PRINTER'S NO. 1229
THE GENERAL ASSEMBLY OF PENNSYLVANIA
SENATE BILL
No.
623
Session of
2017
INTRODUCED BY YAW, RAFFERTY, LEACH, FONTANA, SCHWANK,
McGARRIGLE, BAKER, BROWNE, AUMENT AND BLAKE, OCTOBER 5, 2017
REFERRED TO HEALTH AND HUMAN SERVICES, OCTOBER 5, 2017
AN ACT
Amending Title 20 (Decedents, Estates and Fiduciaries) of the
Pennsylvania Consolidated Statutes, in general provisions
relating to health care, further providing for applicability,
for definitions and for criminal penalties; in living wills,
further providing for emergency medical services; in out-of-
hospital nonresuscitation, further providing for definitions,
for orders, bracelets and necklaces, for revocation, for
absence of order, bracelet or necklace and for emergency
medical services, repealing provisions relating to advisory
committee and providing for discontinuance; providing for
Pennsylvania orders for life-sustaining treatment; and making
editorial changes.
The General Assembly of the Commonwealth of Pennsylvania
hereby enacts as follows:
Section 1. Section 5421(a) of Title 20 of the Pennsylvania
Consolidated Statutes is amended to read:
§ 5421. Applicability.
(a) General rule.--This chapter applies to advance health
care directives [and], out-of-hospital nonresuscitation orders
and Pennsylvania orders for life-sustaining treatment.
* * *
Section 2. The definitions of "medical command physician,"
"order" and "patient" in section 5422 of Title 20 are amended
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and the section is amended by adding definitions to read:
§ 5422. 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:
* * *
"Medical command physician." A licensed physician who is
authorized to give a medical command under [the act of July 3,
1985 (P.L.164, No.45), known as the Emergency Medical Services
Act] 35 Pa.C.S. Ch. 81 (relating to emergency medical services
system).
* * *
"Order." An out-of-hospital do-not-resuscitate order as
defined under section 5483 (relating to definitions) or
Pennsylvania orders for life-sustaining treatment as defined
under section 5493 (relating to definitions).
"Out-of-hospital do-not-resuscitate order" or "OOH-DNR
order." An out-of-hospital do-not-resuscitate order as defined
under section 5483 (relating to definitions).
["Patient." An out-of-hospital do-not-resuscitate patient as
defined under section 5483 (relating to definitions).]
* * *
"Pennsylvania orders for life-sustaining treatment" or
"POLST." Pennsylvania orders for life-sustaining treatment as
defined under section 5493 (relating to definitions).
Section 3. Sections 5432, 5445(b), 5483, 5484(a) and (b),
5485, 5486 and 5487 of Title 20 are amended to read:
§ 5432. Criminal penalties.
(a) Criminal homicide.--A person shall be subject to
prosecution for criminal homicide as provided in 18 Pa.C.S. Ch.
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25 (relating to criminal homicide) if the person intends to
cause the withholding or withdrawal of life-sustaining treatment
contrary to the wishes of the principal or patient and, because
of that action, directly causes life-sustaining treatment to be
withheld or withdrawn and death to be hastened and:
(1) falsifies or forges the advance health care
directive, OOH-DNR order, bracelet [or], necklace or POLST
of that principal or patient; or
(2) willfully conceals or withholds personal knowledge
of a revocation of an advance health care directive or DNR
status.
(b) Interference with health care directive.--A person
commits a felony of the third degree if that person willfully:
(1) conceals, cancels, alters, defaces, obliterates or
damages an advance health care directive, OOH-DNR order,
bracelet [or], necklace or POLST without the consent of the
principal or patient;
(2) causes a person to execute an advance health care
directive or order or wear a bracelet or necklace by undue
influence, fraud or duress; or
(3) falsifies or forges an advance health care
directive, OOH-DNR order, bracelet [or], necklace or POLST
or any amendment or revocation thereof, the result of which
is a direct change in the health care provided to the
principal or patient.
§ 5445. Emergency medical services.
* * *
(b) Applicability.--This section is applicable only in those
instances where an out-of-hospital DNR order is not in effect
under section 5484 (relating to OOH-DNR orders, bracelets and
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necklaces).
§ 5483. Definitions.
The following words and phrases when used in this subchapter
shall have the meanings given to them in this section unless the
context clearly indicates otherwise:
"Department." The Department of Health of the Commonwealth.
"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.] As defined
under 35 Pa.C.S. § 8103 (relating to definitions). 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, certified
or otherwise authorized by the laws of this Commonwealth to
administer or provide 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,] 35 Pa.C.S.
Ch. 81 (relating to emergency medical services system) and those
individuals recognized under 42 Pa.C.S. § 8331.2 (relating to
good Samaritan civil immunity for use of automated external
defibrillator).
"Out-of-hospital do-not-resuscitate bracelet." A bracelet in
the standard format set forth in section 5484 (relating to OOH-
DNR 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 OOH-DNR order.
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"Out-of-hospital do-not-resuscitate necklace." A necklace in
the standard format set forth in section 5484 (relating to OOH-
DNR 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 OOH-DNR order.
