I 
111TH CONGRESS 
1ST SESSION H. R. 1898 
To amend title XVIII of the Social Security Act to provide for coverage 
under the Medicare Program for consultations regarding orders for life 
sustaining treatment and to provide grants for the development and 
expansion of programs for such orders. 
IN THE HOUSE OF REPRESENTATIVES 
APRIL 2, 2009 
Mr. BLUMENAUER (for himself, Mr. BOUSTANY, Mr. DAVIS of Kentucky, Mr. 
KIND, Mr. TIBERI, and Mr. YARMUTH) introduced the following bill; 
which was referred to the Committee on Energy and Commerce, and in 
addition to the Committee on Ways and Means, for a period to be subse-
quently determined by the Speaker, in each case for consideration of such 
provisions as fall within the jurisdiction of the committee concerned 
A BILL 
To amend title XVIII of the Social Security Act to provide 
for coverage under the Medicare Program for consulta-
tions regarding orders for life sustaining treatment and 
to provide grants for the development and expansion 
of programs for such orders. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Life Sustaining Treat-
ment Preferences Act of 2009’’. 
VerDate Nov 24 2008 
04:21 Apr 07, 2009
Jkt 079200
PO 00000
Frm 00001
Fmt 6652
Sfmt 6201
E:\BILLS\H1898.IH
H1898
rfrederick on PROD1PC67 with BILLS
SEC. 2. FINDINGS. 
Congress finds as follows: 
(1) Serious illness, death, and dying are often 
difficult subjects to talk about for individuals, their 
families, and health care professionals. 
(2) Poor communication about preferences for 
care at the end of life can cause distress for both pa-
tients and their families. 
(3) As individuals approach the last chapter of 
their life, more can and should be done to educate 
them about treatment choices and help individuals 
communicate to health providers what care they 
want or do not want to receive. 
(4) A decade of research has demonstrated that 
orders for life sustaining treatment effectively convey 
treatment preferences, guiding medical personnel in 
providing or withholding interventions. 
(5) Orders for life sustaining treatment differ 
from advance directives. Advance directives (includ-
ing living wills and durable powers of attorney for 
health care) must be completed while individuals 
have the capacity to complete them and generally 
apply to future, hypothetical medical circumstances 
when decisionmaking capacity is lost. Patients’ val-
ues, goals, and preferences, as expressed in advance 
directives, require a thoughtful interpretive process 
VerDate Nov 24 2008 
04:21 Apr 07, 2009
Jkt 079200
PO 00000
Frm 00002
Fmt 6652
Sfmt 6201
E:\BILLS\H1898.IH
H1898
rfrederick on PROD1PC67 with BILLS
to apply to specific medical circumstances in real 
time. Yet, patients and proxy decisionmakers are 
often uncertain how to apply and implement pa-
tients’ values and goals in unfamiliar health care 
settings when real treatment plans and complicated 
decisions need to be made. 
(6) Orders for life sustaining treatment com-
plement advances directives by providing a process 
to focus patients’ values, goals, and preferences on 
current medical circumstances and to translate them 
into visible and portable medical orders applicable 
across care settings, including home, long-term care, 
emergency medical services, and hospitals. Without 
such medical orders emergency medical personnel 
may be required to provide treatments that may not 
be consistent with the individual’s preferences. Com-
pletion of such an order is equally valuable to pa-
tients who have not executed advance directives. 
(7) The following States have implemented or 
are developing orders for life sustaining treatment 
programs at the local or statewide level: Alaska, 
California, Colorado, Florida, Georgia, Hawaii, 
Idaho, Iowa, Kansas, Louisiana, Maine, Massachu-
setts, Michigan, Minnesota, Missouri, Montana, Ne-
braska, Nevada, New Hampshire, New York, North 
VerDate Nov 24 2008 
04:21 Apr 07, 2009
Jkt 079200
PO 00000
Frm 00003
Fmt 6652
Sfmt 6201
E:\BILLS\H1898.IH
H1898
rfrederick on PROD1PC67 with BILLS
Carolina, North Dakota, Ohio, Oregon, Pennsyl-
vania, Tennessee, Texas, Utah, Washington, West 
Virginia, Wisconsin and Wyoming. 
(8) Programs for orders for life sustaining 
treatment provide valuable services to individuals, 
their families, and health care providers through 
educational materials, professional training on ad-
vance care planning, coordinating and collaborating 
with hospitals, skilled nursing facilities, hospice pro-
grams, home health agencies, and emergency med-
ical services to implement such orders across the 
continuum of care, and monitoring the success of 
the program. 
(9) Medicare pays for acute care services pro-
vided to beneficiaries, but generally does not pay for 
informed discussions between beneficiaries and 
health providers to allow beneficiaries the oppor-
tunity to determine if they desire such acute care in 
the last months and years of life. 
