Source: https://www.pacodeandbulletin.gov/Display/pacode?file=/secure/pacode/data/028/chapter1051/chap1051toc.html&d=reduce
Timestamp: 2020-07-07 09:49:33
Document Index: 721275140

Matched Legal Cases: ['§ 1027', '§ 5403', '§ 5403', '§ 8331', '§ 1001', '§ 5405', '§ 1051', '§ 1051', '§ 1051', '§ 1051', '§ 1051', '§ 1051', '§ 1051', '§ 1051', '§ 1051', '§ 1051', '§ 8331', '§ 8331', '§ 1051', '§ 1051', '§ 1051', '§ 1051', '§ 1051', '§ 1051', '§ 1051']

28 Pa. Code Chapter 1051. Out-Of-Hospital Do-Not-Recuscitate Orders
1051.11. Patient qualifications to request and revoke out-of-hospital DNR order.
1051.12. Surrogate’s authority to request and revoke out-of-hospital DNR order.
1051.101. Recognition of other states’ out-of-hospital DNR orders.
This chapter cited in 28 Pa. Code § 1027.3 (relating to licensure and general operating standards).
Advance directive—A directive for health care in a declaration issued under 20 Pa.C.S. Chapter 54 (relating to the Advance Directive for Health Care Act).
Attending physician—A physician who has primary responsibility for the medical care and treatment of a patient. A patient may have more than one attending physician.
CPR—Cardiopulmonary resuscitation—Cardiac compression, invasive airway techniques, artificial ventilation, defibrillation and other related procedures used to resuscitate a patient or to prolong the life of a patient.
Declarant—As defined in 20 Pa.C.S. § 5403 (relating to definitions).
Declaration—As defined in 20 Pa.C.S. § 5403.
EMS personnel—Emergency medical services personnel—Prehospital personnel and individuals given good Samaritan civil immunity protection when using an automated external defibrillator under 42 Pa.C.S. § 8331.2 (relating to good Samaritan civil immunity for use of automated external defibrillators).
EMS provider—Emergency medical services provider—EMS personnel, a medical command physician and, as defined in § 1001.2 (relating to definitions), an advance life support service medical director, medical command facility medical director, medical command facility, ambulance service and quick response service.
Health care provider—A person who is licensed, certified or otherwise authorized to administer health care in the ordinary course of a business or practice of a profession. The term includes EMS providers.
Invasive airway technique—Any advanced airway technique, including endotracheal intubation.
Life-sustaining treatment—
Medical command physician—A physician who is approved by a regional emergency medical services council to provide medical command.
Out-of-hospital DNR bracelet—A bracelet which signifies that an out-of-hospital DNR order has been issued.
Out-of-hospital DNR necklace—A necklace which signifies that an out-of-hospital DNR order has been issued.
Out-of-hospital DNR order—A written order, the form for which is supplied by the Department or its designee under this chapter, that is issued by an attending physician and directs EMS providers to withhold CPR from the patient in the event of cardiac or respiratory arrest.
Out-of-hospital DNR patient—A patient for whom an attending physician has issued an out-of-hospital DNR order.
Patient—One of the following:
(ii) A declarant whose declaration has become operative under 20 Pa.C.S. § 5405(2) (relating to when declaration becomes operative) and which provides that CPR may not be provided in the event of the declarant’s cardiac or respiratory arrest if the declarant becomes permanently unconscious, or designates a surrogate to make that decision under those circumstances.
Permanently unconscious—
Person—An individual, corporation, partnership, association or Federal, State or local government or governmental agency.
Prehospital personnel—The term includes any of the following prehospital practitioners:
Surrogate—An individual who has, or individuals who collectively have, legal authority to request an out-of-hospital DNR order for another individual or to revoke that order.
Terminal condition—An incurable and irreversible medical condition in an advanced state caused by injury, disease or physical illness which will, in the opinion of the attending physician, to a reasonable degree of medical certainty, result in death regardless of the continued application of life-sustaining treatment.
(a) Patient requesting an out-of-hospital DNR order. A patient may request and receive an out-of-hospital DNR order from the patient’s attending physician if the patient has a terminal condition and the patient is at least 18 years of age, has graduated from high school, has married or is emancipated.
(b) Patient revoking an out-of-hospital DNR order. An out-of-hospital DNR patient, regardless of age or physical or mental condition, may revoke an out-of-hospital DNR order issued for the out-of-hospital DNR patient whether the order was issued pursuant to the request of the patient or the patient’s surrogate.
§ 1051.12. Surrogate’s authority to request and revoke out-of-hospital DNR order.