"Out-of-hospital do-not-resuscitate order" or "OOH-DNR
order." An order in the standard format set forth in section
5484 (relating to OOH-DNR 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." An individual
who:
(1) Has an end-stage medical condition or is permanently
unconscious.
(2) Pursuant to section 5484(a) (relating to OOH-DNR
orders, bracelets and necklaces), possesses and in any manner
displays or causes to be displayed for emergency medical
services providers an apparently valid OOH-DNR order,
bracelet or necklace.
"Surrogate." A health care agent or a health care
representative.
§ 5484. [Orders] OOH-DNR 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, has married or is an emancipated minor, or the patient's
surrogate if the surrogate is so authorized, shall issue to the
patient an OOH-DNR order and may issue at the request of the
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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 DNR
status.
(b) Format of OOH-DNR 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 standard OOH-DNR 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
or the patient's surrogate has requested this order, and I
have made the determination that the patient is eligible for
an order and satisfies one of the following:
.......... has an end-stage medical condition.
.......... is permanently unconscious and has a living
will directing that no cardiopulmonary resuscitation be
provided to the patient in the event of the patient's cardiac
or respiratory arrest.
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
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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:
I, the undersigned, hereby direct that in the event of my
cardiac and/or respiratory arrest efforts at cardiopulmonary
resuscitation not be initiated and that they may be withdrawn
if 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] providers.
Signature of patient (if capable 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 and be
withdrawn if initiated.
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Signature of surrogate (if patient is incapable of making
informed decisions):
* * *
§ 5485. Revocation.
(a) Patient.--If a patient has obtained an OOH-DNR order,
only the patient may revoke the patient's DNR status.
(b) Surrogate.--If a surrogate has obtained an OOH-DNR
order, the patient or the surrogate may revoke a 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 OOH-DNR order, bracelet or necklace.
§ 5486. Absence of OOH-DNR order, bracelet or necklace.
If an OOH-DNR order has not been issued by an attending
physician, a presumption does not arise as to the intent of the
individual to consent to or to refuse the initiation,
continuation or termination of life-sustaining treatment.
§ 5487. Emergency medical services.
(a) Medical command instructions.--Notwithstanding the
absence of an OOH-DNR 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 OOH-DNR order, bracelet or necklace.--
(1) Emergency medical services providers are authorized
to and shall comply with an OOH-DNR order if made aware of
the order by examining a bracelet, a necklace or the order
itself.
(2) Emergency medical services providers shall provide
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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 OOH-DNR order or discovers
a necklace or bracelet after initiating cardiopulmonary
resuscitation.
(c) Uncertainty regarding validity or applicability of OOH-
DNR order, bracelet or necklace.--
(1) Emergency medical services providers who in good
faith are uncertain about the validity or applicability of an
OOH-DNR 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 OOH-DNR order under this section.
(d) Recognition of other states' orders.--Emergency medical
services or [out-of-hospital DNR] OOH-DNR orders, bracelets or
necklaces valid in states other than this Commonwealth shall be
recognized in this Commonwealth to the extent that these orders,
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bracelets or necklaces and the criteria for their issuance 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.
Section 4. Section 5488 of Title 20 is repealed:
[§ 5488. Advisory committee.
(a) Establishment.--Within 60 days of the effective date of
this section, the department shall establish a committee to
assist it in determining the advisability of using a
standardized form containing orders by qualified physicians that
detail the scope of medical treatment for patients' life-
sustaining wishes.
(b) Membership.--The committee shall include representatives
from the Pennsylvania Medical Society, the Hospital and Health
System Association of Pennsylvania, the Joint State Government
Commission's Advisory Committee on Decedents' Estates Laws, the
Pennsylvania Bar Association, the Department of Aging, the
Department of Public Welfare and other interested persons at the
department's discretion.
(c) Scope of review.--The committee's review shall include,
but not be limited to, examination of the following:
(1) The need to adopt this type of standardized form in
view of the existing use of do-not-resuscitate orders.
(2) The use and evaluation of use of such forms in other
states.
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(3) Any other matters determined by the department to be
relevant to its determination.]
Section 5. Title 20 is amended by adding a section to read:
§ 5489. Discontinuance.
An OOH-DNR order may not be executed on or after the date the
department adopts an initial POLST form under section 5498
(relating to POLST form). This subchapter shall continue to
apply to any OOH-DNR order executed prior to the date the
department adopts an initial POLST form.
Section 6. Chapter 54 of Title 20 is amended by adding a
subchapter to read:
SUBCHAPTER F
PENNSYLVANIA ORDERS FOR LIFE-SUSTAINING TREATMENT
Sec.
5491. Scope of subchapter.
5492. Legislative findings and intent.
5493. Definitions.
5494. Prohibitions on use.
5495. Voluntary consent requirement.
5496. POLST Advisory Committee.
5497. Administration of POLST program.
5498. POLST form.
5498.1. Education about POLST.
5498.2. Requirements for valid POLST.
5498.3. Portability.
5498.4. Team care.
5498.5. Copies of orders.
5498.6. Signature options.
5498.7. Standards for surrogate decision makers.
5498.8. Revocation.
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5498.9. Transfer requirements.
