PRIOR PRINTER'S NOS. 75, 1797 PRINTER'S NO. 2028
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 RE-REPORTED FROM COMMITTEE ON APPROPRIATIONS, HOUSE OF
REPRESENTATIVES, AS AMENDED, JUNE 14, 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
4 care.; 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. FOR THE PURPOSES OF THIS <--
7 ACT, THE TERM SHALL INCLUDE THOSE INDIVIDUALS RECOGNIZED UNDER
8 42 PA.C.S. § 8331.2 (RELATING TO GOOD SAMARITAN CIVIL IMMUNITY
9 FOR USE OF AUTOMATED EXTERNAL DEFIBRILLATOR).
10 "Emergency medical services do-not-resuscitate bracelet" or
11 "EMS-DNR bracelet." A bracelet in the standard format set forth
12 in section 5413 (relating to emergency medical services),
13 supplied by the Department of Health and issued by the attending
14 physician, which may be worn, at the declarant's option, to
15 notify emergency medical service providers of the presence of a
16 do-not-resuscitate order.
17 "Emergency medical services do-not-resuscitate card" or "EMS-
18 DNR card." A wallet-sized card in the standard format set forth
19 in section 5413 (relating to emergency medical services),
20 supplied by the Department of Health and issued by the attending
21 physician, which may be displayed, at the declarant's option, to
22 notify emergency medical service providers of the presence of a
23 do-not-resuscitate order.
24 "Emergency medical services do-not-resuscitate order" or
25 "EMS-DNR order." An order in the standard format set forth in
26 section 5413 (relating to emergency medical services), supplied
27 by the Department of Health and issued by the attending
28 physician, directing emergency medical service providers to
29 withhold cardiopulmonary resuscitation (cardiac compression,
30 endotracheal and esophageal intubation, artificial ventilation, <--
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1 defibrillation and other related procedures) from the declarant
2 in the event of respiratory or cardiac arrest.
3 "Emergency medical services do-not-resuscitate patient" or
4 "EMS-DNR patient." A person who, PURSUANT TO SECTION 5413(B) <--
5 (RELATING TO EMERGENCY MEDICAL SERVICES), possesses and in any
6 manner displays or causes to be displayed for EMS providers an
7 apparently valid EMS-DNR order, bracelet or card.
8 "Health care provider." A person who is licensed or
9 certified by the laws of this Commonwealth to administer health
10 care in the ordinary course of business or practice of a
11 profession. The term includes personnel recognized under the act
12 of July 3, 1985 (P.L.164, No.45), known as the Emergency Medical
13 Services Act. FOR PURPOSES OF THIS ACT, THE TERM SHALL INCLUDE <--
14 THOSE INDIVIDUALS RECOGNIZED UNDER 42 PA.C.S. § 8331.2 (RELATING
15 TO GOOD SAMARITAN CIVIL IMMUNITY FOR USE OF AUTOMATED EXTERNAL
16 DEFIBRILLATOR).
17 "Incompetent." The lack of sufficient capacity for a person
18 to make or communicate decisions concerning himself.
19 "Invasive airway technique." Any advanced airway technique,
20 including endotracheal and esophageal intubation. <--
21 "Life-sustaining treatment." Any medical procedure or
22 intervention that, when administered to a qualified patient,
23 will serve only to prolong the process of dying or to maintain
24 the patient in a state of permanent unconsciousness. Life-
25 sustaining treatment shall include nutrition and hydration
26 administered by gastric tube or intravenously or any other
27 artificial or invasive means if the declaration of the qualified
28 patient so specifically provides.
29 "Medical command physician." A licensed physician who is
30 authorized to give medical command under the act of July 3, 1985
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1 (P.L.164, No.45), known as the Emergency Medical Services Act.
2 "Permanently unconscious." A medical condition that has been
3 diagnosed in accordance with currently accepted medical
4 standards and with reasonable medical certainty as total and
5 irreversible loss of consciousness and capacity for interaction
6 with the environment. The term includes, without limitation, a
7 persistent vegetative state or irreversible coma.