(a) Surrogate requesting an out-of-hospital DNR order. The surrogate of a patient may request and receive from the patient’s attending physician an out-of-hospital DNR order for the patient, regardless of the patient’s age or other physical or mental condition.
(b) Surrogate revoking an out-of-hospital DNR order. A patient’s surrogate may revoke an out-of-hospital DNR order for the patient if the out-of-hospital DNR order was issued at the request of a surrogate.
(a) No authority to revoke out-of-hospital DNR order. A person who acted as a patient’s surrogate when requesting an out-of-hospital DNR order for the patient may not revoke the out-of-hospital DNR order if the person loses the legal authority to serve as the patient’s surrogate.
(b) Duty when person loses surrogate status. If capable of doing so, a person who loses the authority to act as a patient’s surrogate after the person obtained an out-of-hospital DNR order for the patient shall apprise a replacement surrogate, if any, of the patient’s out-of-hospital DNR items and of other pertinent information relating to those items. The former surrogate shall also provide to the replacement surrogate or to the patient if the patient is no longer represented by a surrogate, the name of the physician who issued the out-of-hospital DNR order and any information the person has to help the patient or new surrogate locate the physician. The former surrogate, if capable of doing so, shall also make a reasonable effort to apprise the physician who issued the out-of-hospital DNR order of the change in that person’s status, as well as the name of the person, if any, who replaced that person as the patient’s surrogate and any information the former surrogate has to help the physician locate the patient and the patient’s current surrogate.
(c) Duty when contacted by physician. If a patient’s former surrogate did not attempt to contact the patient’s attending physician as required by subsection (b), or made the attempt but was unsuccessful, and is contacted by the patient’s attending physician for the purpose of communicating information regarding the patient, the patient’s former surrogate shall apprise the physician that the person is no longer the patient’s surrogate and provide the physician any information the former surrogate has to help the physician locate the patient or the patient’s current surrogate.
(d) Duty of replacement surrogate. A person who replaces another person as the patient’s surrogate after an out-of-hospital DNR order has been issued for the patient, and who is made aware of the order and given information regarding the attending physician who issued the order, shall make a reasonable effort to contact the physician to apprise the physician of the change in surrogates unless the new surrogate is able to confirm that the former surrogate has already made the disclosure.
(a) Securing order forms. A physician or the physician’s agent may secure out-of-hospital DNR order forms from the Department unless the Department has contracted with a vendor to provide the order forms, in which case the physician shall secure the order forms by purchasing them from the contracted vendor.
(a) Authority to issue. A patient’s attending physician shall issue an out-of-hospital DNR order for the patient if the patient who is qualified to request the order under § 1051.11(a) (relating to patient qualifications to request and revoke out-of-hospital DNR order) or the patient’s surrogate requests the attending physician to issue an out-of-hospital DNR order for the patient and the attending physician determines that the patient has a terminal condition or is permanently unconscious.
(b) Review of order before signing. Before completing, signing and dating an out-of-hospital DNR order, a patient’s attending physician shall ensure that the patient is identified in the order, that all other provisions of the order have been completed, and that the patient or the patient’s surrogate, as applicable, has signed the order.
(c) Order form. A patient’s attending physician shall issue an out-of-hospital DNR order for the patient only on a form provided by the Department or its designee.
(2) An out-of-hospital DNR order directs an EMS provider to withhold providing CPR to the patient in the event of the patient’s cardiac or respiratory arrest.
(3) The attending physician may also issue an out-of-hospital DNR bracelet or necklace for the patient, and that the necklace and bracelet also direct an EMS provider to withhold providing CPR in the event of the patient’s cardiac or respiratory arrest.
(6) The patient may revoke the out-of-hospital DNR order; the patient may do so without the physician’s approval or knowledge; revocation may be accomplished by destroying or not displaying the order, bracelet or necklace, or by conveying the decision to revoke the out-of-hospital DNR order verbally or otherwise at the time the patient experiences respiratory or cardiac arrest; and neither the patient’s physical nor mental condition will be considered to void the patient’s decision to revoke the out-of-hospital DNR order if that decision is clearly communicated in some manner.
(7) The possibility exists that the EMS provider may administer CPR in the event of the patient’s cardiac or respiratory arrest if an EMS provider is uncertain regarding the validity or applicability of the out-of-hospital DNR order, bracelet or necklace.
(8) An EMS provider who complies with the patient’s out-of-hospital DNR order may provide other medical interventions to the patient to provide comfort or alleviate pain.
§ 1051.24. Disclosures to surrogate requesting out-of-hospital DNR order.