5498.10. Review requirements.
5498.11. Compliance.
5498.12. Emergency medical services.
5498.13. Immunity.
5498.14. Conflict with advance health care directive.
5498.15. POLST executed under prior POLST form.
5498.16. POLST executed under PLSWC form.
5498.17. POLST executed in another state or jurisdiction.
5498.18. POLST registry study.
§ 5491. Scope of subchapter.
This subchapter relates to Pennsylvania Orders for Life-
Sustaining Treatment.
§ 5492. Legislative findings and intent.
The General Assembly finds and declares as follows:
(1) All individuals have a qualified right to control
their health care and should not lose that right if they
become incompetent or have never been a competent adult.
(2) The Commonwealth has recognized this right by
providing for advance health care directives in which
individuals may provide direction and state their goals and
preferences about future health care and by providing for
surrogate decision makers for incompetent adults and
unemancipated minors.
(3) A Pennsylvania order for life-sustaining treatment,
or POLST, differs from an advance health care directive as it
converts an individual's wishes regarding health care into a
medical order that is immediately actionable and applicable
across all health care settings.
(4) The use of POLST may overcome many of the
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limitations and problems associated with advance health care
directives and existing orders regarding cardiopulmonary
resuscitation and other end-of-life care, including out-of-
hospital do-not-resuscitate orders.
(5) In many cases, advance health care directives only
name a surrogate decision maker to make health care decisions
for the principal or lack specificity as to the principal's
goals and preferences for a medical condition that
subsequently develops because it was not foreseen by the
principal.
(6) Existing medical orders frequently are ineffective
when the patient is transferred from one care setting to
another because the procedures, forms and requirements at
each care setting may be different, resulting in a loss in
the ability of patients to have their wishes honored.
(7) Existing emergency medical services protocols may
require emergency medical services personnel to proceed to
cardiopulmonary resuscitation when an individual is found in
cardiac and respiratory arrest, even if the individual has
completed an advance directive or has otherwise clearly
indicated that the individual does not wish to receive
cardiopulmonary resuscitation.
(8) A POLST, which is executed by a health care
practitioner under appropriate circumstances to implement the
wishes of the patient expressed directly by the patient or
through a surrogate decision maker, provides clear direction
for the patient's care regarding health care issues likely to
emerge given the patient's current medical condition.
(9) A key step in the POLST process is the health care
practitioner's review with the patient or the patient's
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surrogate decision maker of the patient's current health
status, diagnoses and prognosis to determine whether a POLST
order would be appropriate or should be updated.
(10) A POLST is appropriate for individuals with serious
illnesses or frailty if their health care practitioner would
not be surprised if they died within the next year and their
current health status, diagnoses and prognosis indicates
standing medical orders concerning treatment options and
other care are appropriate.
(11) A POLST is not recommended for individuals with
stable, even if chronic, medical conditions and years of life
expectancy.
(12) Among vulnerable populations, including persons
with disabilities, POLST are appropriate for seriously ill or
frail patients if their health care practitioner would not be
surprised if they died within the next year. POLST are not
appropriate for the entire population.
(13) It should not be assumed that all patients in any
facility, including a nursing home, should have or would
desire POLST.
(14) The well-being of the patient is paramount in
considering a POLST, not cost savings to the government or
insurers.
(15) A POLST is appropriately entered following a shared
decision-making process that facilitates patient consent that
is voluntary, educated, collaborative and thoughtful,
including a discussion of the patient's current clinical
status, treatment options and likely outcomes, together with
the patient's goals of care, preferences and values.
(16) Conversations about POLST must avoid any bias
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against continuation of care and must not characterize the
continuation of life as burdensome. When appropriate, these
conversations should emphasize palliative care and hospice
availability.
(17) A standardized POLST form, which is easily
recognized, understood and implemented, can greatly advance
the ability of patients to ensure that their medical care is
aligned with their goals of care, preferences and values, as
informed by a shared decision-making process.
(18) Advance health care directives remain critically
important for adults from the age of majority until death. An
advance health care directive, rather than a POLST, is the
appropriate advance care planning tool for healthy patients.
(19) When the use of a POLST becomes appropriate, an
existing advance health care directive will help shape the
choices of the patient or the patient's surrogate decision
maker when discussing a POLST with a health care
professional.
(20) This subchapter is intended to provide a framework
and legal authority for POLST to be valid and portable across
all care settings, consistent with the foregoing findings.
§ 5493. Definitions.
The following words and phrases when used in this subchapter
shall have the meanings given to them in this section unless the
context clearly indicates otherwise:
" Committee." The POLST Advisory Committee established under
this subchapter.
"Department." The Department of Health of the Commonwealth.
"Health care facility." Any of the following:
(1) A facility that is licensed as a health care
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facility by the department under Chapter 8 of the act of July
19, 1979 (P.L.130, No.48), known as the Health Care
Facilities Act, including, but not limited to, a hospital,
long term care facility, home health care agency or hospice.