SEC. 3. MEDICARE COVERAGE OF CONSULTATION REGARD-
ING ORDERS FOR LIFE SUSTAINING TREAT-
MENT. 
(a) IN GENERAL.—Section 1861 of the Social Secu-
rity Act (42 U.S.C. 1395x), as amended by sections 
101(a), 144(a), and 152(b) of the Medicare Improvements 
VerDate Nov 24 2008 
04:21 Apr 07, 2009
Jkt 079200
PO 00000
Frm 00004
Fmt 6652
Sfmt 6201
E:\BILLS\H1898.IH
H1898
rfrederick on PROD1PC67 with BILLS
for Patients and Providers Act of 2008 (Public Law 110– 
275), is amended— 
(1) in subsection (s)(2)— 
(A) by striking ‘‘and’’ at the end of sub-
paragraph (DD); 
(B) by adding ‘‘and’’ at the end of sub-
paragraph (EE); and 
(C) by adding at the end the following new 
subparagraph: 
‘‘(FF) consultations regarding an order for 
life sustaining treatment (as defined in sub-
section (hhh)(1)) for qualified individuals (as 
defined in subsection (hhh)(3));’’; and 
(2) by adding at the end the following new sub-
section: 
‘‘Consultation Regarding an Order for Life Sustaining 
Treatment 
‘‘(hhh)(1) The term ‘consultation regarding an order 
for life sustaining treatment’ means, with respect to a 
qualified individual, consultations between the individual 
and the individual’s physician (as defined in subsection 
(r)(1)) (or other health care professional described in 
paragraph (2)(A)) and, to the extent applicable, registered 
nurses, nurse practitioners, physicians’ assistants, and so-
cial workers, regarding the establishment, implementation, 
VerDate Nov 24 2008 
04:21 Apr 07, 2009
Jkt 079200
PO 00000
Frm 00005
Fmt 6652
Sfmt 6201
E:\BILLS\H1898.IH
H1898
rfrederick on PROD1PC67 with BILLS
and changes in an order regarding life sustaining treat-
ment (as defined in paragraph (2)) for that individual. 
Such a consultation may include a consultation regard-
ing— 
‘‘(A) the reasons why the development of 
such an order is beneficial to the individual and 
the individual’s family and the reasons why 
such an order should be updated periodically as 
the health of the individual changes; 
‘‘(B) the information needed for an indi-
vidual or legal surrogate to make informed deci-
sions regarding the completion of such an 
order; and 
‘‘(C) the identification of resources that an 
individual may use to determine the require-
ments of the State in which such individual re-
sides so that the treatment wishes of that indi-
vidual will be carried out if the individual is un-
able to communicate those wishes, including re-
quirements regarding the designation of a sur-
rogate decisionmaker (also known as a health 
care proxy). 
The Secretary may limit consultations regarding an 
order regarding life sustaining treatment to con-
sultations furnished in States, localities, or other ge-
VerDate Nov 24 2008 
04:21 Apr 07, 2009
Jkt 079200
PO 00000
Frm 00006
Fmt 6652
Sfmt 6201
E:\BILLS\H1898.IH
H1898
rfrederick on PROD1PC67 with BILLS
ographic areas in which such orders have been wide-
ly adopted. 
‘‘(2) The terms ‘order regarding life sustaining treat-
ment’ means, with respect to an individual, an actionable 
medical order relating to the treatment of that individual 
that— 
‘‘(A) is signed and dated by a physician (as de-
fined in subsection (r)(1)) or another health care 
professional (as specified by the Secretary and who 
is acting within the scope of the professional’s au-
thority under State law in signing such an order) 
and is in a form that permits it to stay with the pa-
tient and be followed by health care professionals 
and providers across the continuum of care, includ-
ing home care, hospice, long-term care, community 
and assisted living residences, skilled nursing facili-
ties, inpatient rehabilitation facilities, hospitals, and 
emergency medical services; 
‘‘(B) effectively communicates the individual’s 
preferences regarding life sustaining treatment, in-
cluding an indication of the treatment and care de-
sired by the individual; 
‘‘(C) is uniquely identifiable and standardized 
within a given locality, region, or State (as identified 
by the Secretary); 
VerDate Nov 24 2008 
04:21 Apr 07, 2009
Jkt 079200
PO 00000
Frm 00007
Fmt 6652
Sfmt 6201
E:\BILLS\H1898.IH
H1898
rfrederick on PROD1PC67 with BILLS
‘‘(D) is portable across care settings; and 
‘‘(E) may incorporate any advance directive (as 
defined in section 1866(f)(3)) if executed by the in-
dividual. 
‘‘(3) The term ‘qualified individual’ means an indi-
vidual who a physician (as defined in subsection (r)(1)) 
(or other health care professional described in paragraph 
(2)(A)) determines has a chronic, progressive illness and, 
as a consequence of such illness, is as likely as not to die 
within 1 year. 
