act-2002-0-59•Pennsylvania Act 2002-59 — PROBATE, ESTATES AND FIDUCIARIES CODE (20 PA.C.S.) - AMEND HEALTH CARE ADVANCE DIRECTIVES, EMERGENCY MEDICAL SERVICES AND OUT-OF-HOSPITAL NONRESUSITATION
Pennsylvania Act 2002-59 — PROBATE, ESTATES AND FIDUCIARIES CODE (20 PA.C.S.) - AMEND HEALTH CARE ADVANCE DIRECTIVES, EMERGENCY MEDICAL SERVICES AND OUT-OF-HOSPITAL NONRESUSITATION
act-2002-0-592002 Pa. Act 59Law
Act text
PROBATE, ESTATES AND FIDUCIARIES CODE (20 PA.C.S.) - AMEND HEALTH CARE
ADVANCE DIRECTIVES, EMERGENCY MEDICAL SERVICES AND OUT-OF-HOSPITAL
NONRESUSITATION
Act of Jun. 19, 2002, P.L. 409, No. 59 Cl. 20
Session of 2002
No. 2002-59
HB 96
AN ACT
Amending Title 20 (Decedents, Estates and Fiduciaries) of the
Pennsylvania Consolidated Statutes, further providing for
advance directives for health care, for definitions and for
emergency medical services; and providing for out-of-hospital
nonresuscitation.
The General Assembly of the Commonwealth of Pennsylvania
hereby enacts as follows:
Section 1. The definition of "declarant" in section 5403 of
Title 20 of the Pennsylvania Consolidated Statutes is amended to
read:
§ 5403. Definitions.
The following words and phrases when used in this chapter
shall have the meanings given to them in this section unless the
context clearly indicates otherwise:
* * *
"Declarant." A person who makes a declaration in accordance
with this chapter. The term includes an emancipated minor.
* * *
Section 2. Section 5413 of Title 20 is amended to read:
§ 5413. Emergency medical services.
[(a) Care given prior to declaration taking effect.--Nothing
in this chapter shall be construed to make the provisions of a
declaration apply to care given to a patient by emergency
medical services personnel prior to the declaration's becoming
operative under sections 5405 (relating to when declaration
becomes operative) and 5408 (relating to duty of physician to
confirm terminal condition).
(b) Care given after declaration takes effect.--The
provisions of a declaration shall apply to care given to a
patient by emergency medical services personnel after the
declaration becomes operative under sections 5405 and 5408 only
if:
(1) an original declaration, signed by the declarant or
other authorized person, is presented to the emergency
medical services personnel. The emergency medical services
personnel must immediately notify the medical command
physician of the presence of the declaration; or
(2) the medical command physician, based on prior
notification by the attending physician or other health care
provider that a valid and operative declaration exists,
directs the emergency medical service personnel according to
the provisions of the declaration.
(c) Uncertainty regarding validity of declaration.--
Emergency medical services personnel confronted with any
conflicting information regarding the patient's wishes for life-
sustaining treatment shall act according to the accepted
treatment protocols and standards appropriate to their level of
certification.]
(a) General rule.--An emergency medical services provider
shall, in the course of providing care to a declarant, at all
times comply with the instructions of an authorized medical
command physician to withhold or discontinue cardiopulmonary
resuscitation for a declarant whose advance directive has become
operative under section 5405 (relating to when declaration
becomes operative).
(b) Applicability.--This section is applicable only in those
instances where an out-of-hospital DNR order is not in effect
under section 5404-A(a) (relating to orders, bracelets and
necklaces).
Section 3. Title 20 is amended by adding a chapter to read:
CHAPTER 54A
OUT-OF-HOSPITAL NONRESUSCITATION
Sec.
54A01. Short title of chapter.
54A02. Legislative findings and intent.
54A03. Definitions.
54A04. Orders, bracelets and necklaces.
54A05. Revocation.
54A06. Liability.
54A07. Effect on suicide and life insurance.
54A08. Order optional.
54A09. Preservation of existing rights.
54A10. Emergency medical services.
54A11. Pregnancy.
54A12. Penalties.
54A13. Severability.
§ 54A01. Short title of chapter.
This chapter shall be known and may be cited as the Do-Not-
Resuscitate Act.
§ 54A02. Legislative findings and intent.
