PRIOR PRINTER'S NO. 75 PRINTER'S NO. 1797
No. 96 Session of 1999
INTRODUCED BY FLEAGLE, BARRAR, BELARDI, BROWNE, CORNELL,
FAIRCHILD, GEIST, HARHAI, HENNESSEY, HERMAN, JOSEPHS,
LAUGHLIN, NICKOL, PESCI, ROSS, RUBLEY, SATHER, SAYLOR,
SCHULER, SCRIMENTI, B. SMITH, STEVENSON, E. Z. TAYLOR, TIGUE,
TRAVAGLIO, VANCE, WILLIAMS, WRIGHT, MUNDY, HERSHEY, TRELLO,
SEYFERT, CAPPABIANCA, BENNINGHOFF, S. MILLER, SOLOBAY,
STEELMAN, CORRIGAN AND L. I. COHEN, JANUARY 20, 1999
AS REPORTED FROM COMMITTEE ON JUDICIARY, HOUSE OF
REPRESENTATIVES, AS AMENDED, MAY 11, 1999
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, INCLUDING AN EMANCIPATED MINOR, who <--
1 makes a declaration in accordance with this chapter.
2 "Declaration." A written document voluntarily executed by
3 the declarant in accordance with this chapter.
4 "Emergency medical service provider." A health care provider
5 recognized under the act of July 3, 1985 (P.L.164, No.45), known
6 as the Emergency Medical Services Act.
7 "Emergency medical services do-not-resuscitate bracelet" or
8 "EMS-DNR bracelet." A bracelet in the standard format set forth
9 in section 5413 (relating to emergency medical services),
10 supplied by the Department of Health and issued by the attending
11 physician, which may be worn, at the declarant's option, to
12 notify emergency medical service providers of the presence of a
13 do-not-resuscitate order.
14 "Emergency medical services do-not-resuscitate card" or "EMS-
15 DNR card." A wallet-sized card in the standard format set forth
16 in section 5413 (relating to emergency medical services),
17 supplied by the Department of Health and issued by the attending
18 physician, which may be displayed, at the declarant's option, to
19 notify emergency medical service providers of the presence of a
20 do-not-resuscitate order.
21 "Emergency medical services do-not-resuscitate order" or
22 "EMS-DNR order." An order in the standard format set forth in
23 section 5413 (relating to emergency medical services), supplied
24 by the Department of Health and issued by the attending
25 physician, directing emergency medical service providers to
26 withhold cardiopulmonary resuscitation (cardiac compression,
27 endotracheal AND ESOPHAGEAL intubation, artificial ventilation, <--
28 defibrillation and other related procedures) from the declarant
29 in the event of respiratory or cardiac arrest.
30 "EMERGENCY MEDICAL SERVICES DO-NOT-RESUSCITATE PATIENT" OR <--
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1 "EMS-DNR PATIENT." A PERSON WHO POSSESSES AND IN ANY MANNER
2 DISPLAYS OR CAUSES TO BE DISPLAYED FOR EMS PROVIDERS AN
3 APPARENTLY VALID EMS-DNR ORDER, BRACELET OR CARD.
4 "Health care provider." A person who is licensed or
5 certified by the laws of this Commonwealth to administer health
6 care in the ordinary course of business or practice of a
7 profession. The term includes personnel recognized under the act
8 of July 3, 1985 (P.L.164, No.45), known as the Emergency Medical
9 Services Act.
10 "Incompetent." The lack of sufficient capacity for a person
11 to make or communicate decisions concerning himself.
12 "Invasive airway technique." Any advanced airway technique,
13 including endotracheal and esophageal intubation.
14 "Life-sustaining treatment." Any medical procedure or
15 intervention that, when administered to a qualified patient,
16 will serve only to prolong the process of dying or to maintain
17 the patient in a state of permanent unconsciousness. Life-
18 sustaining treatment shall include nutrition and hydration
19 administered by gastric tube or intravenously or any other
20 artificial or invasive means if the declaration of the qualified
21 patient so specifically provides.
22 ["Medical command physician." A licensed physician who is <--
23 authorized to give medical command under the act of July 3, 1985
24 (P.L.164, No.45), known as the Emergency Medical Services Act.] <--
25 "Permanently unconscious." A medical condition that has been
26 diagnosed in accordance with currently accepted medical
27 standards and with reasonable medical certainty as total and
28 irreversible loss of consciousness and capacity for interaction
29 with the environment. The term includes, without limitation, a
30 persistent vegetative state or irreversible coma.
