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 19980H2085B3998 - 2 -
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 19980H2085B3998 - 3 -
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 19980H2085B3998 - 5 -
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 19980H2085B3998 - 6 -
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 19980H2085B3998 - 7 -
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 19980H2085B3998 - 8 -
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. 19980H2085B3998 - 9 -
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 19980H2085B3998 - 10 -
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 19980H2085B3998 - 11 -
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. <-- G25L20JRW/19980H2085B3998 - 12 -