The General Assembly finds and declares as follows:
(1) Although cardiopulmonary resuscitation has saved the
lives of individuals about to experience sudden, unexpected
death, present medical data indicates that cardiopulmonary
resuscitation rarely leads to prolonged survival in
individuals with terminal illnesses in whom death is
expected.
(2) In many circumstances, the performance of
cardiopulmonary resuscitation may cause infliction of
unwanted and unnecessary pain and suffering.
(3) Existing emergency medical services protocols may
require emergency medical services personnel to proceed to
cardiopulmonary resuscitation when an individual is found in
a cardiac or respiratory arrest even if the individual has
completed a living will or advance directive indicating that
the individual does not wish to receive cardiopulmonary
resuscitation.
(4) The administration of cardiopulmonary resuscitation
by emergency medical services personnel to an individual with
an out-of-hospital do-not-resuscitate order offends the
dignity of the individual and conflicts with standards of
accepted medical practice.
(5) This chapter provides clear direction to emergency
medical services personnel and other health care providers in
regard to the performance of cardiopulmonary resuscitation.
(6) Nothing in this chapter is intended to condone,
authorize or approve mercy killing, euthanasia or aided
suicide or to permit any affirmative or deliberate act or
omission to end life other than as defined in this chapter.
§ 54A03. Definitions.
The following words and phrases when used in this chapter
shall have the meanings given to them in this section unless the
context clearly indicates otherwise:
"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,
invasive airway techniques, artificial ventilation,
defibrillation and other related procedures.
"Declarant." As defined in section 5403 (relating to
definitions).
"Declaration." As defined in section 5403 (relating to
definitions).
"Department." The Department of Health of the Commonwealth.
"DNR." Do not resuscitate.
"Emergency medical services provider." A health care
provider recognized under the act of July 3, 1985 (P.L.164,
No.45), known as the Emergency Medical Services Act. The term
includes those individuals recognized under 42 Pa.C.S. § 8331.2
(relating to good Samaritan civil immunity for use of automated
external defibrillator).
"EMS." Emergency medical services.
"Health care provider." A person who is licensed or
certified by the laws of this Commonwealth to administer health
care in the ordinary course of business or practice of a
profession. The term includes personnel recognized under the act
of July 3, 1985 (P.L.164, No.45), known as the Emergency Medical
Services Act. The term includes those individuals recognized
under 42 Pa.C.S. § 8331.2 (relating to good Samaritan civil
immunity for use of automated external defibrillator).
"Incompetent." The lack of sufficient capacity for a person
to make or communicate decisions concerning himself.
"Invasive airway technique." Any advanced airway technique,
including endotracheal intubation.
"Life-sustaining treatment." Any medical procedure or
intervention that, when administered to a patient, will serve
only to prolong the process of dying or to maintain the patient
in a state of permanent unconsciousness. "Life-sustaining
treatment" shall include nutrition and hydration administered by
gastric tube or intravenously or any other artificial or
invasive means if the order of the patient so specifically
provides.
"Medical command physician." A licensed physician who is
authorized to give medical command under the act of July 3, 1985
(P.L.164, No.45), known as the Emergency Medical Services Act.
"Necklace." An out-of-hospital do-not-resuscitate necklace.
"Order." An out-of-hospital do-not-resuscitate order.
"Out-of-hospital do-not-resuscitate bracelet." A bracelet in
the standard format set forth in section 54A04 (relating to
orders, bracelets and necklaces), supplied by the department and
issued by the attending physician, which may be worn at the
patient's option to notify emergency medical services providers
of the presence of an order.
"Out-of-hospital do-not-resuscitate necklace." A necklace in
the standard format set forth in section 54A04 (relating to
orders, bracelets and necklaces), supplied by the department and
issued by the attending physician, which may be worn at the
patient's option to notify emergency medical services providers
of the presence of an order.
"Out-of-hospital do-not-resuscitate order." An order in the
standard format set forth in section 54A04 (relating to orders,
bracelets and necklaces), supplied by the department and issued
by the attending physician, directing emergency medical services
providers to withhold cardiopulmonary resuscitation from the
patient in the event of respiratory or cardiac arrest.
"Out-of-hospital do-not-resuscitate patient." Any of the
following:
(1) An individual:
(i) who is in a terminal condition; and
(ii) who, pursuant to section 54A04(a) (relating to
orders, bracelets and necklaces), possesses and in any
manner displays or causes to be displayed for emergency
medical services providers an apparently valid order,
bracelet or necklace.
