal instructions to the emergency medical
27 service providers, by physical cancellation or
28 destruction of this form or my EMS-DNR bracelet or card,
29 or by simply not displaying this form or the EMS-DNR
30 bracelet or card for my EMS caregivers.
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1 Signature of surrogate (if patient is incapable of
2 making informed decisions):
3 I, the undersigned, hereby certify that I am
4 authorized to provide consent on the patient's behalf by
5 virtue of having been designated as the patient's
6 surrogate and/or by virtue of my relationship to the
7 patient (specify relationship: _________________). I
8 hereby direct that in the event of the patient's cardiac
9 and/or respiratory arrest, efforts at cardiopulmonary
10 resuscitation not be initiated. I understand that I may
11 revoke these directions at any time by giving verbal
12 instructions to the emergency medical service providers,
13 by physical cancellation or destruction of this form
14 and/or the patient's EMS-DNR bracelet or card, or by
15 simply not displaying this form or the EMS-DNR bracelet
16 or card for the patient's EMS caregivers.
17 (h) Format of EMS-DNR bracelet.--The Department of Health
18 shall, with the advice of the Pennsylvania Emergency Health
19 Services Council and with the assistance of the regional
20 emergency medical services councils, make available within 180
21 days of the effective date of this subsection standard EMS-DNR
22 bracelets for issuance to declarants by attending physicians.
23 The bracelets shall be uniform in design and shall AT A MINIMUM <--
24 on the face clearly indicate EMS-DNR and the name of the patient
25 and attending physician.
26 (i) Format of EMS-DNR card.--The Department of Health shall,
27 with the advice of the Pennsylvania Emergency Health Services
28 Council and with the assistance of the regional emergency
29 medical services councils, make available within 180 days of the
30 effective date of this subsection standard EMS-DNR cards for
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1 issuance to declarants by attending physicians. The cards shall
2 be wallet-sized and contain, BUT NOT BE LIMITED TO, the <--
3 following:
4 PENNSYLVANIA EMERGENCY MEDICAL SERVICES
5 DO-NOT-RESUSCITATE CARD
6 Patient's full legal name:
7 Attending physician's name:
8 This patient has an operative advance directive and
9 emergency medical services do-not-resuscitate order. EMS
10 personnel are instructed not to perform cardiopulmonary
11 resuscitation (cardiac compression, endotracheal
12 intubation, artificial ventilation, defibrillation and
13 other related procedures) on this patient in the event of
14 the patient's respiratory or cardiac arrest. Do provide
15 to the patient other medical interventions, such as
16 intravenous fluids, oxygen or other therapies deemed
17 necessary to provide comfort care or to alleviate pain,
18 unless directed otherwise by the declarant or the
19 declarant's lawful surrogate.
20 § 5415. Penalties.
21 Any person who willfully conceals, cancels, defaces,
22 obliterates or damages the declaration or EMS-DNR order,
23 bracelet or card of another without the consent of the declarant
24 commits a felony of the third degree. Any person who falsifies
25 or forges the declaration or EMS-DNR order, bracelet or card of
26 another, or willfully conceals or withholds personal knowledge
27 of a revocation as provided in section 5406 (relating to
28 revocation) or 5413(c) (relating to emergency medical services),
29 with the intent to cause a withholding or withdrawal of life-
30 sustaining treatment contrary to the wishes of the declarant
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1 and, because of such an act, directly causes life-sustaining
2 treatment to be withheld or withdrawn and death to be hastened
3 shall be subject to prosecution for criminal homicide as
4 provided in 18 Pa.C.S. Ch. 25 (relating to criminal homicide).
5 Any person who willfully, by undue influence, fraud or duress,
6 causes a person to execute a declaration or EMS-DNR order
7 pursuant to this chapter commits a felony of the third degree.
8 SECTION 2. THE DEPARTMENT OF HEALTH SHALL, WITH THE ADVICE <--
9 OF THE PENNSYLVANIA EMERGENCY HEALTH SERVICES COUNCIL AND WITH
10 THE ASSISTANCE OF THE REGIONAL EMERGENCY MEDICAL SERVICES
11 COUNCILS, DEVELOP AND MAKE AVAILABLE TO HEALTH CARE PROVIDERS
12 RECOGNIZED UNDER THE ACT OF JULY 3, 1985 (P.L.164, NO.45), KNOWN
13 AS THE EMERGENCY MEDICAL SERVICES ACT, WITHIN 180 DAYS OF THE
14 EFFECTIVE DATE OF THIS ACT EDUCATIONAL MATERIALS RELATING TO THE
15 IMPLEMENTATION OF THE PROVISIONS OF THIS ACT. THE DEPARTMENT
16 SHALL ALSO CAUSE THE REQUIREMENTS OF THIS ACT TO BE INCLUDED AS
17 PART OF THE CURRICULA FOR HEALTH CARE PROVIDERS RECOGNIZED UNDER
18 THE EMERGENCY MEDICAL SERVICES ACT.
19 SECTION 3. THE SUM OF $50,000, OR AS MUCH THEREOF AS MAY BE
20 NECESSARY, IS HEREBY APPROPRIATED TO THE DEPARTMENT OF HEALTH
21 FOR THE FISCAL YEAR JULY 1, 1998, TO JUNE 30, 1999, TO CARRY OUT
22 THE PROVISIONS OF THIS ACT.
23 Section 2 4. This act shall take effect in 60 days. <--
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