8 "Person." An individual, corporation, partnership,
9 association or Federal, State or local government or
10 governmental agency.
11 "Qualified patient." A person who has executed a declaration
12 and who has been determined to be in a terminal condition or to
13 be permanently unconscious or an EMS-DNR patient.
14 "Terminal condition." An incurable and irreversible medical
15 condition in an advanced state caused by injury, disease or
16 physical illness which will, in the opinion of the attending
17 physician, to a reasonable degree of medical certainty, result
18 in death regardless of the continued application of life-
19 sustaining treatment.
20 § 5407. Liability.
21 (a) General rule.--No physician, emergency medical service
22 provider or other health care provider who, consistent with this
23 chapter, causes or participates in the initiating, continuing,
24 withholding or withdrawal of life-sustaining treatment from an
25 EMS-DNR patient or a qualified patient who is incompetent shall,
26 as a result thereof, be subject to criminal or civil liability
27 or be found to have committed an act of unprofessional conduct
28 if the attending physician, health care provider or EMS provider
29 has followed the declarant's wishes as expressed earlier by the
30 declarant in the form of a declaration and/or EMS-DNR order
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1 executed pursuant to this chapter.
2 (b) Absence of declaration or EMS-DNR order, bracelet or
3 card.--The absence of a declaration or EMS-DNR order, bracelet
4 or card by a patient shall not give rise to any presumption as
5 to the intent of the patient to consent to or to refuse the
6 initiation, continuation or termination of life-sustaining
7 treatment.
8 § 5410. Effect on suicide and life insurance.
9 * * *
10 (b) Life insurance.--The making of or failure to make a
11 declaration or EMS-DNR order in accordance with this chapter
12 shall not affect in any manner the sale, procurement or issuance
13 of any policy of life insurance nor shall it be deemed to modify
14 the terms of an existing policy of life insurance. No policy of
15 life insurance shall be legally impaired or invalidated in any
16 manner by the withholding or withdrawal of life-sustaining
17 treatment from an insured patient, notwithstanding any term of
18 the policy to the contrary.
19 § 5411. Declaration optional.
20 No physician or other health care provider and no health care
21 service plan, health maintenance organization, insurer issuing
22 disability insurance, self-insured employee welfare benefit
23 plan, nonprofit hospital plan or Federal, State or local
24 government sponsored or operated program shall:
25 (1) require any person to execute a declaration or EMS-
26 DNR order as a condition for being insured for or receiving
27 health care services; or
28 (2) charge any person a different rate or fee whether or
29 not the person executes or has executed a declaration.
30 § 5413. Emergency medical services.
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1 [(a) Care given prior to declaration taking effect.--Nothing
2 in this chapter shall be construed to make the provisions of a
3 declaration apply to care given to a patient by emergency
4 medical services personnel prior to the declaration's becoming
5 operative under sections 5405 (relating to when declaration
6 becomes operative) and 5408 (relating to duty of physician to
7 confirm terminal condition).
8 (b) Care given after declaration takes effect.--The
9 provisions of a declaration shall apply to care given to a
10 patient by emergency medical services personnel after the
11 declaration becomes operative under sections 5405 and 5408 only
12 if:
13 (1) an original declaration, signed by the declarant or
14 other authorized person, is presented to the emergency
15 medical services personnel. The emergency medical services
16 personnel must immediately notify the medical command
17 physician of the presence of the declaration; or
18 (2) the medical command physician, based on prior
19 notification by the attending physician or other health care
20 provider that a valid and operative declaration exists,
21 directs the emergency medical service personnel according to
22 the provisions of the declaration.
23 (c) Uncertainty regarding validity of declaration.--
24 Emergency medical services personnel confronted with any
25 conflicting information regarding the patient's wishes for life-
26 sustaining treatment shall act according to the accepted
27 treatment protocols and standards appropriate to their level of
28 certification.]
29 (a) Medical command instructions.--Notwithstanding the
30 absence of an EMS-DNR order, bracelet or card pursuant to this
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1 section, EMS providers shall at all times comply with the
2 instructions of an authorized medical command physician to
3 withhold or discontinue resuscitation.
