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S.B. 451, 452, & 836: ENROLLED ANALYSIS DO-NOT-RESUSCITATE ORDERS
Senate Bill 451 (as enrolled) PUBLIC ACT 192 of 1996
Senate Bill 452 (as enrolled) PUBLIC ACT 193 of 1996
Senate Bill 836 (as enrolled) PUBLIC ACT 194 of 1996
Sponsor: Senator Dale L. Shugars (S.B. 451 & 836) Sponsor: Senator John J.H. Schwarz, M.D. (S.B. 452) Senate Committee: Health Policy and Senior Citizens House Committee: Health Policy
Date Completed: 8-6-96
Advances in medical technology have made it possible, in some instances, to continue the life of a person whose heart, circulatory system, and breathing have ceased functioning. Through technology and life-saving techniques, such as cardiopulmonary resuscitation (CPR) and the use of electrical shock in automatic defibrillators, persons who appear to have died can sometimes be revived. While the efforts may be welcome in many instances, they may be considered inappropriate in certain situations.
It has been pointed out that while a person in the latter stages of a serious or terminal illness can request that he or she not be resuscitated if heart function or respiration stops, these requests are honored only if the person is in a hospital or other health facility. If a person is at home, current protocols pertaining to emergency medical personnel require that CPR be started and procedures initiated to re-start the heart when a victim has stopped breathing, blood pressure cannot be measured, and a heartbeat cannot be detected. In some cases, ambulances have been called to homes to help a person who is in the final stages of a terminal disease and who has collapsed. Even though that individual's family may be aware of the patient's wishes not to be revived under these circumstances, emergency medical personnel have no choice under current protocols but to attempt to revive the person. Furthermore, there apparently has been no legally recognized vehicle available in Michigan under which persons could make known their desire not to be resuscitated. Some people believe that the wishes of patients should be respected, and that a
means should be provided in law to allow these persons to inform caretakers and emergency personnel that in event of complete heart and respiratory failure, they do not want to be revived.
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Senate Bill 452 created the "Michigan Do-Not-
Resuscitate Procedure Act" to allow a person to execute a do-not-resuscitate order
under certain circumstances; forbid
certain persons from attempting to resuscitate a person; provide an exemption
from criminal or civil liability
for withholding medical
treatment; and place certain restrictions on insurers. Senate Bill 451 amended
the Public Health Code to prohibit a health facility
from requiring a do- not-resuscitate order as a condition for
admission, and to require the development of protocols for emergency service
personnel in complying
with the new Act. Senate Bill 836 amended
the Adult Foster Care Facility
Licensing Act to provide that a licensee,
who
provides foster care to a resident
who is enrolled
in a licensed hospice program
and whose assessment plan includes a do-not- resuscitate order, is considered to be protecting the health and safety of the resident if the licensee contacts the hospice program, under certain conditions.
Senate Bills 451 and 836 are tie-barred to Senate Bill 452. The bills took effect August 1, 1996. Following is a detailed description of each bill.
Under the bill, a do-not-resuscitate order is a document (executed pursuant to the bill) directing that, in the event that a patient (the declarant) suffers cessation of both spontaneous respiration and circulation, in a setting outside of a hospital, a nursing home, or a mental health facility owned or operated by the Department of Community Health, no resuscitation is to be initiated.
The bill allows a person 18 years old or older, of sound mind, to execute a do-not-resuscitate (D-N-
R) order on his or her own behalf. Further, a patient advocate (an individual designated to make medical treatment decisions for a patient under the provisions of the Revised Probate Code) of a person 18 years old or older, may execute a D-N- R order on behalf of the person. The order must be dated and executed voluntarily, and remain in effect until it is revoked by the declarant. The order must be signed by the declarant or another person acting pursuant to the directions of the declarant in his or her presence; the declarant's attending physician; and two witnesses who are 18 years old or older, at least one of whom is not the declarant's spouse, parent, child, grandchild, sibling, or presumptive heir. The names of the declarant, attending physician, and each witness must be printed or typed below the corresponding signatures. A witness may not sign an order unless the declarant appears to the witness to be of sound mind and under no duress, fraud, or undue influence. A declarant who executes an order will have to maintain possession of the order and have it accessible within his or her residence or other setting outside of a hospital, a nursing home, or a mental health facility owned or operated by the Department of Community Health. An order must include but is not limited to the language of, and must be in substantially the same form as, an order prescribed in the bill.
