2012 -- S 2361 SUBSTITUTE A

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LC01287/SUB A

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STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2012

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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:

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

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

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

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chapter:

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

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

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

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procedures from, a qualified patient.

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

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

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

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treatment and care of the patient.

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

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

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

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

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

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services personnel acting within the ordinary course of their professions.

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

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

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

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

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

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practice of a profession.

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

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

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

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

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

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

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

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

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measures.

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

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practitioner who is authorized by the patient to sign a MOLST form.

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

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Rhode Island general laws, chapter 5-54.

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

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

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entity.

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

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

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

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terminal condition.

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

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Island general laws, chapter 5-34.

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

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

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

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

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

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

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

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maker; and

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

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

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life sustaining measures is a medical order.

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

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

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result in death.

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

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

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

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

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

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Medical Orders for Life Sustaining Treatment forms.

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

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sustaining treatment provided that:

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

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

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

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

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

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patient; and

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

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

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

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her recognized health care decision maker.

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

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

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authority is valid.

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

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

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

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4.11.

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

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

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

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

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

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qualified patient’s health status and care preferences.

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

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

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modify that a qualified patient’s MOLST.

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

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

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implementation of this section.

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

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

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

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

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

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

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

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

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

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

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sustaining or resuscitative measures.

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

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

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

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pursuant to this section shall immediately:

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

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

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

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patient's care of the revocation and any cancellations.

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

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

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

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

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

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immediately:

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

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

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life-sustaining treatment;

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

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withdraw treatment; and

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

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

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care.

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

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

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

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

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

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sustaining treatment pursuant to this chapter.

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

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elect a MOLST.

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     SECTION 3. This act shall take effect upon passage.

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LC01287/SUB A

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EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N A C T

RELATING TO HEALTH AND SAFETY

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

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

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     This act would take effect upon passage.

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LC01287/SUB A

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