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1 "Person." An individual, corporation, partnership,
2 association or Federal, State or local government or
3 governmental agency.
4 "Qualified patient." A person who has executed a declaration
5 and who has been determined to be in a terminal condition or to
6 be permanently unconscious OR AN EMS-DNR PATIENT. <--
7 "Terminal condition." An incurable and irreversible medical
8 condition in an advanced state caused by injury, disease or
9 physical illness which will, in the opinion of the attending
10 physician, to a reasonable degree of medical certainty, result
11 in death regardless of the continued application of life-
12 sustaining treatment.
13 § 5407. Liability.
14 (a) General rule.--No physician, emergency medical service
15 provider or other health care provider who, consistent with this
16 chapter, causes or participates in the initiating, continuing,
17 withholding or withdrawal of life-sustaining treatment from AN <--
18 EMS-DNR PATIENT OR a qualified patient who is incompetent shall,
19 as a result thereof, be subject to criminal or civil liability
20 or be found to have committed an act of unprofessional conduct
21 if the attending physician, HEALTH CARE PROVIDER OR EMS PROVIDER <--
22 has followed the declarant's wishes as expressed earlier by the
23 declarant in the form of a declaration and/or EMS-DNR order
24 executed pursuant to this chapter.
25 (b) Absence of declaration or EMS-DNR order, bracelet or
26 card.--The absence of a declaration or EMS-DNR order, bracelet
27 or card by a patient shall not give rise to any presumption as
28 to the intent of the patient to consent to or to refuse the
29 initiation, continuation or termination of life-sustaining
30 treatment.
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1 § 5410. Effect on suicide and life insurance.
2 * * *
3 (b) Life insurance.--The making of or failure to make a
4 declaration or EMS-DNR order in accordance with this chapter
5 shall not affect in any manner the sale, procurement or issuance
6 of any policy of life insurance nor shall it be deemed to modify
7 the terms of an existing policy of life insurance. No policy of
8 life insurance shall be legally impaired or invalidated in any
9 manner by the withholding or withdrawal of life-sustaining
10 treatment from an insured patient, notwithstanding any term of
11 the policy to the contrary.
12 § 5411. Declaration optional.
13 No physician or other health care provider and no health care
14 service plan, health maintenance organization, insurer issuing
15 disability insurance, self-insured employee welfare benefit
16 plan, nonprofit hospital plan or Federal, State or local
17 government sponsored or operated program shall:
18 (1) require any person to execute a declaration or EMS-
19 DNR order as a condition for being insured for or receiving
20 health care services; or
21 (2) charge any person a different rate or fee whether or
22 not the person executes or has executed a declaration.
23 § 5413. Emergency medical services.
24 [(a) Care given prior to declaration taking effect.--Nothing <--
25 in this chapter shall be construed to make the provisions of a
26 declaration apply to care given to a patient by emergency
27 medical services personnel prior to the declaration's becoming
28 operative under sections 5405 (relating to when declaration
29 becomes operative) and 5408 (relating to duty of physician to
30 confirm terminal condition).
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1 [(b) Care given after declaration takes effect.--The <--
2 provisions of a declaration shall apply to care given to a
3 patient by emergency medical services personnel after the
4 declaration becomes operative under sections 5405 and 5408 only
5 if:
6 (1) an original declaration, signed by the declarant or
7 other authorized person, is presented to the emergency
8 medical services personnel. The emergency medical services
9 personnel must immediately notify the medical command
10 physician of the presence of the declaration; or
11 (2) the medical command physician, based on prior
12 notification by the attending physician or other health care
13 provider that a valid and operative declaration exists,
14 directs the emergency medical service personnel according to
15 the provisions of the declaration.
16 (c) Uncertainty regarding validity of declaration.--
17 Emergency medical services personnel confronted with any
18 conflicting information regarding the patient's wishes for life-
19 sustaining treatment shall act according to the accepted
20 treatment protocols and standards appropriate to their level of
21 certification.]