The bill also provides that an individual who is 18 years old or older, of sound mind, and an adherent of a church or religious denomination whose members depend upon spiritual means through prayer alone for healing, may execute a D-N-R order on his or her own behalf. A patient advocate of an individual who is 18 years old or older, and an adherent of a church or religious denomination whose members depend upon spiritual means through prayer alone for healing, may execute a D- N-R order on behalf of the person. An order executed under this provision must be on a form described in the bill. The order must be dated and executed voluntarily, and signed by all the persons except a physician whom the bill requires to sign other do-not-resuscitate orders.
The bill defines do-not-resuscitate identification bracelet as a wrist bracelet that is worn by a declarant while a D-N-R order is in effect. At any time after a D-N-R order is signed and witnessed the declarant, or an individual designated by the declarant, may apply a do-not-resuscitate identification bracelet to the declarant s wrist. The bracelet must possess features that make it clearly recognizable as a do-not resuscitate identification bracelet including, but not limited to, the following: the bracelet has to be imprinted with the words DO-NOT-RESUSCITATE , printed in a type size and style that are as easily read as practicable given the size of the bracelet; the bracelet also must be imprinted with the name and address of the declarant, and the name and telephone number of the declarant s attending physician, if any.
The bill prohibits a person from applying a do-not- resuscitate identification bracelet to another person, unless he or she knows that the other person is a declarant. A person who violates this provision is guilty of a misdemeanor punishable by imprisonment for up to two years, a fine up to
$1,000, or both.
An attending physician who signs a declarant's order immediately must make a copy of the order or obtain a duplicate from the declarant, and make the copy or duplicate a part of the declarant's medical record.
If a person interested in the welfare of the declarant has reason to believe that an order has been executed contrary to the wishes of the declarant, the person may petition the probate court to have the order and the conditions of its execution reviewed.
A declarant or a patient advocate who executes an order on behalf of a declarant may revoke the order at any time and in any manner by which he or she is able to communicate an intent to revoke the order. If the revocation is not in writing, a person who observes the revocation must describe the circumstances of the revocation in writing and sign the writing. Upon revocation, the declarant, patient advocate, or attending physician (or the attending physician s delegatee , who has actual notice of the revocation) must destroy the order and remove the do-not-resuscitate identification bracelet. A physician (or the physician s delegatee) who receives notice of a revocation immediately must make the revocation (including, if available, the written description of its circumstances) part of the declarant's medical record. A declarant's or patient advocate s revocation of an order is binding upon another
person at the time that the other person receives actual notice of the revocation. (Under the bill, a delegatee is an individual to whom a physician has delegated the authority to perform one or more selected acts, tasks, or functions as provided under the Public Health Code.)
One or more of the following health professionals who arrive at a declarant's location outside of a hospital, a nursing home, or a mental health facility owned or operated by the Department of Community Health must determine whether the declarant has a pulse or evidence of respiration (whether or not the professional views or is provided with a do-not-resuscitate order alleged to have been signed by the declarant or other person authorized to execute the order): a paramedic; an emergency medical technician; an emergency medical technician specialist; a physician; a nurse; a medical first responder; or a respiratory therapist. The health professional is prohibited from attempting to resuscitate the declarant if the professional determines that the declarant has no pulse or evidence of respiration, and determines that the declarant is wearing a do-not-resuscitate identification bracelet, or is provided with a D-N-R order.
A person or organization is not subject to civil or criminal liability for withholding resuscitative procedures from a declarant in accordance with the bill's provisions. In addition, a person or organization is not subject to civil or criminal liability for either of the following:
-- Attempting to resuscitate an individual who has executed a D-N-R order or on whose behalf an order has been executed, if the person or organization has no actual notice of the order.
-- Failing to resuscitate an individual who has revoked a D-N-R order or on whose behalf a D-N-R order has been revoked, if the person or organization does not receive actual notice of the revocation.
A person or organization may not require the execution of an order as a condition for insurance coverage, admittance to a health care facility, or receiving health care benefits or services, or for any other reason.
A life insurer may not do any of the following because of the execution or implementation of an order:
-- Refuse to provide or continue coverage to the declarant.
-- Charge the declarant a higher premium.
-- Offer the declarant different policy terms because he or she has executed an order.
-- Consider the terms of an existing policy of life insurance to have been breached or modified.
-- Invoke a suicide or intentional death exemption or exclusion in any policy covering the declarant.