(2) A declarant:
(i) whose declaration has become operative under
section 5405(2) (relating to when declaration becomes
operative); and
(ii) who, pursuant to section 54A04(a), possesses
and in any manner displays or causes to be displayed for
emergency medical services providers an apparently valid
order, bracelet or necklace.
"Patient." An out-of-hospital do-not-resuscitate patient.
"Permanently unconscious." A medical condition that has been
diagnosed in accordance with currently accepted medical
standards and with reasonable medical certainty as total and
irreversible loss of consciousness and capacity for interaction
with the environment. The term includes, without limitation, a
persistent vegetative state or irreversible coma.
"Person." An individual, corporation, partnership,
association or Federal, State or local government or
governmental agency.
"Terminal condition." An incurable and irreversible medical
condition in an advanced state caused by injury, disease or
physical illness which will, in the opinion of the attending
physician, to a reasonable degree of medical certainty result in
death regardless of the continued application of life-sustaining
treatment.
§ 54A04. Orders, bracelets and necklaces.
(a) Issuance.--An attending physician, upon the request of a
patient who is at least 18 years of age, has graduated from high
school or has married, or the patient's surrogate if the
surrogate is so authorized, shall issue to the patient an order
and may issue at the request of the patient or the patient's
surrogate a bracelet or necklace supplied by the department. The
patient may, at the patient's option, wear the bracelet or
display the order or necklace to notify emergency medical
services providers of the patient's do-not-resuscitate status.
(b) Format of order.--The department shall, with the advice
of the Pennsylvania Emergency Health Services Council and with
the assistance of the regional emergency medical services
councils, make available within 180 days of the effective date
of this subsection standard orders for issuance to patients by
attending physicians of this Commonwealth. The form of the order
shall contain, but not be limited to, the following:
PENNSYLVANIA OUT-OF-HOSPITAL
DO-NOT-RESUSCITATE ORDER
Patient's full legal name:
I, the undersigned, state that I am the attending
physician of the patient named above. The above-named
patient has requested this order, and I have made the
determination that this patient is in a terminal
condition and eligible for an order.
I direct any and all emergency medical services
personnel, commencing on the effective date of this
order, to withhold cardiopulmonary resuscitation (cardiac
compression, invasive airway techniques, artificial
ventilation, defibrillation and other related procedures)
from the patient in the event of the patient's
respiratory or cardiac arrest. I further direct such
personnel to provide to the patient other medical
interventions, such as intravenous fluids, oxygen or
other therapies necessary to provide comfort care or to
alleviate pain, unless directed otherwise by the patient
or the emergency medical services provider's authorized
medical command physician.
Signature of attending physician:
Printed name of attending physician:
Dated:
Attending physician's emergency telephone number:
Signature of patient (if capable of making informed
decisions):
I, the undersigned, hereby direct that in the event
of my cardiac and/or respiratory arrest efforts at
cardiopulmonary resuscitation not be initiated. I
understand that I may revoke these directions at any time
by giving verbal instructions to the emergency medical
services providers, by physical cancellation or
destruction of this form or my bracelet or necklace or by
simply not displaying this form or the bracelet or
necklace for my EMS caregivers.
Signature of surrogate (if patient is incapable of
making informed decisions):
I, the undersigned, hereby certify that I am
authorized to execute this order on the patient's behalf
by virtue of having been designated as the patient's
surrogate and/or by virtue of my relationship to the
patient (specify relationship: _________________). I
hereby direct that in the event of the patient's cardiac
and/or respiratory arrest efforts at cardiopulmonary
resuscitation not be initiated.
(c) Format of bracelet.--The department shall, with the
advice of the Pennsylvania Emergency Health Services Council and
with the assistance of the regional emergency medical services
councils, make available within 180 days of the effective date
of this subsection standard bracelets for issuance to patients
by attending physicians. The bracelets shall be uniform in
design and shall, at a minimum, on the face clearly indicate
OUT-OF-HOSPITAL DNR and the name of the patient and attending
physician as well as the dated signature of the attending
physician.
