2012 -- S 2361 SUBSTITUTE B

=======

LC01287/SUB B/2

=======

STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2012

____________

A N A C T

RELATING TO HEALTH AND SAFETY

     Introduced By: Senators Perry, Miller, DeVall, Nesselbush, and Sosnowski

     Date Introduced: February 14, 2012

     Referred To: Senate Health & Human Services

It is enacted by the General Assembly as follows:

1-1

     SECTION 1. Section 23-4.11-2 of the General Laws in Chapter 23-4.11 entitled "Rights

1-2

of the Terminally Ill Act" is hereby amended to read as follows:

1-3

     23-4.11-2. Definitions. -- The following definitions govern the construction of this

1-4

chapter:

1-5

      (1) "Advance directive protocol" means a standardized, state-wide method developed for

1-6

emergency medical services personnel by the department of health and approved by the

1-7

ambulance service advisory board, of providing palliative care to, and withholding life-sustaining

1-8

procedures from, a qualified patient.

1-9

      (2) "Artificial feeding" means the provision of nutrition or hydration by parenteral,

1-10

nasogastric, gastric or any means other than through per oral voluntary sustenance.

1-11

      (3) "Attending physician" means the physician who has primary responsibility for the

1-12

treatment and care of the patient.

1-13

     (4) "Declaration" means a witnessed document executed in accordance with the

1-14

requirements of section sections 23-4.11-3 or 23-4.11-3.1.

1-15

     (5) "Director" means the director of health.

1-16

     (6) "Emergency medical services personnel" means paid or volunteer firefighters, law

1-17

enforcement officers, first responders, emergency medical technicians, or other emergency

1-18

services personnel acting within the ordinary course of their professions.

1-19

     (7) “Health care decision maker” means a person authorized by law or by the qualified

1-20

patient to make health care decisions for the qualified patient. The qualified patient may revoke at

2-1

any time and in any manner the appointment of a health care decision maker.

2-2

     (7)(8) "Health care provider" means a person who is licensed, certified, or otherwise

2-3

authorized by the law of this state to administer health care in the ordinary course of business or

2-4

practice of a profession.

2-5

     (8)(9) "Life sustaining procedure" means any medical procedure or intervention that,

2-6

when administered to a qualified patient, will serve only to prolong the dying process. "Life

2-7

sustaining procedure" shall not include any medical procedure or intervention considered

2-8

necessary by the attending physician to provide comfort and care or alleviate pain.

2-9

     (10) “Medical orders for life sustaining treatment” or “MOLST” means a voluntary

2-10

request that directs a health care provider regarding resuscitative and life-sustaining measures.

2-11

     (11) “Medical orders for life sustaining treatment form” or “MOLST Form” means a

2-12

document which directs health care providers regarding resuscitative and life-sustaining

2-13

measures.

2-14

     (12) “MOLST qualified health care provider” means the physician, registered nurse

2-15

practitioner, or physician assistant who is authorized by the patient to sign a MOLST form.

2-16

     (13) “Physician assistant” shall mean a person licensed as a physician assistant under

2-17

Rhode Island general laws, chapter 5-54.

2-18

     (9)(14) "Person" means an individual, corporation, business trust, estate, trust,

2-19

partnership, association, government, governmental subdivision or agency, or any other legal

2-20

entity.

2-21

     (10)(15) "Physician" means an individual licensed to practice medicine in this state under

2-22

subdivision 5-37-1(13).

2-23

     (11)(16) "Qualified patient" means a patient who has executed a declaration in

2-24

accordance with this chapter and who has been determined by the attending physician to be in a

2-25

terminal condition.

2-26

     (17) “Registered nurse practitioner” shall mean a person licensed as such under Rhode

2-27

Island general laws, chapter 5-34.

2-28

     (12)(18) "Reliable documentation" means a standardized, state-wide form of

2-29

identification such as a nontransferable necklace or bracelet of uniform design, adopted by the

2-30

director of health, with consultation from the local community emergency medical services

2-31

agencies and licensed hospice and home health agencies, that signifies and certifies that a valid

2-32

and current declaration is on file and that the individual is a qualified patient.

2-33

     (19) “Request regarding resuscitative and life sustaining measures” means a written

2-34

document, signed by: (i) A qualified patient with capacity, or a recognized health care decision

3-1

maker; and

3-2

     (ii) The MOLST qualified health care provider, which directs a health care provider

3-3

regarding resuscitative and life sustaining measures. Such a request regarding resuscitative and

3-4

life sustaining measures is a medical order.

3-5

     (13)(20) "Terminal condition" means an incurable or irreversible condition that, without

3-6

the administration of life sustaining procedures, will, in the opinion of the attending physician,

3-7

result in death.

3-8

     SECTION 2. Chapter 23-4.11 of the General Laws entitled “Rights of the Terminally Ill

3-9

Act” is hereby amended by adding thereto the following sections:

3-10

     23-4.11-3.1. Medical Orders for Life Sustaining Treatment. -- (a) The department of

3-11

health shall establish rules and regulations, consistent with the provisions of this section, for the

3-12

establishment of Medical Orders for Life Sustaining Treatment and the structure and content of

3-13

Medical Orders for Life Sustaining Treatment forms.