(2) A facility that is licensed or approved by the
Department of Human Services under Article IX or X of the act
of June 13, 1967 (P.L.31, No.21), known as the Human Services
Code, and provides health care services, including, but not
limited to, a psychiatric facility or intermediate care
facility for the developmentally or intellectually disabled.
(3) A facility that is licensed as a prescribed
pediatric extended care center by the department under the
act of November 24, 1999 (P.L.884, No.54), known as the
Prescribed Pediatric Extended Care Centers Act.
"Health care insurer." Any person, corporation or other
entity that offers administrative, indemnity or payment services
under a program of health care or disability benefits,
including, but not limited to, the following:
(1) An insurance company, association, exchange or
fraternal benefit society subject to the act of May 17, 1921
(P.L.682, No.284), known as The Insurance Company Law of
1921.
(2) A health maintenance organization subject to the act
of December 29, 1972 (P.L.1701, No.364), known as the Health
Maintenance Organization Act.
(3) A hospital plan corporation subject to 40 Pa.C.S.
Ch. 61 (relating to hospital plan corporations).
(4) A professional health service corporation subject to
40 Pa.C.S. Ch. 63 (relating to professional health services
plan corporations).
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(5) A self-insured employee welfare benefit plan.
(6) A third-party administrator of a self-insured
employee welfare benefit plan.
(7) A Federal, State or local government sponsored or
operated program.
"Health care practitioner." A physician, physician assistant
or certified registered nurse practitioner acting in accordance
with applicable law, including, but not limited to, their
respective licensing acts and regulations.
"Patient Life-Sustaining Wishes Committee." The committee
appointed to assist the department in determining the
advisability of using a standardized form containing orders by
qualified physicians that detail the scope of medical treatment
for patients' life-sustaining wishes under former section 5488
(relating to advisory committee).
"Pennsylvania orders for life-sustaining treatment" or
"POLST." One or more medical orders, issued for the care of an
individual, regarding cardiopulmonary resuscitation or other
medical interventions that are entered in accordance with
section 5498.2 (relating to requirements for valid POLST).
"PLSWC form." The form for a POLST previously approved by
the department on the
recommendation of the Patient Life-
Sustaining Wishes Committee.
"POLST form." The form for a POLST adopted under section
5498 (relating to POLST form).
"Secretary." The Secretary of Health of the Commonwealth.
"Surrogate decision maker." A health care agent, health care
representative, guardian of the person or parent of a minor who
is legally authorized to make a health care decision for a
patient.
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§ 5494. Prohibitions on use.
Nothing in this subchapter shall be construed to advance or
support euthanasia, suicide or health care practitioner-assisted
suicide.
§ 5495. Voluntary consent requirement.
(a) Patient consent.--No POLST shall be valid without the
voluntary consent of the patient or a surrogate decision maker.
(b) Health insurance or coverage.--A health care insurer may
not:
(1) Require an individual to consent to a POLST or to
have a POLST as a condition for being insured.
(2) Charge an individual a different rate or fee whether
or not the individual consents to, or has, a POLST.
(3) Require a health care provider to have a policy to
offer a POLST to any individual.
(4) Provide a health care provider a financial
incentive, payment, discount or rating incentive for having a
policy or procedure relating to POLST completion.
(5) Impose a rating or reimbursement penalty if a health
care provider fails to achieve a target for POLST
completions.
(c) Consultation.--Notwithstanding subsection (b), a health
care provider may be paid for consultation with or counseling of
a patient concerning a POLST or offering advance health care
planning.
(d) Health care provider and health care facility
policies.--The following shall apply:
(1) A health care provider and a health care facility
may not make consent to a POLST or having a POLST a condition
of admission to, continued occupancy at, or the provision of
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health care services by the health care provider or a health
care facility.
(2) A health care provider and a health care facility
may not provide a patient or surrogate decision maker an in-
kind or financial incentive, payment or discount for
consenting to or having a POLST.
(3) In complying with paragraphs (1) and (2), a health
care provider and a health care facility may have a policy to
offer a POLST to appropriate individuals as part of a
conversation about goals of care, personal values and
preferences, benefits of various treatment options and
avoiding unwanted burden.
§ 5496. POLST Advisory Committee.
(a) Appointment.--The secretary shall appoint a POLST
Advisory Committee, including a chairperson and vice chairperson
of the committee.
(b) Role of committee.--The committee shall advise the
department on POLST-related matters, including, but not limited
to, the format and content of the POLST form and education about
POLST.
(c) Composition.--The following shall apply:
(1) After consulting Statewide organizations comprised
of relevant stakeholders, the secretary shall appoint one or
more representatives of the following to the committee:
(i) The Pennsylvania Medical Society.
(ii) The Hospital and Healthsystem Association of
Pennsylvania.
(iii) The Pennsylvania Homecare Association.
(iv) The Pennsylvania Bar Association.
(v) The Joint State Government Commission's Advisory
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Committee on Decedents' Estates Laws.
(vi) State and local emergency medical services
providers.