22 (b) EMS-DNR orders, bracelets and cards.--The attending <--
23 physician who makes the determination pursuant to section
24 5405(2) (relating to when declaration becomes operative) shall,
25 if appropriate based on the declaration, issue to the declarant
26 (A) MEDICAL COMMAND INSTRUCTIONS.--NOTWITHSTANDING THE <--
27 ABSENCE OF AN EMS-DNR ORDER, BRACELET OR CARD PURSUANT TO THIS
28 SECTION, EMS PROVIDERS SHALL AT ALL TIMES COMPLY WITH THE
29 INSTRUCTIONS OF AN AUTHORIZED MEDICAL COMMAND PHYSICIAN TO
30 WITHHOLD OR DISCONTINUE RESUSCITATION.
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1 (B) EMS-DNR ORDERS, BRACELETS AND CARDS.--A DECLARANT'S
2 ATTENDING PHYSICIAN, UPON THE REQUEST OF A DECLARANT IN A
3 TERMINAL CONDITION OR HIS SURROGATE, IF THE SURROGATE IS SO
4 AUTHORIZED, OR UPON MAKING A DETERMINATION PURSUANT TO SECTION
5 5405(2) (RELATING TO WHEN DECLARATION BECOMES OPERATIVE), SHALL,
6 IF APPROPRIATE BASED ON THE DECLARATION, ISSUE TO THE DECLARANT
7 an emergency medical services do-not-resuscitate order, and may
8 issue at the request of the declarant or his surrogate an EMS-
9 DNR bracelet and/or card supplied by the Department of Health.
10 The declarant may, at the declarant's option, wear the bracelet
11 and/or display the order or card to notify emergency medical
12 service providers of the declarant's do-not-resuscitate status.
13 (c) Revocation of EMS-DNR order.--The declarant or the <--
14 declarant's surrogate may revoke the declarant's EMS-DNR status
15 (C) REVOCATION OF EMS-DNR ORDER.--THE DECLARANT MAY REVOKE <--
16 HIS EMS-DNR STATUS at any time without regard to the declarant's
17 physical or mental condition and in any manner, including
18 verbally or by destroying or not displaying the order, bracelet
19 or card. Revocation of the declaration shall also serve to
20 revoke the EMS-DNR order, though emergency medical service
21 providers shall not be subject to civil or criminal liability or
22 administrative sanction for failure to verify the declaration
23 prior to complying with the EMS-DNR order.
24 (d) Effect of EMS-DNR order, bracelet or card.--Emergency
25 medical service providers are hereby authorized to and shall, <--
26 WITH INSTRUCTIONS FROM AN AUTHORIZED MEDICAL COMMAND PHYSICIAN
27 WHERE REQUIRED, comply, subject to subsection (e), with an
28 approved Department of Health-issued EMS-DNR order if made aware
29 of such by examining an EMS-DNR bracelet, card or the order
30 itself. Such providers shall have no duty to examine the
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1 underlying declaration. "Compliance" for purposes of this
2 subsection shall mean the withholding of cardiopulmonary
3 resuscitation (cardiac compression, invasive airway techniques,
4 artificial ventilation, defibrillation and other related
5 procedures) from the declarant in the event of respiratory or
6 cardiac arrest. "Compliance" shall also mean the discontinuance
7 and cessation of such resuscitative measures in the event the
8 emergency medical service provider is presented with an EMS-DNR
9 order, card and/or bracelet after initiating such resuscitative
10 measures. Emergency medical service providers shall provide
11 other medical interventions necessary and appropriate to provide
12 comfort and alleviate pain, including intravenous fluids,
13 medications, oxygen and any other intervention appropriate to
14 the level of the certification of the provider, unless otherwise
15 directed by the declarant or the declarant's surrogate. <--
16 (e) Unwillingness of emergency medical service provider to
17 comply.--Emergency medical services providers who cannot in good
18 conscience comply with an EMS-DNR order shall make a good faith
19 effort to proceed under section 5409 (relating to unwillingness
20 to comply; transfer of declarant) and, so long as such good
21 faith effort is made, shall not be subject to civil or criminal
22 liability or administrative sanction for failure to comply with
23 an EMS-DNR order. Emergency medical service providers unable to
24 comply with an EMS-DNR order under this subsection shall not be
25 subject to discipline, termination, demotion or other
26 retribution by their employer or the EMS organization with which
27 they are affiliated solely for their actions under this
28 subsection.
29 (f) Uncertainty regarding validity of order, bracelet or <--
30 (F) UNCERTAINTY REGARDING VALIDITY OR APPLICABILITY OF <--
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1 ORDER, BRACELET OR card.--Emergency medical service providers
2 who in good faith are uncertain about the validity OR <--
3 APPLICABILITY of an EMS-DNR order, bracelet or card shall render
4 care in accordance with their level of certification. Such
5 providers shall not be subject to civil or criminal liability or
6 administrative sanction for failure to comply with an EMS-DNR
7 order under this subsection.