The provisions of the bill are cumulative and do not impair or supersede a legal right that a person has to consent to or refuse medical treatment for himself or herself, or that a parent, guardian, or other individual has to consent to or refuse medical treatment on behalf of another. The bill does not create a presumption concerning the intention of a person executing an order to consent to or refuse medical treatment in circumstances other than the cessation of both spontaneous circulation and respiration. The bill does not create a presumption concerning the intention of an individual who has not executed an order to consent to or refuse any type of medical treatment.
The bill prohibits a health facility or agency from requiring the execution of a do-not-resuscitate order under the Michigan Do-Not-Resuscitate Procedure Act as a condition for admission or receipt of services.
Under the Public Health Code, a local medical control authority must establish written protocols for the practice of life support agencies and licensed emergency medical services personnel within its region. The protocols are developed and adopted in accordance with procedures established by the Department of Community Health. The Code lists the protocols that must be adopted. The bill adds to the list protocols for complying with the Michigan Do-Not-Resuscitate Procedure Act; and provides that a protocol established may not conflict with that Act.
Under the Adult Foster Care Facility Licensing Act, a licensee (an entity that had been issued a license to operate an adult foster care facility) must provide protection to a resident; that is, the continual responsibility of the licensee to take reasonable action to insure the health, safety, and well-being of a resident, including protection from physical harm... . The bill provides that a licensee providing foster care to a resident, who is enrolled in a licensed hospice program and whose assessment plan includes a do-not-resuscitate order, is considered to be providing protection to
the resident if, in the event the resident suffers cessation of both spontaneous respiration and circulation, the licensee contacts the hospice program.
The Act defines adult foster care facility to include a facility for adults who are aged, mentally ill, developmentally disabled, or physically handicapped who require supervision on an ongoing basis but who do not require continuous nursing care. The bill provides that a resident of an adult foster care facility who is enrolled in a licensed hospice program is not considered to require continuous nursing care, for purposes of the Act s requirement.
MCL 333.20192 & 333.20919 (S.B. 451)
333.1051-333.1067 (S.B. 452)
400.703 et al. (S.B. 836)
(Please note: The arguments contained in this analysis originate from sources outside the Senate Fiscal Agency. The Senate Fiscal Agency neither supports nor opposes legislation.)
Hospitals and many long-term health care facilities have over the years developed policies and procedures for honoring do-not-resuscitate requests from seriously ill patients, but no such system has evolved for handling the cases of persons outside a health facility. Increasing numbers of seriously or terminally ill persons are choosing to spend their last days at home rather than in hospitals or medical institutions. When it appears that such a person has stopped breathing and may have died, family, friends, and caretakers often notify the authorities by calling either an ambulance service or the police, who then send an emergency unit to the house. In many cases, the patient has let it be known that he or she does not want to be resuscitated when respiratory functions have ceased. Even though family members or caretakers may know of this desire and convey this information either orally or in written form, such as a letter signed by the patient, to the emergency medical technicians (EMTs), the EMTs have had no choice under the law but to try to revive the person. Reportedly, emergency personnel must make every effort to revive a patient except in certain cases, such as when the body has decomposed, rigor mortis has set in, the body has been decapitated, or the body has been consumed by fire. Thus, even in cases in which the patient prior to the collapse clearly was near death, resuscitative measures still must be undertaken. This can be especially traumatic for the family and caretakers who knew that their loved one did not want to be revived. This has
placed the patient, emergency medical personnel, and the patient's caretakers in a situation that none desired, because there has not been a State law specifically allowing certain health or emergency personnel to honor do-not-resuscitate requests. Senate Bill 452 creates a legally recognized means whereby such requests will have to be honored.
Senate Bill 452 is restrictive in its application in that it will apply only to a person who suffers cessation of both spontaneous respiration and circulation. The bill also contains a number of safeguards that concern the issuance of a do-not- resuscitate order as well as provides for the revocation of an order. It should be noted, in addition, that the bill does not establish a right-to- die procedure since it prohibits the use of life- saving techniques only after a person's cardiac and respiratory functions have ceased--in effect after the patient has died.
Legislative Analyst: G. Towne
The bills will have no fiscal impact on State or local government.
Fiscal Analyst: P. Graham
A9596\S451EA
This analysis was prepared by nonpartisan Senate staff for use by the Senate in its deliberations and does not constitute an official statement of legislative intent.
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