10 LC 38
0973
House
Bill 999
By:
Representatives Lindsey of the
54th,
Jacobs of the
80th,
Oliver of the
83rd,
Willard of the
49th,
and Crawford of the
16th
A
BILL TO BE ENTITLED
AN ACT
AN ACT
To
amend Title 31 of the Official Code of Georgia Annotated, relating to health, so
as to provide for legislative intent; to provide for definitions; to provide for
portable medical orders; to provide for requirements regarding who may
administer a portable medical order; to provide who is authorized to issue a
portable medical order; to provide for the cancellation of a portable medical
order; to provide for the revocation of a portable medical order; to provide
that the Department of Community Health design a standardized portable medical
order form; to provide for immunity from certain liability for certain persons
carrying out in good faith decisions regarding a portable medical order; to
provide for the effect of a portable medical order on life insurance policies;
to provide for the approval of the court with respect to certain portable
medical orders; to provide for related matters; to repeal conflicting laws; and
for other purposes.
BE
IT ENACTED BY THE GENERAL ASSEMBLY OF GEORGIA:
SECTION
1.
Title
31 of the Official Code of Georgia Annotated, relating to health, is amended by
revising in its entirety Chapter 39, relating to cardiopulmonary resuscitation,
as follows:
"CHAPTER
39
31-39-1.
The
General Assembly finds that although cardiopulmonary resuscitation
has
and other
life-sustaining procedures have proved
invaluable in the reversal of sudden, unexpected death, it is appropriate for an
attending physician, in certain circumstances, to issue an order not to attempt
cardiopulmonary resuscitation of a patient
or other
life-sustaining procedures where
appropriate consent or authorization has been obtained. The General Assembly
further finds that there is a need to establish and clarify the rights and
obligations of patients, their families or representatives, and health care
providers regarding cardiopulmonary resuscitation and the issuance of orders not
to resuscitate
and with
respect to the administration of life-sustaining
procedures. The General Assembly further
finds that, in the interest of protecting individual autonomy, cardiopulmonary
resuscitation
or the
administration of life-sustaining
procedures in some circumstances may cause
loss of patient dignity and unnecessary pain and suffering. In recognition of
the considerable uncertainty in the medical and legal professions as to the
legality of implementing orders not to resuscitate
or not to
perform life-sustaining procedures, in
recognition of the request of the Supreme Court of Georgia for legislative
guidance in this area, and in recognition of the dignity and privacy which
patients have a right to expect, the General Assembly declares that the laws of
the State of Georgia shall recognize the right of patients or other authorized
persons to instruct physicians and other health care personnel to refrain from
cardiopulmonary resuscitation
or from
performing life-sustaining
procedures.
31-39-2.
As
used in this chapter, the term:
(1)
'Adult' means any person who is 18 years of age or older, is the parent of a
child, or has married.
(2)
'Attending physician' means the physician selected by or assigned to a patient
to have primary responsibility for the treatment and care of the patient. Where
more than one physician share such responsibility, any such physician may act as
the attending physician pursuant to this chapter.
(3)
'Authorized person' means any one person from the following list in the order of
priority as listed below:
(A)
Any agent under a durable power of attorney for health care or health care agent
under an advance directive for health care appointed pursuant to Chapter 32 of
this title;
(B)
A spouse;
(C)
A guardian over the person appointed pursuant to the provisions of Code Section
29-4-1;
(D)
A son or daughter 18 years of age or older;
(E)
A parent; or
(F)
A brother or sister 18 years of age or older.
(4)
'Candidate for nonresuscitation' means a patient who, based on a determination
to a reasonable degree of medical certainty by an attending physician with the
concurrence of another physician:
(A)
Has a medical condition which can reasonably be expected to result in the
imminent death of the patient;
(B)
Is in a noncognitive state with no reasonable possibility of regaining cognitive
functions; or
(C)
Is a person for whom cardiopulmonary resuscitation would be medically futile in
that such resuscitation will likely be unsuccessful in restoring cardiac and
respiratory function or will only restore cardiac and respiratory function for a
brief period of time so that the patient will likely experience repeated need
for cardiopulmonary resuscitation over a short period of time or that such
resuscitation would be otherwise medically futile.