8 (g) Format of EMS-DNR order.--The Department of Health
9 shall, with the advice of the Pennsylvania Emergency Health
10 Services Council and with the assistance of the regional
11 emergency medical services councils, make available within 180
12 days of the effective date of this subsection standard EMS-DNR
13 orders for issuance to declarants by attending physicians of
14 this Commonwealth. The form of the order shall contain, but not
15 be limited to, the following:
16 PENNSYLVANIA EMERGENCY MEDICAL SERVICES
17 DO-NOT-RESUSCITATE ORDER
18 Patient's full legal name:
19 I, the undersigned, state that I am the attending
20 physician of the patient named above. The above-named
21 patient has executed an advance directive for health care
22 AND THIS EMS-DNR ORDER and I have made the determination <--
23 that this patient is incompetent and in a terminal <--
24 condition or in a state of permanent unconsciousness and
25 that their declaration is now operative. IN A TERMINAL <--
26 CONDITION AND ELIGIBLE FOR AN EMS-DNR ORDER.
27 I direct any and all emergency medical service
28 personnel, commencing on the effective date of this
29 order, to withhold cardiopulmonary resuscitation (cardiac
30 compression, invasive airway techniques, artificial
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1 ventilation, defibrillation and other related procedures)
2 from the declarant in the event of the declarant's
3 respiratory or cardiac arrest. I further direct such
4 personnel to provide to the patient other medical
5 interventions, such as intravenous fluids, oxygen or
6 other therapies necessary to provide comfort care or to
7 alleviate pain, unless directed otherwise by the
8 declarant or the declarant's lawful surrogate. OR THE EMS <--
9 PROVIDER'S AUTHORIZED MEDICAL COMMAND PHYSICIAN.
10 Signature of attending physician:
11 Printed name of attending physician:
12 Dated:
13 Attending physician's emergency telephone number:
14 Signature of patient (if capable of making informed
15 decisions):
16 I, the undersigned, hereby direct that in the event
17 of my cardiac and/or respiratory arrest, efforts at
18 cardiopulmonary resuscitation not be initiated. I
19 understand that I may revoke these directions at any time
20 by giving verbal instructions to the emergency medical
21 service providers, by physical cancellation or
22 destruction of this form or my EMS-DNR bracelet or card,
23 or by simply not displaying this form or the EMS-DNR
24 bracelet or card for my EMS caregivers.
25 Signature of surrogate (if patient is incapable of
26 making informed decisions):
27 I, the undersigned, hereby certify that I am
28 authorized to provide consent EXECUTE THIS EMS-DNR ORDER <--
29 on the patient's behalf by virtue of having been
30 designated as the patient's surrogate and/or by virtue of
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1 my relationship to the patient (specify relationship:
2 _________________). I hereby direct that in the event of
3 the patient's cardiac and/or respiratory arrest, efforts
4 at cardiopulmonary resuscitation not be initiated. I <--
5 understand that I may revoke these directions at any time
6 by giving verbal instructions to the emergency medical
7 service providers, by physical cancellation or
8 destruction of this form and/or the patient's EMS-DNR
9 bracelet or card, or by simply not displaying this form
10 or the EMS-DNR bracelet or card for the patient's EMS
11 caregivers. RESUSCITATION NOT BE INITIATED. <--
12 (h) Format of EMS-DNR bracelet.--The Department of Health
13 shall, with the advice of the Pennsylvania Emergency Health
14 Services Council and with the assistance of the regional
15 emergency medical services councils, make available within 180
16 days of the effective date of this subsection standard EMS-DNR
17 bracelets for issuance to declarants by attending physicians.