(vii) Long-term care facilities and providers of
long-term support.
(viii) Patient advocates.
(ix) Disability rights advocates.
(x) Faith-based health care providers.
(xi) Bioethicists, including both a secular and
faith-based representative.
(2) The secretary may appoint additional individuals to
the committee to provide expertise and a broad representation
of interests.
(3) The secretary shall ensure that members appointed to
the committee include individuals with knowledge about:
(i) community POLST coalition efforts; and
(ii) nationally-accepted physician orders for life-
sustaining treatment standards and educational resources,
such as the National POLST Paradigm Task Force.
§ 5497. Administration of POLST program.
(a) Duties.--The department shall perform the following
duties in consultation with the committee:
(1) Adopt and update a POLST form under section 5498
(relating to POLST form).
(2) Develop and update basic education materials on
POLST under section 5498.1 (relating to education about
POLST).
(3) Make the POLST form and its educational materials
available and accessible through the department's publicly
accessible Internet website.
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(b) Plain language requirement.--In consultation with the
committee, the department shall make the POLST form and its
educational materials clear, concise, well-organized and
otherwise understandable to patients, their families, other
surrogate decision makers and health care providers.
(c) Coordination.--In the performance of its
responsibilities under this subchapter, the department shall
coordinate with other State agencies that address the special
needs of individuals with disabilities and older persons,
including the Departments of Aging and Human Services.
§ 5498. POLST form.
(a) General rule.--In consultation with the committee, the
department shall adopt, and periodically update when
appropriate, a standard POLST form for health care practitioners
to issue a POLST with the voluntary consent of the patient or an
authorized surrogate decision maker.
(b) Medical order options.--The following shall apply:
(1) The POLST form shall include options for a set of
medical orders for cardiopulmonary resuscitation and other
medical interventions that are determined to be appropriate
for a POLST.
(2) The POLST form shall be outcome neutral. The medical
order options shall range from full treatment to comfort care
only, with options in between.
(3) The POLST form may include options for nutrition and
hydration administered by gastric tube or intravenously or by
other medically administered means. If the consent is
provided by a surrogate decision maker, the following
requirements shall apply:
(i) Section 5456(c)(5)(iii) (relating to authority
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of health care agent).
(ii) Section 5461(c) (relating to decisions by
health care representative).
(iii) Section 5462(c) (relating to duties of
attending physician and health care provider).
(4) Except as provided under section 5498.2(a)(2)
(relating to requirements for valid POLST), no medical order
option section shall be required to be completed for the
POLST to be valid.
(c) Notices.--The following shall apply:
(1) The POLST form shall clearly and conspicuously state
that a POLST may only be issued with the voluntary consent of
the patient or the patient's authorized surrogate decision
maker and that a patient or surrogate decision maker may not
be compelled by a health care provider or health care insurer
to complete or sign a POLST.
(2) The POLST form may include other notices regarding
patient rights, health care practitioner responsibilities and
availability of educational information which the department,
in consultation with the committee, determines are
appropriate.
(d) Identification and signatures.--The following shall
apply:
(1) The POLST form shall provide for identification of
the patient, any surrogate
decision maker who consents to the
POLST on behalf of the patient and the health care
practitioner who issues the POLST.
(2) The POLST form shall provide for the signatures of
the patient, any surrogate
decision maker and the health care
practitioner who issues the POLST.
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(e) Instructions.--The POLST form shall include instructions
for its completion. The instructions shall clearly convey:
(1) The sections required to be completed for the POLST
to be valid.
(2) The optional sections, including those regarding
health care other than cardiopulmonary resuscitation.
(f) Opportunity for comment.--The following shall apply:
(1) Prior to adopting the initial POLST form developed
after the effective date of this section, the department
shall submit for publication notice of the proposed form in
the Pennsylvania Bulletin and provide an opportunity for
comment on the proposed form for at least 60 days after
publication of the notice. The following shall apply:
(i) In addition to submitting for publication notice
of the initial form in the Pennsylvania Bulletin, the
department shall serve a copy of the form to the Health
and Human Services Committee of the Senate and the Health
Committee of the House of Representatives.
(ii) Within 60 days after the close of the comment
period, the department shall submit for publication a
subsequent notice in the Pennsylvania Bulletin that
responds to each comment the department has received. In
providing responses to each comment, the department shall
indicate the reasons for adopting or rejecting the
recommendations made during the comment period. The
department shall submit for publication a final version
of the POLST form in the Pennsylvania Bulletin and on the
department's publicly accessible Internet website.
(2) The department shall comply with the procedures
under paragraph (1) for updates to the POLST form.
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(3) The adoption of the initial POLST form and any
subsequent updates to the POLST form shall be exempt from the
following:
(i) Article II of the act of July 31, 1968
(P.L.7569, No.240) known as the Commonwealth Documents
Law.
(ii) Sections 204(b) and 301(10) of the act of
October 15, 1980 (P.L.950, No.164), known as the
Commonwealth Attorneys Act.
(iii) The act of June 25, 1982 (P.L.633, No .181),
known as the Regulatory Review Act.