(5)
'Candidate for withholding life-sustaining procedures' means a patient who,
based on a determination to a reasonable degree of medical certainty by an
attending physician with the concurrence of another physician:
(A)
Has a medical condition which can reasonably be expected to result in the
imminent death of the patient;
(B)
Is a person for whom life-sustaining procedures would be medically futile in
that such life-sustaining procedures will likely be unsuccessful in changing the
patient's
terminal
medical condition and that such life-sustaining procedures would otherwise be
medically futile; or
(C)
Is in a state of permanent unconsciousness.
(5)(6)
'Cardiopulmonary resuscitation' means only those measures used to restore or
support cardiac or respiratory function in the event of a cardiac or respiratory
arrest.
(6)(7)
'Decision-making capacity' means the ability to understand and appreciate the
nature and consequences of an order not to resuscitate, including the benefits
and disadvantages of such an order, and to reach an informed decision regarding
the order.
(6.1)(8)
'Emergency medical technician' means a person certified as an emergency medical
technician, paramedic, or cardiac technician under Chapter 11 of this
title.
(7)(9)
'Health care facility' means an institution which is licensed as a hospital or
nursing home pursuant to Article 1 of Chapter 7 of this title or licensed as a
hospice pursuant to Article 9 of Chapter 7 of this title, or a home health
agency licensed pursuant to Article 7 of Chapter 7 of this title.
(10)
'Life-sustaining procedures' means medications, machines, or other medical
procedures or interventions which, when applied to a patient in a terminal
condition or in a state of permanent unconsciousness, could in reasonable
medical judgment keep the patient alive but cannot cure the patient and where,
in the judgment of the attending physician and a second physician, death will
occur without such procedures or interventions. The term 'life-sustaining
procedures' shall include, but not be limited to, the provision of nourishment
or hydration and the administration of medication to alleviate pain or the
performance of any medical procedure deemed necessary to alleviate
pain.
(8)(11)
'Minor' means any person who is not an adult.
(9)(12)
'Order not to resuscitate' means an order not to attempt cardiopulmonary
resuscitation in the event a patient suffers cardiac or respiratory arrest, or
both.
(10)(13)
'Parent' means a parent who has custody of a minor or is the parent of an adult
without decision-making capacity.
(11)(14)
'Patient' means a person who is receiving care and treatment from an attending
physician.
(15)
'Portable medical order' means an order given by an attending physician to
withhold life-sustaining procedures from a candidate for withholding
life-sustaining procedures.
(12)(16)
'Reasonably available' means that a person to be contacted can be contacted with
diligent efforts by an attending physician, another person acting on behalf of
the attending physician, or the health care facility within a reasonable period
of time as determined by the attending physician.
31-39-3.
(a)
Every patient shall be presumed to consent to the administration of
cardiopulmonary resuscitation in the event of cardiac or respiratory arrest
or to the
administration of life-sustaining procedures in the event of a terminal
illness, unless there is consent or
authorization for the issuance of an order not to resuscitate
or to withhold
life-sustaining procedures. Such
presumption of consent does not presume that every patient shall be administered
cardiopulmonary resuscitation
or
life-sustaining procedures, but rather
that every patient agrees to its administration unless it is medically
futile.
(b)
Every adult shall be presumed to have the capacity to make a decision regarding
cardiopulmonary resuscitation
or the
administration of life-sustaining
procedures unless determined otherwise in
writing in the patient's medical record pursuant to this Code section or
pursuant to a court order. When an order not to resuscitate is requested by an
adult with decision-making capacity, such order shall be presumed, unless
revoked pursuant to Code Section 31-39-6, to be the direction of such person
regarding resuscitation.
When a
portable medical order has been properly administered pursuant to Code Section
31-39-4, such order shall be presumed, unless revoked pursuant to Code Section
31-39-6, to be the direction of such person regarding such portable medical
order.
(c)
Nothing in this chapter shall require a health care facility, any other
facility, or a health care provider to expand its existing equipment and
facilities to provide cardiopulmonary resuscitation
or
life-sustaining procedures.
31-39-4.
(a)
It shall be lawful for the attending physician to issue an order not to
resuscitate pursuant to the requirements of this chapter. Any written order
issued by the attending physician using the term 'do not resuscitate,' 'DNR,'
'order not to resuscitate,' 'no code,' or substantially similar language in the
patient's chart shall constitute a legally sufficient order and shall authorize
a physician, health care professional, or emergency medical technician to
withhold or withdraw cardiopulmonary resuscitation. Such an order shall remain
effective, whether or not the patient is receiving treatment from or is a
resident of a health care facility, until the order is canceled as provided in
Code Section 31-39-5 or until consent for such order is revoked as provided in
Code Section 31-39-6, whichever occurs earlier. An attending physician who has
issued such an order and who transfers care of the patient to another physician
shall inform the receiving physician and the health care facility, if
applicable, of the order.
