Chapter 7-8 Out-of-Hospital Do-Not-Resuscitate Order

• Jurisdiction: United States

7-8 Out-of-Hospital Do-Not-Resuscitate Order

The 1995 Texas Legislature authorized a physician, in accordance with his or her patient's wishes or the wishes of the patient's legally authorized representative, to issue an order directing health care professionals acting in out-of-hospital settings to refrain from initiating or continuing certain life-sustaining procedures. These provisions were re-codified in 1999 as part of the Advance Directives Act. This order is designated as an OOH-DNR order. OOH-DNR orders are effective when a patient, in a terminal condition, is in a setting such as a long-term care facility, hospice, or even a private home and health care professionals are called for assistance.⁹⁹ The order also applies to situations where the person is in transport in an ambulance or other vehicle.¹⁰⁰

7-8.1 Life-Sustaining Procedures Covered by the Out-of-

Hospital DNR Order

The OOH-DNR order is effective only with respect to certain specified life-sustaining procedures including:

1. cardiopulmonary resuscitation;
2. advanced airway management;
3. artificial ventilation;
4. defibrillation;
5. transcutaneous cardiac pacing; and
6. other life-sustaining treatment specified by the Texas Board of Heath.¹⁰¹

An OOH-DNR order may not authorize the withholding of any treatment designed to provide comfort, care, or pain relief, or the withholding of water and/or nutrition.¹⁰²

7-8:2 Requirements for the Out-of-Hospital DNR Order

The requirements for an OOH-DNR are provided for in Health and Safety Code § 166.082.

7-8:3 Rules Governing Execution

A competent person any at any time execute an OOH-DNR order.¹⁰³ The declarant must sign the OOH-DNR order in the presence of two witnesses, both of whom qualify under Health and Safety Code § 166.003 and at least one of whom must be a witness who qualifies under Health and Safety Code § 166.003(2). The witnesses must sign the order. The declarant's attending physician must sign the order, and must make the fact of the order's existence and the reasons for its execution a part of the declarant's medical record.¹⁰⁴ In lieu of signing in front of witnesses, the declarant may sign the OOH-DNR order and have the signature acknowledged before a notary public.¹⁰⁵

7-8:4 Out-of-Hospital DNR Order for Incompetent Person With Previously Executed Directive to Physicians

If the person is incompetent but had previously executed or issued a directive to physicians, the physician may rely on the directive as the person's instructions to issue an OOH-DNR order and shall place a copy of the directive in the person's medical record. The physician shall sign the order in the declarant's stead, and may use a digital or electronic signature authorized under Health and Safety Code § 166.011 to do so.¹⁰⁶

7-8:5 Out-of-Hospital DNR Order for Incompetent Person With Previously Executed Directive to Physicians Designating a Proxy

If the person is incompetent but previously executed or issued a directive to physicians designating a proxy, the proxy may make any decisions required of the designating person as to an OOH-DNR order and shall sign the order in lieu of the person designated by Health and Safety Code § 166.082(b).¹⁰⁷

7-8:6 Out-of-Hospital DNR Order for Incompetent Person With Previously Executed Medical Power of Attorney Designating Agent

If the person is now incompetent but previously executed or issued a medical power of attorney designating an agent, the agent may make any decisions required of the designating person as to an OOH-DNR order and shall sign the order.¹⁰⁸

7-8:7 Effectiveness of Out-of-Hospital Order

An OOH-DNR order is effective on its execution.¹⁰⁹

7-8:8 Form of Out-of-Hospital DNR Order

A written OOH-DNR order must be in the standard form specified by the Texas Department of Health.¹¹⁰ We include a copy of the form in Appendix 17.

7-8:9 Issuance of Out-of-Hospital DNR Order by Non-Written Communication

If a patient is awake, aware, and competent, he or she can issue a non-written OOH-DNR order. The statement must be made in the presence of the patient's doctor and two qualified witnesses. The doctor and...