(iv) Section 612 of the act of April 9, 1929 (P.L.
177, No. 175), known as The Administrative Code of 1929.
(g) POLST forms.--POLST forms executed prior to the
effective date of this section shall be recognized as valid
POLST forms and shall have full force and effect as if executed
on or after the effective date of this section.
(h) Printed copies.--The POLST form may not be required to
be obtained exclusively from the department or any particular
vendor. The department shall provide a process for the POLST
form to be downloaded free of charge from a publicly accessible
Internet website.
§ 5498.1. Education about POLST.
(a) General rule.--In consultation with the committee, the
department shall develop, and periodically update when
appropriate, educational materials about POLST for patients,
surrogate decision makers, health care providers and the public.
(b) Basic education.--The department shall make its basic
educational materials available in alternative formats that are
accessible to persons with a disability. The department's POLST
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educational materials shall include basic information that
explains and provides guidance on the following:
(1) The definition of a POLST, including the types of
medical interventions that may be covered.
(2) How a POLST is an immediately actionable medical
order and is valid and portable across all patient settings.
(3) When a POLST may be useful and appropriate and when
a POLST may not be appropriate.
(4) The differences between a POLST and an advance
health care directive.
(5) The voluntary consent requirement, including a
patient's right to refuse to execute a POLST without adverse
consequences under section 5495(b) and (d) (relating to
voluntary consent requirement).
(6) The importance of a shared decision-making process
to assure understanding and voluntary consent by patients and
surrogate decision makers.
(7) When review of a POLST is required or recommended.
(8) The obligation of health care providers to comply
with a POLST under this subchapter.
(9) Legal requirements for surrogate decision making.
(10) Appropriate inclusion of patients, to the extent
possible, regardless of their physical or mental condition,
in decision making when decisions are made on their behalf by
surrogate decision makers.
(c) Training recommendations.--The department's educational
materials shall include recommendations for training of health
care practitioners and others who educate patients about POLST
or assist in completion of a POLST form to assure that they have
the practiced skills of those conversations and understand the
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applicable law, medical issues and treatments covered by a
POLST. These materials shall incorporate information consistent
with the findings in section 5492(9) through (16) (relating to
legislative findings and intent).
(d) Other resources.--The department may provide information
about the availability of educational materials from other
sources, such as non-profit organizations that provide
education, training and
resources for POLST programs.
§ 5498.2. Requirements for valid POLST.
(a) General rule.--To be valid, a POLST shall require each
of the following:
(1) Use of the POLST form, except as provided under
section 5498.5 (relating to copies of orders), section
5498.15 (relating to POLST executed under prior POLST form),
section 5498.16 (related to POLST executed under PLSWC form)
and section 5498.17 (related to POLST executed in another
state or jurisdiction).
(2) Completion of the medical order section regarding
cardiopulmonary resuscitation.
(3) The date and signature of a health care practitioner
in accordance with
section 5498.6 (related to signature
options), except as provided under subsection (b).
(4) The date and signature of the patient or a surrogate
decision maker in accordance with section 5498.6,
except as
provided under subsection (c).
(b) Verbal orders.--A verbal order is effective from the
date given without countersignature until the expiration of the
period of countersignature set forth under paragraph (2) or (3).
A health care practitioner's verbal order for a POLST shall be
deemed to meet the requirements of subsection (a)(2) if all of
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the following requirements are met:
(1) The order is entered for a patient receiving care
from a health care facility.
(2) The order is documented on the POLST form and
countersigned by the health care practitioner in accordance
with any applicable laws and regulations governing the health
care facility, including but not limited to a timeframe in
which the order must be countersigned.
(3) No law or regulation governing the health care
facility establishes a time limit in which the order must be
countersigned, and the order is countersigned by the health
care practitioner within seven days.
(c) Verbal consent.--A surrogate decision maker's verbal
consent for a POLST shall be deemed to satisfy the requirements
of subsection (a)(4) if all of the following requirements are
met:
(1) Obtaining the signature of the surrogate decision
maker is not feasible in a timely manner.
(2) The consent is documented on the POLST form by the
health care facility in accordance with its policies and
procedures.
(3) The signature of the surrogate decision maker is
obtained as soon as feasible.
(d) Effectiveness.--A POLST shall be effective on the date
it meets the requirement of this section.
§ 5498.3. Portability.
(a) General rule.--A POLST executed in accordance with this
subchapter shall be valid anywhere within this Commonwealth,
including, but not limited to, all health care facilities, the
patient's residence and other care settings outside of a health
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care facility, and while the patient is in transit from one
health care facility or care setting to another.
(b) Authority of health care practitioners.--A POLST
executed in accordance with this subchapter shall be valid in a
health care facility regardless of whether the health care
practitioner who signed the order has clinical privileges with
the health care facility.
(c) Other orders.--This subchapter does not prohibit a do-
not-resuscitate or other order issued for care within a health
care facility from being valid and actionable within that health
care facility in accordance with the laws and regulations
governing the health care facility.
§ 5498.4. Team care.