18 The bracelets shall be uniform in design and shall at a minimum
19 on the face clearly indicate EMS-DNR and the name of the patient
20 and attending physician, AS WELL AS THE DATED SIGNATURE OF THE <--
21 ATTENDING PHYSICIAN.
22 (i) Format of EMS-DNR card.--The Department of Health shall,
23 with the advice of the Pennsylvania Emergency Health Services
24 Council and with the assistance of the regional emergency
25 medical services councils, make available within 180 days of the
26 effective date of this subsection standard EMS-DNR cards for
27 issuance to declarants by attending physicians. The cards shall
28 be wallet-sized and contain, but not be limited to, the
29 following:
30 PENNSYLVANIA EMERGENCY MEDICAL SERVICES
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1 DO-NOT-RESUSCITATE CARD
2 Patient's full legal name:
3 Attending physician's name:
4 This patient has an operative advance directive and A <--
5 VALID emergency medical services do-not-resuscitate
6 order. EMS personnel are instructed not to perform
7 cardiopulmonary resuscitation (cardiac compression,
8 endotracheal intubation, artificial ventilation,
9 defibrillation and other related procedures) on this
10 patient in the event of the patient's respiratory or
11 cardiac arrest. Do provide to the patient other medical
12 interventions, such as intravenous fluids, oxygen or
13 other therapies deemed necessary to provide comfort care
14 or to alleviate pain, unless directed otherwise by the
15 declarant or the declarant's lawful surrogate. EMS <--
16 PROVIDER'S AUTHORIZED MEDICAL COMMAND PHYSICIAN.
17 ATTENDING PHYSICIAN'S SIGNATURE:
18 DATE:
19 (J) RECOGNITION OF OTHER STATES' EMS OR OUT-OF-HOSPITAL DNR
20 ORDERS.--EMS OR OUT-OF-HOSPITAL DNR ORDERS, BRACELETS OR CARDS
21 VALID IN STATES OTHER THAN THIS COMMONWEALTH SHALL BE RECOGNIZED
22 IN THIS COMMONWEALTH TO THE EXTENT THAT THESE ORDERS, BRACELETS
23 OR CARDS ARE CONSISTENT WITH THE LAWS OF THIS COMMONWEALTH. EMS
24 PROVIDERS SHALL ACT IN ACCORDANCE WITH THE PROVISIONS OF SECTION
25 5413(E) (RELATING TO EMERGENCY MEDICAL SERVICES) WHEN
26 ENCOUNTERING A PATIENT WITH AN APPARENTLY VALID EMS OR OUT-OF-
27 HOSPITAL DNR FORM, BRACELET OR CARD ISSUED BY ANOTHER STATE. EMS
28 PROVIDERS ACTING IN GOOD FAITH UNDER THIS SECTION SHALL BE
29 ENTITLED TO THE SAME IMMUNITIES AND PROTECTIONS THAT WOULD
30 OTHERWISE BE APPLICABLE.
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1 § 5415. Penalties.
2 Any person who willfully conceals, cancels, defaces,
3 obliterates or damages the declaration or EMS-DNR order,
4 bracelet or card of another without the consent of the declarant
5 commits a felony of the third degree. Any person who falsifies
6 or forges the declaration or EMS-DNR order, bracelet or card of
7 another, or willfully conceals or withholds personal knowledge
8 of a revocation as provided in section 5406 (relating to
9 revocation) or 5413(c) (relating to emergency medical services),
10 with the intent to cause a withholding or withdrawal of life-
11 sustaining treatment contrary to the wishes of the declarant
12 and, because of such an act, directly causes life-sustaining
13 treatment to be withheld or withdrawn and death to be hastened
14 shall be subject to prosecution for criminal homicide as
15 provided in 18 Pa.C.S. Ch. 25 (relating to criminal homicide).
16 Any person who willfully, by undue influence, fraud or duress,
17 causes a person to execute a declaration or EMS-DNR order
18 pursuant to this chapter commits a felony of the third degree.
19 Section 2. The Department of Health shall, with the advice
20 of the Pennsylvania Emergency Health Services Council and with
21 the assistance of the regional emergency medical services
22 councils, develop and make available to health care providers
23 recognized under the act of July 3, 1985 (P.L.164, No.45), known
24 as the Emergency Medical Services Act, within 180 days of the
25 effective date of this act educational materials relating to the
26 implementation of the provisions of this act. The department
27 shall also cause the requirements of this act to be included as
28 part of the curricula for health care providers recognized under
29 the Emergency Medical Services Act.
30 Section 3. The sum of $50,000, or as much thereof as may be
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1 necessary, is hereby appropriated to the Department of Health
2 for the fiscal year July 1, 1999, to June 30, 2000, to carry out
3 the provisions of this act.
4 SECTION 4. THE DEPARTMENT OF HEALTH MAY CONTRACT WITH ANY <--
5 PUBLIC OR PRIVATE ENTITY TO FACILITATE ALL OR PART OF ITS
6 RESPONSIBILITIES UNDER 20 PA.C.S. CH. 54.
7 Section 4 5. This act shall take effect in 60 days. <--
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