(d) Format of necklace.--The department shall, with the
advice of the Pennsylvania Emergency Health Services Council and
with the assistance of the regional emergency medical services
councils, make available within 180 days of the effective date
of this subsection standard necklaces for issuance to patients
by attending physicians. The necklaces shall be uniform in
design and shall, at a minimum, on the face clearly indicate
OUT-OF-HOSPITAL DNR and the name of the patient and attending
physician as well as the dated signature of the attending
physician.
§ 54A05. Revocation.
(a) 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
any time without regard to the patient's physical or mental
condition and in any manner, including verbally or by destroying
or not displaying the order, bracelet or necklace.
§ 54A06. Liability.
(a) General rule.--No physician, emergency medical services
provider or other health care provider who, consistent with this
chapter, causes or participates in the initiating, continuing,
withholding or withdrawal of life-sustaining treatment or
cardiopulmonary resuscitation from a patient shall, as a result
of such action, be subject to criminal or civil liability or be
found to have committed an act of unprofessional conduct if the
attending physician, health care provider or emergency medical
services provider has followed the patient's expressed wishes in
the form of a declaration, order or revocation executed pursuant
to this chapter.
(b) Absence of order, bracelet or necklace.--The absence of
an order, bracelet or necklace by a patient shall not give rise
to any presumption as to the intent of the patient to consent to
or to refuse the initiation, continuation or termination of
life-sustaining treatment.
§ 54A07. Effect on suicide and life insurance.
(a) Criminal effect.--The withholding or withdrawal of life-
sustaining treatment from a patient in accordance with the
provisions of this chapter shall not, for any purpose,
constitute suicide or homicide.
(b) Life insurance.--The making of or failure to make an
order in accordance with this chapter shall not affect in any
manner the sale, procurement or issuance of any policy of life
insurance nor shall it be deemed to modify the terms of an
existing policy of life insurance. No policy of life insurance
shall be legally impaired or invalidated in any manner by the
withholding or withdrawal of life-sustaining treatment from an
insured patient, notwithstanding any term of the policy to the
contrary.
§ 54A08. Order optional.
No physician or other health care provider and no health care
service plan, health maintenance organization, insurer issuing
disability insurance, self-insured employee welfare benefit
plan, nonprofit hospital plan or Federal, State or local
government-sponsored or -operated program may:
(1) require any person to execute an order as a
condition for being insured for or receiving health care
services; or
(2) charge any person a different rate or fee whether or
not the person executes or has executed an order.
§ 54A09. Preservation of existing rights.
The provisions of this chapter shall not impair or supersede
any existing rights or responsibilities not addressed in this
chapter.
§ 54A10. Emergency medical services.
(a) Medical command instructions.--Notwithstanding the
absence of an order, bracelet or necklace pursuant to this
section, emergency medical services providers shall at all times
comply with the instructions of an authorized medical command
physician to withhold or discontinue resuscitation.
(b) 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 order
by examining a bracelet, a necklace or the order itself.
(2) Emergency medical services providers shall provide
other medical interventions necessary and appropriate to
provide comfort and alleviate pain, including intravenous
fluids, medications, oxygen and any other intervention
appropriate to the level of the certification of the
provider, unless otherwise directed by the patient or the
emergency medical services provider's authorized medical
command physician.
(3) As used in this subsection, the term "comply" means:
(i) to withhold cardiopulmonary resuscitation from
the patient in the event of respiratory or cardiac
arrest; or
(ii) to discontinue and cease cardiopulmonary
resuscitation in the event the emergency medical services
provider is presented with an order or discovers a
necklace or bracelet after initiating cardiopulmonary
resuscitation.
(c) Uncertainty regarding validity or applicability of
order, bracelet or necklace.--
(1) Emergency medical services providers who in good
faith are uncertain about the validity or applicability of an
order, bracelet or necklace shall render care in accordance
with their level of certification.
(2) Emergency medical services providers who act under
paragraph (1) shall not be subject to civil or criminal
liability or administrative sanction for failure to comply
with an order under this section.
(d) Recognition of other states' orders.--Emergency medical
services or out-of-hospital DNR orders, bracelets or necklaces
valid in states other than this Commonwealth shall be recognized
in this Commonwealth to the extent that these orders, bracelets
or necklaces are consistent with the laws of this Commonwealth.