(b)
It shall be lawful for the attending physician to issue a portable medical order
to a candidate for withholding life-sustaining procedures pursuant to the
requirements of this chapter. Such order shall be documented on a form subject
to the requirements established by Code Section 31-39-6.1. A portable medical
order shall require both the signature of the attending physician and the
patient. If the patient does not have the capacity to sign the portable medical
order, then an authorized person shall sign the order. An attending physician
shall be required to review a portable medical order administered to a patient
at least once every year and to indicate that such order is still appropriate by
his or her signature. A portable medical order issued by the attending
physician clearly indicating that life-sustaining procedures should not be
administered to a patient shall constitute a legally sufficient order and shall
authorize a physician, health care professional, or emergency medical technician
to withhold life-sustaining procedures. A portable medical order administered
pursuant to this subsection shall be valid in any medical facility in which the
patient who is the subject of such portable medical order is being
treated.
(b)(c)
An adult person with decision-making capacity may consent orally or in writing
to an order not to resuscitate and its implementation at a present or future
date, regardless of that person's mental or physical condition on such future
date. If the attending physician determines at any time that an order not to
resuscitate or
a portable medical order issued at the
request of the patient is no longer appropriate because the patient's medical
condition has improved, the physician shall immediately notify the
patient.
(c)(d)
The appropriate authorized person may, after being informed of the provisions of
this Code section, consent orally or in writing to an order not to resuscitate
for an adult candidate for nonresuscitation
or a portable
medical order for an adult candidate for withholding life-sustaining
procedures; provided, however, that such
consent is based in good faith upon what such authorized person determines such
candidate for nonresuscitation
or for
withholding life-sustaining procedures
would have wanted had such candidate for
nonresuscitation
or for
withholding life-sustaining procedures
understood the circumstances under which such order is being considered. Where
such authorized person is an agent under a durable power of attorney for health
care or health care agent under an advance directive for health care appointed
pursuant to Chapter 32 of this title, the attending physician may issue an order
not to resuscitate a candidate for nonresuscitation
or a portable
medical order for a candidate for withholding life-sustaining procedures
pursuant to the requirements of this
chapter without the concurrence of another physician, notwithstanding the
provisions of paragraph (4) of Code Section 31-39-2.
(d)(e)
Any parent may consent orally or in writing to an order not to resuscitate
or to a
portable medical order for his or her
minor child when such child is a candidate for nonresuscitation
or a candidate
for withholding life-sustaining
procedures. If in the opinion of the
attending physician the minor is of sufficient maturity to understand the nature
and effect of an order not to resuscitate
or a portable
medical order, then no such order shall be
valid without the assent of such minor.
(e)(f)
If none of the persons specified in subsections
(b)(c),
(c)(d),
and
(d)(e)
of this Code section is reasonably available or competent to make a decision
regarding an order not to
resuscitate or
a portable medical order, an attending
physician may issue an order not to resuscitate for a patient, provided
that:
(1)
Such physician determines with the concurrence of a second physician, in writing
in the patient's medical record, that such patient is a candidate for
nonresuscitation
or a candidate
for withholding life-sustaining
procedures;
(2)
An ethics committee or similar panel, as designated by the health care facility,
concurs in the opinion of the attending physician and the concurring physician
that the patient is a candidate for nonresuscitation
or a candidate
for withholding life-sustaining
procedures; and
(3)
The patient is receiving inpatient or outpatient treatment from or is a resident
of a health care facility other than a hospice or a home health
agency.
31-39-5.
(a)
An attending physician for whose patient an order not to resuscitate
or a portable
medical order has been issued pursuant to
subsection
(c)(d),
(d)(e),
or
(e)(f)
of Code Section 31-39-4 shall examine that patient at such intervals as
determined periodically by the physician to determine whether the patient still
qualifies as a candidate for nonresuscitation
or as a
candidate for withholding life-sustaining
procedures, unless that order has been
canceled or consent thereto revoked as provided in this chapter. That physician
shall record such determination in the patient's medical chart. Failure to
comply with this subsection shall not invalidate that order.