4 (b) EMS-DNR orders, bracelets and cards.--A declarant's
5 attending physician, upon the request of a declarant in a
6 terminal condition or his surrogate, if the surrogate is so
7 authorized, or upon making a determination pursuant to section
8 5405(2) (relating to when declaration becomes operative), shall,
9 if appropriate based on the declaration, issue to the declarant
10 an emergency medical services do-not-resuscitate order, and may
11 issue at the request of the declarant or his surrogate an EMS-
12 DNR bracelet and/or card supplied by the Department of Health.
13 The declarant may, at the declarant's option, wear the bracelet
14 and/or display the order or card to notify emergency medical
15 service providers of the declarant's do-not-resuscitate status.
16 (c) Revocation of EMS-DNR order.--The declarant may revoke
17 his EMS-DNR status at any time without regard to the declarant's
18 physical or mental condition and in any manner, including
19 verbally or by destroying or not displaying the order, bracelet
20 or card. Revocation of the declaration shall also serve to
21 revoke the EMS-DNR order, though emergency medical service
22 providers shall not be subject to civil or criminal liability or
23 administrative sanction for failure to verify the declaration
24 prior to complying with the EMS-DNR order.
25 (d) Effect of EMS-DNR order, bracelet or card.--Emergency
26 medical service providers are hereby authorized to and shall,
27 with instructions from an authorized medical command physician <--
28 where required, comply, subject to subsection (e), with an
29 approved Department of Health-issued EMS-DNR order if made aware
30 of such by examining an EMS-DNR bracelet, card or the order
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1 itself. Such providers shall have no duty to examine the
2 underlying declaration. "Compliance" for purposes of this
3 subsection shall mean the withholding of cardiopulmonary
4 resuscitation (cardiac compression, invasive airway techniques,
5 artificial ventilation, defibrillation and other related
6 procedures) from the declarant in the event of respiratory or
7 cardiac arrest. "Compliance" shall also mean the discontinuance
8 and cessation of such resuscitative measures in the event the
9 emergency medical service provider is presented with an EMS-DNR
10 order, card and/or bracelet after initiating such resuscitative
11 measures. Emergency medical service providers shall provide
12 other medical interventions necessary and appropriate to provide
13 comfort and alleviate pain, including intravenous fluids,
14 medications, oxygen and any other intervention appropriate to
15 the level of the certification of the provider, unless otherwise
16 directed by the declarant OR THE EMS PROVIDER'S AUTHORIZED <--
17 MEDICAL COMMAND PHYSICIAN.
18 (e) Unwillingness of emergency medical service provider to
19 comply.--Emergency medical services providers who cannot in good
20 conscience comply with an EMS-DNR order shall make a good faith
21 effort to proceed under section 5409 (relating to unwillingness
22 to comply; transfer of declarant) and, so long as such good
23 faith effort is made, shall not be subject to civil or criminal
24 liability or administrative sanction for failure to comply with
25 an EMS-DNR order. Emergency medical service providers unable to
26 comply with an EMS-DNR order under this subsection shall not be
27 subject to discipline, termination, demotion or other
28 retribution by their employer or the EMS organization with which
29 they are affiliated solely for their actions under this
30 subsection.
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1 (f) Uncertainty regarding validity or applicability of
2 order, bracelet or card.--Emergency medical service providers
3 who in good faith are uncertain about the validity or
4 applicability of an EMS-DNR order, bracelet or card shall render
5 care in accordance with their level of certification. Such
6 providers shall not be subject to civil or criminal liability or
7 administrative sanction for failure to comply with an EMS-DNR
8 order under this subsection.