Emergency medical services providers shall act in accordance
with the provisions of this section when encountering a patient
with an apparently valid EMS or out-of-hospital DNR form,
bracelet or necklace issued by another state. Emergency medical
services providers acting in good faith under this section shall
be entitled to the same immunities and protections that would
otherwise be applicable.
§ 54A11. Pregnancy.
(a) General rule.--Notwithstanding the existence of an order
or direction to the contrary, life-sustaining treatment,
cardiopulmonary resuscitation, nutrition and hydration must be
provided to a pregnant patient unless, to a reasonable degree of
medical certainty as certified on the patient's medical record
by the attending physician and an obstetrician who has examined
the patient, life-sustaining treatment, nutrition and hydration:
(1) will not maintain the pregnant patient in such a way
as to permit the continuing development and live birth of the
unborn child;
(2) will be physically harmful to the pregnant patient;
or
(3) would cause pain to the pregnant patient which
cannot be alleviated by medication.
(b) Pregnancy test.--Nothing in this section shall require a
physician to perform a pregnancy test unless the physician has
reason to believe that the patient may be pregnant.
(c) Payment of expenses by Commonwealth.--
(1) In the event that treatment, cardiopulmonary
resuscitation, nutrition or hydration are provided to a
pregnant patient, notwithstanding the existence of an order
or direction to the contrary, the Commonwealth shall pay all
usual, customary and reasonable expenses directly and
indirectly incurred by the pregnant patient to whom such
treatment, nutrition and hydration are provided.
(2) The Commonwealth shall have the right of subrogation
against all moneys paid by any third-party health insurer on
behalf of the pregnant patient.
(3) The expenditures incurred on behalf of the pregnant
patient shall constitute a grant, and no lien shall be placed
upon the property of the pregnant patient, her estate or her
heirs.
§ 54A12. Penalties.
Any person who intentionally conceals, cancels, defaces,
obliterates or damages the order, bracelet or necklace of
another without the consent of the patient commits a felony of
the third degree. Any person who falsifies or forges the order,
bracelet or necklace of another, or conceals or withholds
personal knowledge of a revocation as provided in section 54A05
(relating to revocation), with the intent to cause a withholding
or withdrawal of life-sustaining treatment contrary to the
wishes of the patient and, because of such an act, directly
causes life-sustaining treatment to be withheld or withdrawn and
death to be hastened shall be subject to prosecution for
criminal homicide as provided in 18 Pa.C.S. Ch. 25 (relating to
criminal homicide). Any person who intentionally, by undue
influence, fraud or duress, causes a person to execute an order
pursuant to this chapter commits a felony of the third degree.
§ 54A13. Severability.
The provisions of this chapter are severable, and if any
word, phrase, clause, sentence, section or provision of this
chapter is for any reason held to be unconstitutional, the
decision of the court shall not affect or impair any of the
remaining provisions of this chapter. It is hereby declared as
the legislative intent that this chapter would have been adopted
had such unconstitutional word, phrase, clause, sentence,
section or provision thereof not been included herein.
Section 4. The Department of Health shall, with the advice
of the Pennsylvania Emergency Health Services Council and with
the assistance of the regional emergency medical services
councils, develop and make available to health care providers
recognized under the act of July 3, 1985 (P.L.164, No.45), known
as the Emergency Medical Services Act, including those
individuals recognized under 42 Pa.C.S. § 8331.2, within 180
days of the effective date of this act, educational materials
relating to the implementation of the provisions of this act.
The department shall also cause the requirements of this act to
be included as part of the curricula for health care providers
recognized under the Emergency Medical Services Act.
Section 5. The Department of Health may contract with any
public or private entity to facilitate all or part of its
responsibilities under 20 Pa.C.S. Ch. 54 or 54A.
Section 6. The Department of Health, upon the conclusion of
at least one public hearing, shall publish interim regulations
regarding implementation of 20 Pa.C.S. Ch. 54A in the
Pennsylvania Bulletin within 120 days of the effective date of
this act. The interim regulations shall not be subject to the
act of June 25, 1982 (P.L.633, No.181), known as the Regulatory
Review Act. The interim regulations shall expire 18 months
following the effective date of this act or when final
regulations are promulgated by the department, whichever occurs
first. Final regulations shall be promulgated no later than 18
months following the effective date of this act.
Section 7. This act shall take effect in 60 days.
APPROVED--The 19th day of June, A. D. 2002.
MARK S. SCHWEIKER
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