3-14

     (b)(1) A declaration by a qualified patient may be recorded as a medical order for life-

3-15

sustaining treatment provided that:

3-16

     (i) The medical orders for life-sustaining treatment and medical intervention and

3-17

procedures are explained by a MOLST qualified health care provider to the qualified patient or

3-18

health care decision maker. The MOLST qualified health care provider shall further inform the

3-19

patient of the difference between an advance health care directive and MOLST medical order;

3-20

     (ii) A MOLST qualified health care provider has conducted an evaluation of the qualified

3-21

patient; and

3-22

     (iii) A MOLST form documenting the declaration has been completed by a MOLST

3-23

qualified health care provider based on qualified patient preferences and medical appropriateness,

3-24

and has been signed by a MOLST qualified health care provider and the qualified patient or his or

3-25

her recognized health care decision maker.

3-26

     (2) A health care decision maker may execute the MOLST form if the qualified patient

3-27

lacks capacity, or if the qualified patient has designated that the health care decision maker’s

3-28

authority is valid.

3-29

     (3) A request regarding resuscitative measures may also be evidenced by the words “do

3-30

not resuscitate” or the letters “DNR,” in a qualified patient’s medical record and/or through a

3-31

mechanism established by the department of health consistent with the provisions of chapter 23-

3-32

4.11.

3-33

     (c)(1) A health care provider shall treat a qualified patient in accordance with the

3-34

qualified patient’s MOLST, subject to the provisions of this chapter.

4-1

     (2) A MOLST qualified health care provider may conduct an evaluation of the qualified

4-2

patient and if necessary, in consultation with the qualified patient or recognized health care

4-3

decision maker, issue a new MOLST consistent with the most current information available about

4-4

the qualified patient’s health status and care preferences.

4-5

     (3) The recognized health care decision maker of a qualified patient who is without

4-6

capacity shall consult with the MOLST qualified health care provider prior to making a request to

4-7

modify that a qualified patient’s MOLST.

4-8

     (d)(1) MOLST Form. A MOLST shall be documented on an easily identifiable form

4-9

approved by the director. The director shall promulgate rules and regulations for the

4-10

implementation of this section.

4-11

     (2) The MOLST form shall be signed by the qualified patient, or the qualified patient’s

4-12

recognized health care decision maker, and a MOLST qualified health care provider.

4-13

     (3) The MOLST form shall contain all other information as required by this section.

4-14

     (e)(1) A MOLST shall apply regardless of whether the qualified patient executes the

4-15

MOLST form within or outside a hospital or other health care setting.

4-16

     (2) The MOLST form is valid within or outside a hospital or other health care setting.

4-17

     (f)(1) Revocation. A qualified patient or his/her recognized health care decision maker

4-18

may, at any time, revoke in any manner that communicates an intent to revoke his/her declaration

4-19

by informing the MOLST qualified health care providers, other health care providers, or any

4-20

member of the medical or nursing staff of the revocation of the declaration concerning life-

4-21

sustaining or resuscitative measures.

4-22

     (2) Any member of the medical or nursing staff informed of a revocation shall

4-23

immediately notify a MOLST qualified health care provider of the revocation.

4-24

     (3) The MOLST qualified health care provider informed of a revocation of MOLST made

4-25

pursuant to this section shall immediately:

4-26

     (i) Record the revocation in the qualified patient's medical record;

4-27

     (ii) Cancel any orders implementing the decision to withhold or withdraw treatment; and

4-28

     (iii) Notify the health care providers and staff directly responsible for the qualified

4-29

patient's care of the revocation and any cancellations.

4-30

     (4) If a decision to withhold or withdraw life-sustaining treatment has been made by a

4-31

recognized health care decision maker pursuant to this section, and the MOLST qualified health

4-32

care provider determines at any time that the decision is no longer appropriate or authorized

4-33

because the qualified patient has regained decision-making capacity or because the qualified

4-34

patient’s condition has otherwise improved, the MOLST qualified health care provider shall

5-1

immediately:

5-2

     (i) Include such determination in the qualified patient's medical record;

5-3

     (ii) Cancel any orders or plans of care implementing the decision to withhold or withdraw

5-4

life-sustaining treatment;

5-5

     (iii) Notify the health care decision maker who made the decision to withhold or

5-6

withdraw treatment; and

5-7

     (iv) Notify the other health care providers, including the medical and nursing staff

5-8

directly responsible for the qualified patient’s care, of any cancelled MOLST orders or plans of

5-9

care.

5-10

     (g) If a qualified patient with a MOLST order is transferred from a hospital, a licensed

5-11

health facility, or the community, the MOLST order or plan shall remain effective until a MOLST

5-12

qualified health care provider first examines the transferred qualified patient, whereupon a

5-13

MOLST qualified health care provider shall issue appropriate orders to continue the prior order or

5-14

plan. Such orders may be issued without obtaining another consent to withhold or withdraw life-

5-15

sustaining treatment pursuant to this chapter.

5-16

     (h) The MOLST is a voluntary option for qualified patients. No patient is required to

5-17

elect a MOLST.

5-18

     SECTION 3. This act shall take effect upon passage.

=======

LC01287/SUB B/2

========

EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N A C T

RELATING TO HEALTH AND SAFETY

***

6-1

     This act would provide a statutory framework for administration of “medical orders for

6-2

life sustaining treatment” or “MOLST” with respect to terminally ill patients.

6-3

     This act would take effect upon passage.

=======

LC01287/SUB B/2

=======