9 (g) Format of EMS-DNR order.--The Department of Health
10 shall, with the advice of the Pennsylvania Emergency Health
11 Services Council and with the assistance of the regional
12 emergency medical services councils, make available within 180
13 days of the effective date of this subsection standard EMS-DNR
14 orders for issuance to declarants by attending physicians of
15 this Commonwealth. The form of the order shall contain, but not
16 be limited to, the following:
17 PENNSYLVANIA EMERGENCY MEDICAL SERVICES
18 DO-NOT-RESUSCITATE ORDER
19 Patient's full legal name:
20 I, the undersigned, state that I am the attending
21 physician of the patient named above. The above-named
22 patient has executed an advance directive for health care
23 and this EMS-DNR order and I have made the determination
24 that this patient is in a terminal condition and eligible
25 for an EMS-DNR order.
26 I direct any and all emergency medical service
27 personnel, commencing on the effective date of this
28 order, to withhold cardiopulmonary resuscitation (cardiac
29 compression, invasive airway techniques, artificial
30 ventilation, defibrillation and other related procedures)
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1 from the declarant in the event of the declarant's
2 respiratory or cardiac arrest. I further direct such
3 personnel to provide to the patient other medical
4 interventions, such as intravenous fluids, oxygen or
5 other therapies necessary to provide comfort care or to
6 alleviate pain, unless directed otherwise by the
7 declarant or the EMS provider's authorized medical
8 command physician.
9 Signature of attending physician:
10 Printed name of attending physician:
11 Dated:
12 Attending physician's emergency telephone number:
13 Signature of patient (if capable of making informed
14 decisions):
15 I, the undersigned, hereby direct that in the event
16 of my cardiac and/or respiratory arrest, efforts at
17 cardiopulmonary resuscitation not be initiated. I
18 understand that I may revoke these directions at any time
19 by giving verbal instructions to the emergency medical
20 service providers, by physical cancellation or
21 destruction of this form or my EMS-DNR bracelet or card,
22 or by simply not displaying this form or the EMS-DNR
23 bracelet or card for my EMS caregivers.
24 Signature of surrogate (if patient is incapable of
25 making informed decisions):
26 I, the undersigned, hereby certify that I am
27 authorized to execute this EMS-DNR order on the patient's
28 behalf by virtue of having been designated as the
29 patient's surrogate and/or by virtue of my relationship
30 to the patient (specify relationship: _________________).
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1 I hereby direct that in the event of the patient's
2 cardiac and/or respiratory arrest, efforts at
3 cardiopulmonary resuscitation not be initiated.
4 (h) Format of EMS-DNR bracelet.--The Department of Health
5 shall, with the advice of the Pennsylvania Emergency Health
6 Services Council and with the assistance of the regional
7 emergency medical services councils, make available within 180
8 days of the effective date of this subsection standard EMS-DNR
9 bracelets for issuance to declarants by attending physicians.
10 The bracelets shall be uniform in design and shall at a minimum
11 on the face clearly indicate EMS-DNR and the name of the patient
12 and attending physician, as well as the dated signature of the
13 attending physician.
14 (i) Format of EMS-DNR card.--The Department of Health shall,
15 with the advice of the Pennsylvania Emergency Health Services
16 Council and with the assistance of the regional emergency
17 medical services councils, make available within 180 days of the
18 effective date of this subsection standard EMS-DNR cards for
19 issuance to declarants by attending physicians. The cards shall
20 be wallet-sized and contain, but not be limited to, the
21 following:
22 PENNSYLVANIA EMERGENCY MEDICAL SERVICES
23 DO-NOT-RESUSCITATE CARD
24 Patient's full legal name:
25 Attending physician's name:
26 This patient has a valid emergency medical services
27 do-not-resuscitate order. EMS personnel are instructed
28 not to perform cardiopulmonary resuscitation (cardiac
29 compression, endotracheal intubation, artificial
30 ventilation, defibrillation and other related procedures)
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1 on this patient in the event of the patient's respiratory
2 or cardiac arrest. Do provide to the patient other
3 medical interventions, such as intravenous fluids, oxygen
4 or other therapies deemed necessary to provide comfort
5 care or to alleviate pain, unless directed otherwise by
6 the declarant or the EMS provider's authorized medical
7 command physician.