A health care facility may designate individuals who have
been trained in a manner consistent with section 5498.1(c)
(relating to education about POLST), including, but not limited
to, nurses and social workers, to participate in conversations
with a patient or the patient's surrogate decision maker
regarding a POLST or assisting in completion of the POLST form.
§ 5498.5. Copies of orders.
A copy of a POLST, including a photocopy, a facsimile or
other electronic copy, shall be as effective as the original
POLST.
§ 5498.6. Signature options.
(a) Options.--A signature required by section 5498.2
(relating to requirements for valid POLST) may be provided by a
hand-written signature or any other means allowed under this
section.
(b) Patient unable to sign.--If a patient is unable to sign
by a written signature, it shall be sufficient for:
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(1) the patient to sign by a mark; or
(2) another individual to sign for the patient if that
patient specifically directs the other individual to sign the
POLST for the patient.
(c) Electronic signatures.--In the case of a patient
receiving care from a health care facility, a signature on a
POLST may be obtained by any electronic means that is authorized
by the policies and procedures of the facility and is consistent
with the laws governing the facility, including, but not limited
to, a digitized signature and a digital signature. A copy of the
POLST shall show a representative image of the signature in the
applicable signature field.
§ 5498.7. Standards for surrogate decision makers.
(a) General rule.--When making a decision about a POLST on
behalf of a patient, a surrogate decision maker shall comply
with all applicable legal requirements for health care decision
making by a surrogate decision maker, including, but not limited
to, those provided under subsection (b), and the decisions of
the surrogate decision maker are subject to all applicable legal
restrictions on decisions by a surrogate decision maker.
(b) Specific laws.--Surrogate decision makers must comply
with the following:
(1) Subchapter C (relating to health care agents and
representatives), including but not limited to:
(i) Section 5456(c) (relating to authority of health
care agent).
(ii) Section 5461(c) (relating to decisions by
health care representative).
(iii) Section 5462(c) (relating to duties of
attending physician and health care provider).
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(2) Chapter 55 (relating to incapacitated persons).
(c) Minors.--A surrogate decision maker for an unemancipated
minor shall be subject to the requirements and restrictions
applicable to a health care representative for an adult when
making a decision about a POLST on behalf of the minor.
(d) Competent patient.--This section does not limit the
right of a competent patient to consent to a POLST.
§ 5498.8. Revocation.
(a) Consent.--A patient or a surrogate decision maker acting
within his decision-making authority may revoke consent to all
or part of a POLST at any time and in any manner that
communicates an intent to revoke.
(b) Notice.--A health care professional or surrogate
decision maker who is informed of a revocation shall promptly
communicate the fact of the revocation to any attending health
care professional and to any health care facility from which the
patient is receiving care.
(c) Implementation.--A health care provider that is notified
of a POLST revocation shall record that the POLST is void in any
medical records containing the order that are maintained by the
health care provider.
§ 5498.9. Transfer requirements.
(a) Notice of POLST.--A health care facility that transfers
a patient with a POLST to another health care facility shall
provide the POLST to the receiving facility and any health care
providers who are responsible for the patient's care during
transport to the receiving facility. The notice of the order
shall be provided prior to the transfer, or, if prior notice is
not feasible, as soon as feasible thereafter.
(b) Compliance.--The requirements of section 5498.11
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(relating to compliance) shall apply in the event that the
receiving health care provider or health care provider involved
in the transfer is unable in good conscience to comply with the
POLST or the policies of the health care provider preclude
compliance.
§ 5498.10. Review requirements.
(a) Mandatory review.--In the event a patient with a POLST
is admitted or transferred to a health care facility, the
treating health care professional at the health care facility
shall review the POLST as soon as feasible with the patient or
the patient's authorized surrogate decision maker. The POLST
shall remain effective unless and until modified or voided as a
result of the review.
(b) Recommended review.--In consultation with the committee,
the department shall develop recommendations for other
situations in which it is appropriate or advisable for a POLST
to be reviewed, giving consideration to the following
circumstances:
(1) A substantial change in the patient's health status.
(2) A change in the patient's goals of care or treatment
preferences.
§ 5498.11. Compliance.
(a) Notification by attending physician or health care
provider.--If an attending physician or other health care
provider cannot in good conscience comply with a POLST or if the
policies of a health care provider preclude compliance with a
POLST, the attending physician or health care provider shall so
inform the patient, if the patient is competent, and any
surrogate decision maker who consented to the order on behalf of
the patient.
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(b) Transfer.--The attending physician or health care
provider under subsection (a) shall make every reasonable effort
to assist in the transfer of the patient to another physician or
health care provider who will comply with the POLST.
(c) Liability.--If transfer under subsection (b) is
impossible, the provision of care necessary to sustain life to a
patient may not subject an attending physician or a health care
provider to criminal or civil liability or administrative
sanction for failure to carry out the POLST.
(d) Policies.--The department shall require health care
facilities to have policies and procedures for implementation of
a POLST.
§ 5498.12. Emergency medical services.