Before issuing an out-of-hospital DNR order for a patient that is requested by the patient’s surrogate, the attending physician shall disclose the following information to the surrogate:
(4) The patient or surrogate may revoke the out-of-hospital DNR order; the patient or surrogate may do so without the physician’s approval or knowledge; revocation may be accomplished by destroying or not displaying the order, bracelet or necklace, or by conveying the decision to revoke the out-of-hospital DNR order verbally or otherwise at the time the patient experiences cardiac or respiratory arrest; and neither the physical nor mental condition of the patient will be considered to void the decision of the patient or surrogate to revoke the out-of-hospital DNR order if that decision is clearly communicated in some manner. The physician shall also apprise the surrogate, if it seems appropriate under the circumstances, that the power of the surrogate to revoke the out-of-hospital DNR order for the patient will terminate if the surrogate loses the legal authority to make that decision.
(6) If the patient is female, there are additional procedures that an EMS provider will need to follow to implement an out-of-hospital DNR order if the patient is pregnant at the time of cardiac or respiratory arrest. If the patient is pregnant or the patient’s surrogate requests information regarding the additional procedures, the physician shall explain the requirements of § 1051.61 (relating to pregnant patients).
Before issuing an out-of-hospital DNR order for a patient that is requested by the patient’s surrogate, the attending physician shall disclose to the patient the information in § 1051.23 (relating to disclosures to patient requesting out-of-hospital DNR order) that the physician in good faith believes the patient needs to have to make a future decision to revoke or not revoke the order. In making this assessment, the physician shall consult with the patient’s surrogate and consider factors such as the reason the patient is not able to request an out-of-hospital DNR order, the patient’s ability to comprehend and retain the information, and the patient’s age and maturity. The attending physician shall refuse to issue the order if the physician and surrogate cannot agree to the information that is to be disclosed to the patient by the physician.
An attending physician who is not willing to issue an out-of-hospital DNR order for a reason other than described in § 1051.25 (relating to disclosures to patient when surrogate requests out-of-hospital DNR order) shall explain the reason to the patient or the patient’s surrogate, as appropriate. If the request is made by a patient’s surrogate, or by a patient who qualifies to make the request under § 1051.11 (relating to patient qualifications to request and revoke out-of-hospital DNR order), and the physician determines that the patient is qualified to receive an out-of-hospital DNR order, the physician shall also do the following:
(a) Bracelet and necklace. A patient’s attending physician may provide to the patient, or to the patient’s surrogate for the patient, an out-of-hospital DNR bracelet or necklace, or both, if the physician has issued or is issuing an out-of-hospital DNR order for the patient and the patient or the surrogate requests the item.
(b) Order also required. A patient’s attending physician may not provide an out-of-hospital DNR bracelet or necklace for the patient without also issuing, or having issued, an out-of-hospital DNR order for the patient.
(c) Department vendor. A patient’s attending physician may provide to or for the patient only an out-of-hospital DNR bracelet or necklace produced by a vendor with which the Department has contracted to produce the bracelet or necklace.
An attending physician who issues an out-of-hospital DNR order for a patient shall maintain a copy of that order in the patient’s medical record and shall document in that order whether the physician also provided an out-of-hospital DNR bracelet or necklace, or both. If the attending physician provides an out-of-hospital DNR bracelet or necklace after issuing the out-of-hospital DNR order, the physician shall document the patient’s medical record to reflect that the bracelet or necklace was also provided for the patient.
If a physician who issued an out-of-hospital DNR order for the patient subsequently determines that the diagnosis that the patient is in a terminal condition or is permanently unconscious was in error, the physician shall make every reasonable effort to promptly contact the patient or the patient’s surrogate to disclose the error. The physician shall also request the return of the order, and the bracelet and necklace if the physician provided those items.
This section cited in 28 Pa. Code § 1051.30 (relating to physician destruction of out-of-hospital DNR order, bracelet or necklace).
§ 1051.30. Physician destruction of out-of-hospital DNR order, bracelet or necklace.
(1) The physician shall shred or otherwise destroy beyond identification the original order and mark all copies of the order in the physician’s possession as having been revoked.
(b) Documentation of order when items not destroyed. A physician who requests the return of an out-of-hospital DNR order, bracelet or necklace under § 1051.29 may not mark copies of the order in the physician’s possession as having been revoked without having destroyed, or confirmed from a reliable person the destruction of the original out-of-hospital DNR order and any out-of-hospital DNR bracelet or necklace the physician provided for the patient.