8 Attending physician's signature:
9 Date:
10 (j) Recognition of other states' EMS or out-of-hospital DNR
11 orders.--EMS or out-of-hospital DNR orders, bracelets or cards
12 valid in states other than this Commonwealth shall be recognized
13 in this Commonwealth to the extent that these orders, bracelets
14 or cards are consistent with the laws of this Commonwealth. EMS
15 providers shall act in accordance with the provisions of section
16 5413(e) (relating to emergency medical services) when
17 encountering a patient with an apparently valid EMS or out-of-
18 hospital DNR form, bracelet or card issued by another state. EMS
19 providers acting in good faith under this section shall be
20 entitled to the same immunities and protections that would
21 otherwise be applicable.
22 § 5415. Penalties.
23 Any person who willfully conceals, cancels, defaces,
24 obliterates or damages the declaration or EMS-DNR order,
25 bracelet or card of another without the consent of the declarant
26 commits a felony of the third degree. Any person who falsifies
27 or forges the declaration or EMS-DNR order, bracelet or card of
28 another, or willfully conceals or withholds personal knowledge
29 of a revocation as provided in section 5406 (relating to
30 revocation) or 5413(c) (relating to emergency medical services),
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1 with the intent to cause a withholding or withdrawal of life-
2 sustaining treatment contrary to the wishes of the declarant
3 and, because of such an act, directly causes life-sustaining
4 treatment to be withheld or withdrawn and death to be hastened
5 shall be subject to prosecution for criminal homicide as
6 provided in 18 Pa.C.S. Ch. 25 (relating to criminal homicide).
7 Any person who willfully, by undue influence, fraud or duress,
8 causes a person to execute a declaration or EMS-DNR order
9 pursuant to this chapter commits a felony of the third degree.
10 Section 2. The Department of Health shall, with the advice
11 of the Pennsylvania Emergency Health Services Council and with
12 the assistance of the regional emergency medical services
13 councils, develop and make available to health care providers
14 recognized under the act of July 3, 1985 (P.L.164, No.45), known
15 as the Emergency Medical Services Act, INCLUDING THOSE <--
16 INDIVIDUALS RECOGNIZED UNDER 42 PA.C.S. § 8331.2, within 180
17 days of the effective date of this act educational materials
18 relating to the implementation of the provisions of this act.
19 The department shall also cause the requirements of this act to
20 be included as part of the curricula for health care providers
21 recognized under the Emergency Medical Services Act.
22 Section 3. The sum of $50,000, or as much thereof as may be <--
23 necessary, is hereby appropriated to the Department of Health
24 for the fiscal year July 1, 1999, to June 30, 2000, to carry out
25 the provisions of this act.
26 Section 4 3. The Department of Health may contract with any <--
27 public or private entity to facilitate all or part of its
28 responsibilities under 20 Pa.C.S. Ch. 54.
29 SECTION 4. THE DEPARTMENT OF HEALTH, UPON THE CONCLUSION OF <--
30 AT LEAST ONE PUBLIC HEARING, SHALL PUBLISH INTERIM REGULATIONS
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1 IN THE PENNSYLVANIA BULLETIN WITHIN 120 DAYS OF THE EFFECTIVE
2 DATE OF THIS ACT. THE INTERIM REGULATIONS SHALL NOT BE SUBJECT
3 TO THE ACT OF JULY 31, 1968 (P.L.769, NO.240), REFERRED TO AS
4 THE COMMONWEALTH DOCUMENTS LAW, OR TO THE ACT OF JUNE 25, 1982
5 (P.L.633, NO.181), KNOWN AS THE REGULATORY REVIEW ACT. THE
6 INTERIM REGULATIONS SHALL BE EFFECTIVE UNTIL FINAL REGULATIONS
7 ARE PROMULGATED BY THE DEPARTMENT. FINAL REGULATIONS SHALL BE
8 PROMULGATED NO LATER THAN 18 MONTHS FOLLOWING THE EFFECTIVE DATE
9 OF THIS ACT.
10 Section 5. This act shall take effect in 60 days.
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