‘‘(4) The level of treatment indicated under para-
graph (2)(B) may range from an indication for full treat-
ment to an indication to limit some or all or specified 
interventions. Such indicated levels of treatment may in-
clude indications respecting, among other items— 
‘‘(A) the intensity of medical intervention if the 
patient is pulseless, apneic, or, has serious cardiac 
or pulmonary problems; 
‘‘(B) the individual’s desire regarding transfer 
to a hospital or remaining at the current care set-
ting; 
‘‘(C) the use of antibiotics; and 
‘‘(D) the use of artificially administered nutri-
tion and hydration.’’. 
(b) PAYMENT.— 
VerDate Nov 24 2008 
04:21 Apr 07, 2009
Jkt 079200
PO 00000
Frm 00008
Fmt 6652
Sfmt 6201
E:\BILLS\H1898.IH
H1898
rfrederick on PROD1PC67 with BILLS
(1) IN GENERAL.—Section 1848(j)(3) of such 
Act (42 U.S.C. 1395w–4(j)(3)), as amended by sec-
tions 144(a)(2) and 152(b)(1)(C) of the Medicare 
Improvements for Patients and Providers Act of 
2008 
(Public 
Law 
110–275), 
by 
inserting 
‘‘(2)(FF),’’ after ‘‘(2)(EE),’’. 
(2) CONSTRUCTION.—Nothing in this section 
shall be construed as preventing the payment for a 
consultation regarding an order regarding life sus-
taining treatment to be made to multiple health care 
providers if they are providing such consultation as 
a team, so long as the total amount of payment is 
not increased by reason of the payment to multiple 
providers. 
(c) EFFECTIVE DATE.—The amendments made by 
this section shall apply to consultations furnished on or 
after January 1, 2010. 
SEC. 4. GRANTS FOR PROGRAMS FOR ORDERS REGARDING 
LIFE SUSTAINING TREATMENT. 
(a) IN GENERAL.—The Secretary of Health and 
Human Services shall make grants to eligible entities for 
the purpose of— 
(1) establishing new programs for orders re-
garding life sustaining treatment in States or local-
ities; 
VerDate Nov 24 2008 
22:57 Apr 07, 2009
Jkt 079200
PO 00000
Frm 00009
Fmt 6652
Sfmt 6201
E:\BILLS\H1898.IH
H1898
rfrederick on PROD1PC67 with BILLS
(2) expanding or enhancing an existing pro-
gram for orders regarding life sustaining treatment 
in States or localities; or 
(3) providing a clearinghouse of information on 
programs for orders for life sustaining treatment 
and consultative services for the development or en-
hancement of such programs. 
(b) AUTHORIZED
ACTIVITIES.—Activities funded 
through a grant under this section for an area may in-
clude— 
(1) developing such a program for the area that 
includes home care, hospice, long-term care, commu-
nity and assisted living residences, skilled nursing 
facilities, inpatient rehabilitation facilities, hospitals, 
and emergency medical services within the area; 
(2) securing consultative services and advice 
from institutions with experience in developing and 
managing such programs; and 
(3) expanding an existing program for orders 
regarding life sustaining treatment to serve more pa-
tients or enhance the quality of services, including 
educational services for patients and patients’ fami-
lies or training of health care professionals. 
(c) DISTRIBUTION OF FUNDS.—In funding grants 
under this section, the Secretary shall ensure that, of the 
VerDate Nov 24 2008 
04:21 Apr 07, 2009
Jkt 079200
PO 00000
Frm 00010
Fmt 6652
Sfmt 6201
E:\BILLS\H1898.IH
H1898
rfrederick on PROD1PC67 with BILLS
funds appropriated to carry out this section for each fiscal 
year— 
(1) at least two-thirds are used for establishing 
or developing new programs for orders regarding life 
sustaining treatment; and 
(2) one-third is used for expanding or enhanc-
ing existing programs for orders regarding life sus-
taining treatment. 
(d) DEFINITIONS.—In this section: 
(1) The term ‘‘eligible entity’’ includes— 
(A) an academic medical center, a medical 
school, a State health department, a State med-
ical association, a multi-State taskforce, a hos-
pital, or a health system capable of admin-
istering a program for orders regarding life sus-
taining treatment for a State or locality; or 
(B) any other health care agency or entity 
as the Secretary determines appropriate. 
(2) The term ‘‘order regarding life sustaining 
treatment’’ has the meaning given such term in sec-
tion 1861(hhh)(2) of the Social Security Act, as 
added by section 3. 
(3) The term ‘‘program for orders regarding 
life sustaining treatment’’ means, with respect to an 
VerDate Nov 24 2008 
04:21 Apr 07, 2009
Jkt 079200
PO 00000
Frm 00011
Fmt 6652
Sfmt 6201
E:\BILLS\H1898.IH
H1898
rfrederick on PROD1PC67 with BILLS