(a) Display of order, bracelet or necklace. An EMS provider may not provide CPR to a patient who is experiencing cardiac or respiratory arrest if an out-of-hospital DNR order, bracelet or necklace is displayed with the patient or the patient’s surrogate presents the EMS provider with an out-of-hospital DNR order for the patient, and neither the patient nor the patient’s surrogate acts to revoke the order at that time. When an EMS provider observes an out-of-hospital DNR order without also observing an out-of-hospital DNR bracelet or necklace, the EMS provider shall implement the out-of-hospital DNR order only if it contains original signatures.
(b) Discovery after CPR initiated. If after initiating CPR an EMS provider becomes aware of an out-of-hospital DNR order that is effective under subsection (a), the EMS provider shall discontinue CPR.
(c) Prehospital practitioner uncertainty. If a prehospital practitioner is uncertain as to whether an out-of-hospital DNR order has been revoked for a patient who is experiencing cardiac or respiratory arrest, the prehospital practitioner shall provide CPR to the patient subject to the following:
(d) Discontinuation of CPR not initiated by prehospital practitioner. If CPR had been initiated for the patient before a prehospital practitioner arrived at the scene, and the prehospital practitioner determines that an out-of-hospital DNR order is effective under subsection (a), the prehospital practitioner may not discontinue the CPR without being directed to do so by a medical command physician.
(e) AED good Samaritan. If an individual who is given good Samaritan civil immunity protection when using an automated external defibrillator (AED) under 42 Pa.C.S. § 8331.2 (relating to good Samaritan civil immunity for use of automated external defibrillators) is uncertain as to whether an out-of-hospital DNR order has been revoked for a patient who is experiencing cardiac arrest, the individual may provide CPR to the patient as permitted by 42 Pa.C.S. § 8331.2, but shall discontinue CPR if directed by a medical command physician directly or as relayed by a prehospital practitioner.
(f) Providing comfort and alleviating pain. When a prehospital practitioner complies with an out-of-hospital DNR order, the prehospital practitioner, within the practitioner’s scope of practice, shall provide other medical interventions necessary and appropriate to provide comfort to the patient and alleviate the patient’s pain, unless otherwise directed by the patient or the prehospital practitioner’s medical command physician.
This section cited in 28 Pa. Code § 1051.52 (relating to procedure when both advance directive and out-of-hospital DNR order are present); and 28 Pa. Code § 1051.101 (relating to recognition of other states’ out-of-hospital DNR orders).
This section cited in 28 Pa. Code § 1051.101 (relating to recognition of other states’ out-of-hospital DNR orders).
Notwithstanding the existence of an order or direction to the contrary, life-sustaining treatment, CPR, nutrition and hydration shall be provided to a pregnant patient by a health care provider unless, to a reasonable degree of medical certainty as certified on the patient’s medical record by the patient’s attending physician and a second physician who is an obstetrician who has examined the patient, life-sustaining treatment, nutrition and hydration will have one of the following consequences:
This section cited in 28 Pa. Code § 1051.23 (relating to disclosures to patient requesting out-of-hospital DNR order); 28 Pa. Code § 1051.24 (relating to disclosures to surrogate requesting out-of-hospital DNR order); and 28 Pa. Code § 1051.101 (relating to recognition of other states’ out-of-hospital DNR orders).
(a) Compliance with out-of-hospital DNR order. If a medical command physician is in contact with a prehospital practitioner when the prehospital practitioner is attending to a patient in cardiac or respiratory arrest and the prehospital practitioner is made aware of an out-of-hospital DNR order for the patient by examining an out-of-hospital DNR order, bracelet or necklace, the medical command physician shall honor the out-of-hospital DNR order. If appropriate, the medical command physician shall direct the prehospital practitioner to provide other medical interventions within the practitioner’s scope of practice to provide comfort to the patient and alleviate the patient’s pain, unless the prehospital practitioner is otherwise directed by the patient.
(c) Pregnant patient. If a medical command physician is in contact with a prehospital practitioner when the prehospital practitioner is attending to a pregnant patient in cardiac or respiratory arrest, and the prehospital practitioner is made aware of an out-of-hospital DNR order for the pregnant patient by examining an out-of-hospital DNR order, bracelet or necklace for the patient, and apprises the medical command physician of the out-of-hospital DNR order, the medical command physician shall direct the prehospital practitioner to ignore the out-of-hospital DNR order unless the medical command physician has knowledge that the patient’s attending physician and a second physician who is an obstetrician had examined the patient, and both certified in the patient’s medical record that, to a reasonable degree of medical certainty, life-sustaining treatment, nutrition, hydration and CPR will have one of the following consequences:
§ 1051.101. Recognition of other states’ out-of-hospital DNR orders.