(b)
If the order not to resuscitate
or the
portable medical order was entered
pursuant to subsection
(c)(d),
(d)(e),
or
(e)(f)
of Code Section 31-39-4 and the attending physician who issued the order or, if
that attending physician is unavailable, another attending physician, at any
time determines that the patient no longer qualifies as a candidate for
nonresuscitation
or as a
candidate for withholding life-sustaining
procedures, the attending physician or the
physician's designee shall immediately include such determination in the
patient's chart, cancel the order, and notify the patient, the person who
consented to the order, and all health care facility staff responsible for the
patient's care of the cancellation.
(c)
If an order not to resuscitate
or a portable
medical order was entered pursuant to
subsection
(c)(d),
(d)(e),
or
(e)(f)
of Code Section 31-39-4 and the patient at any time regains decision-making
capacity, the attending physician who issued the order or, if that attending
physician is unavailable, another attending physician, shall immediately
determine if the patient consents to the order not to resuscitate
or to the
portable medical order and, if the patient
does not so consent, the attending physician or the physician's designee shall
cancel the order by an appropriate entry on the record and notify all health
care facility staff responsible for the patient's care of the
cancellation.
31-39-6.
(a)
A patient may, at any time, revoke his or her consent to an order not to
resuscitate or
portable medical order by making either a
written or an oral declaration or by any other act evidencing a specific intent
to revoke such consent which is communicated to or in the presence of an
attending physician or a member of the nursing staff at the health care
facility, a health care professional, or an emergency medical
technician.
(b)
Any parent or authorized person may at any time revoke his or her consent to an
order not to resuscitate a patient
or to a
portable medical order by making either a
written or an oral declaration or by any other act evidencing a specific intent
to revoke such consent which is communicated to or in the presence of an
attending physician or a member of the nursing staff at the health care
facility, a health care professional, or an emergency medical
technician.
(c)
Any physician who is informed of or provided with a revocation of consent
pursuant to this Code section shall, either by himself or herself or by
designee, immediately include the revocation in the patient's chart, cancel the
order, and notify any health care facility staff responsible for the patient's
care of the revocation and cancellation. Any member of the nursing staff, a
health care professional, or emergency medical technician who is informed of or
provided with a revocation of consent pursuant to this Code section shall
immediately notify a physician of such revocation.
31-39-6.1.
(a)
In addition to those orders not to resuscitate authorized elsewhere in this
chapter, any physician, health care professional, or emergency medical
technician shall be authorized to effectuate an order not to resuscitate for a
person who is not a patient in a hospital, nursing home, or licensed hospice and
the order is evidenced in writing containing the patient's name, date of the
form, printed name of the attending physician, and signed by the attending
physician on a form substantially similar to the following:
'DO
NOT RESUSCITATE ORDER
NAME
OF PATIENT: __________________________________________________
THIS
CERTIFIES THAT AN ORDER NOT TO RESUSCITATE HAS BEEN ENTERED ON THE ABOVE-NAMED
PATIENT.
SIGNED:_______________________
ATTENDING PHYSICIAN
ATTENDING PHYSICIAN
PRINTED
OR TYPED NAME OF ATTENDING PHYSICIAN: _________________
ATTENDING
PHYSICIAN'S TELEPHONE NUMBER: _______________________
DATE:____________________'
(b)
A person who is not a patient in a hospital, nursing home, or licensed hospice
and who has an order not to resuscitate pursuant to this Code section shall wear
an identifying bracelet on either the wrist or the ankle or an identifying
necklace. The bracelet shall be substantially similar to identification
bracelets worn in hospitals. The bracelet or necklace shall be on an orange
background and shall provide the following information in boldface type:
'DO
NOT RESUSCITATE ORDER
Patient's
name: _________________________________________________________
Authorized
person's name and telephone number, if applicable:
__________________
Patient's
physician's printed name and telephone number:
___________________
Date
of order not to resuscitate:
___________________________________________'
Any
physician, health care professional, or emergency medical technician shall be
authorized to regard such a bracelet or necklace as a legally sufficient order
not to resuscitate in the same manner as an order issued pursuant to this
chapter unless such person has actual knowledge that such order has been
canceled or consent thereto revoked as provided in this chapter.
(c)
Any order not to resuscitate evidenced pursuant to subsection (a) or (b) of this
Code section may be revoked as provided in Code Section 31-39-6 and may be
canceled as provided in Code Section 31-39-5.