(a) Medical command instructions.--Notwithstanding the
absence of a do-not-resuscitate order in a POLST, 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 POLST do-not-resuscitate order.--The following
shall apply:
(1) Emergency medical services providers shall comply
with a do-not-resuscitate order in a POLST if made aware of
the order. In order to be in compliance with the do-not-
resuscitate order in a POLST, an emergency medical service
provider must:
(i) withhold cardiopulmonary resuscitation from the
patient in the event of respiratory and cardiac arrest;
or
(ii) discontinue and cease cardiopulmonary
resuscitation, in the event the emergency medical
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services provider is presented with a do-not-resuscitate
order in a POLST after initiating cardiopulmonary
resuscitation.
(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.
(c) Uncertainty regarding validity or applicability of do-
not resuscitate order in POLST.--The following shall apply:
(1) Emergency medical services providers who in good
faith are uncertain about the validity or
applicability of a
do-not-resuscitate order in a POLST shall render care in
accordance with their level of
certification.
(2) Emergency medical services providers who act under
paragraph (1) may not be subject to
civil or criminal
liability or administrative sanction for failure to comply
with a do-not-resuscitate order in a POLST.
(d) Uncertainty regarding validity or applicability of
POLST.--Emergency medical services providers are not required
to, but may if they deem it necessary, contact their medical
command physician prior to complying with a POLST.
§ 5498.13. Immunity.
(a) Compliance.--A health care provider or other person may
not be subject to civil or criminal liability or to discipline
for unprofessional conduct for complying with a POLST based upon
the good faith assumption that the orders therein were valid
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when made and have not been revoked or terminated.
(b) Noncompliance.--A health care provider or other person
may not be subject to civil or criminal liability or to
discipline for unprofessional conduct for refusing to comply
with a POLST on the good faith belief that:
(1) The POLST is not valid.
(2) Compliance with the POLST would be unethical or, to
a reasonable degree of medical certainty, would result in
medical care having no medical basis in addressing any
medical need or condition of the patient, provided that the
health care provider complies in good faith with sections
5462(c) (relating to duties of attending physician and health
care provider) and 5498.11 (relating to compliance).
(c) Other protection.--This section does not limit the
immunity available to a health care provider or person under
sections 5431 (relating to liability) or 5498.12(c)(2) (relating
to emergency medical services).
§ 5498.14. Conflict with advance health care directive.
If a POLST conflicts with a provision of an advance health
care directive, the provision of the
instrument latest in date
of execution shall prevail to the extent of the conflict.
§ 5498.15. POLST executed under prior POLST form.
A POLST executed on a POLST form that was valid when executed
shall remain valid even if the department subsequently adopts a
revised form.
§ 5498.16. POLST executed under PLSWC form.
(a) Validity.--Except as provided under subsection (b), a
POLST executed on the PLSWC form prior to the adoption of a
POLST form under this subchapter is effective to the same extent
as it would be effective if executed on the POLST form.
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(b) Emergency medical services providers.--Emergency medical
services providers are not required to, but may if they deem it
necessary, contact their medical command physician prior to
complying with a POLST executed on the PLSWC form.
(c) Immunity.--For purposes of the immunity under sections
5431 (relating to liability) and 5498.13 (relating to immunity),
a POLST executed on the PLSWC form shall be deemed to be a POLST
executed under this subchapter.
§ 5498.17. POLST executed in another state or jurisdiction.
(a) Validity.--Except as provided under subsection (b), a
health care provider may comply with a POLST, or its substantial
equivalent executed under the laws of another state or
jurisdiction and in conformity with the laws of that state or
jurisdiction, if:
(1) the order meets the requirements of section
5498.2(a)(2) through (4) (relating to requirements for valid
POLST); and
(2) the health care provider consults, as soon as
feasible, with the patient if competent and any surrogate
decision maker regarding continued compliance with the order.
(b) Exception.--Subsection (a) shall not apply to orders
executed in another state or jurisdiction to the extent that the
order directs procedures or the withholding or withdrawal of
procedures under circumstances that are inconsistent with the
laws of this Commonwealth, including, but not limited to,
section 5498.7 (relating to standards for surrogate decision
makers).
(c) Immunity.--For purposes of the immunity under section
5431 (relating to liability) and section 5498.13 (related to
immunity), a POLST, or its substantial equivalent that was
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executed under the laws of another state or jurisdiction and is
valid under subsections (a) and (b), shall be deemed to be a
POLST executed under this subchapter.
§ 5498.18. POLST registry study.
(a) Study.--In consultation with the committee and the
Pennsylvania eHealth Partnership Authority, the department shall
study the feasibility and cost of creating an Internet-based
POLST registry that would allow health care providers caring for
a patient to obtain a current POLST for the patient.
(b) Report.--The department shall report the results of its
study to the Health and Human Services Committee of the Senate
and the Health Committee of the House of Representatives. The
department shall report the status of the study to the
committees at least every 180 days until the final results are
reported.
Section 7. This act shall take effect as follows:
(1) The following provisions shall take effect
immediately:
(i) This section.
(ii) The addition of 20 Pa.C.S. § 5496.
(2) The remainder of this act shall take effect in 90
days.
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