(d)
The Department of Community Health is authorized to develop a standardized
portable medical order form. Such form shall describe the appropriate course of
action for a patient who is a candidate for withholding life-sustaining
procedures. The form shall include, but not be limited to, the following
information:
(1)
Full scope of treatment, which may include such treatment as intubation,
advanced airway interventions, mechanical ventilation, and
cardioversion;
(2)
Limited additional interventions, which may include such treatment as
intravenous solutions and cardiac monitoring;
(3)
Comfort measures, which may include such treatments and medication intended to
relieve pain and suffering; and
(4)
Under what conditions transfer to a hospital would be necessary.
Nothing
in this chapter shall preclude the inclusion of a do not resuscitate order as
part of a form produced pursuant to this subsection. The Department of
Community Health may develop a registry of patients who have completed a
portable medical order form pursuant to this chapter. Patients shall submit
their information on a voluntary basis for such registry.
31-39-7.
(a)
No physician, health care professional, health care facility, emergency medical
technician, or person employed by, acting as the agent of, or under contract
with any of the foregoing shall be subject to criminal prosecution or civil
liability or be deemed to have engaged in unprofessional conduct for carrying
out in good faith a decision regarding cardiopulmonary resuscitation
or a decision
regarding the withholding of life-sustaining
procedures authorized by this chapter by
or on behalf of a patient or for those actions taken in compliance with the
standards and procedures set forth in this chapter.
(b)
No physician, health care professional, health care facility, emergency medical
technician, or person employed by, acting as the agent of, or under contract
with any of the foregoing shall be subject to criminal prosecution or civil
liability or be deemed to have engaged in unprofessional conduct for providing
cardiopulmonary resuscitation to a patient for whom an order not to resuscitate
has been issued
or for
administering life-sustaining procedures to a patient for whom a portable
medical order has been issued, provided
that such physician or person:
(1)
Reasonably and in good faith was unaware of the issuance of an order not to
resuscitate or
a portable medical order; or
(2)
Reasonably and in good faith believed that consent to the order not to
resuscitate or
portable medical order had been revoked or
canceled.
(c)
No persons shall be civilly liable for failing or refusing in good faith to
effectuate an order not to resuscitate
or a portable
medical order. No person shall be subject
to criminal prosecution or civil liability for consenting or declining to
consent in good faith, on behalf of a patient, to the issuance of an order not
to resuscitate
or a portable
medical order pursuant to this
chapter.
(d)
Any attending physician who fails or refuses to comply with an order not to
resuscitate or
a portable medical order entered pursuant
to this chapter shall endeavor to advise promptly the patient, if conscious, or
the next of kin or authorized person of the patient that such physician is
unwilling to effectuate the order. The attending physician shall thereafter at
the election of the next of kin or authorized person:
(1)
Make a good faith attempt to effect the transfer of the patient to another
physician who will effectuate the order not to resuscitate
or the
portable medical order; or
(2)
Permit the next of kin or authorized person to obtain another physician who will
effectuate the order not to resuscitate
or the
portable medical order.
(e)
Any emergency medical technician who fails or refuses to comply with an order
not to resuscitate
or a portable
medical order entered pursuant to this
chapter shall endeavor to advise promptly the patient, if conscious, or the next
of kin or authorized person of the patient, if reasonably available, that such
emergency medical technician is unwilling to effectuate the order.
31-39-8.
(a)
No policy of life insurance shall be legally impaired, modified, or invalidated
in any manner by the issuance of an order not to resuscitate
or a portable
medical order notwithstanding any term of
the policy to the contrary.
(b)
A person may not prohibit or require the issuance of an order not to resuscitate
or a portable
medical order for an individual as a
condition for such individual's being insured or receiving health care
services.
31-39-9.
(a)
Nothing in this chapter shall impair or supersede any legal right or legal
responsibility which any person may have to effect the withholding or withdrawal
of cardiopulmonary resuscitation
or
life-sustaining procedures in any lawful
manner or affect the validity of orders not to resuscitate
or a portable
medical order issued and implemented under
other circumstances. In such respect, the provisions of this chapter are
cumulative.
(b)
Nothing in this chapter shall be construed to preclude a court of competent
jurisdiction from approving the issuance of an order not to resuscitate
or a portable
medical order under circumstances other
than those under which such an order may be issued pursuant to this
chapter."
SECTION
2.
All
laws and parts of laws in conflict with this Act are repealed.