Senate Bill 1890c1
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Florida Senate - 2000 CS for SB 1890
By the Committee on Health, Aging and Long-Term Care; and
Senator Klein
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1 A bill to be entitled
2 An act relating to end-of-life care; amending
3 s. 395.1041, F.S.; specifying conditions under
4 which hospital personnel may withhold
5 resuscitation; clarifying intent regarding
6 orders not to resuscitate; amending ss.
7 400.142, 400.4255, 400.6095, F.S.; clarifying
8 intent regarding orders not to resuscitate
9 issued and acted upon by a physician and staff,
10 respectively, in a nursing home, assisted
11 living facility, or hospice; amending s.
12 401.45, F.S.; relating to emergency treatment,
13 requiring use of official form for valid
14 do-not-resuscitate order; specifying required
15 signatures; specifying authorized substitute
16 signatures; amending s. 455.597, F.S., relating
17 to licensure renewal requirements for certain
18 health care professionals; providing for
19 substitution of continuing education programs
20 or courses on end-of-life care and palliative
21 health care for any authorized domestic
22 violence continuing education program or course
23 taken within a specified period; amending s.
24 765.102, F.S., relating to legislative findings
25 and intent; adding legislative intent to allow
26 a person to plan for future incapacity orally
27 or by executing a document; encouraging health
28 care professionals to rapidly increase their
29 understanding of end-of-life and palliative
30 health care; requiring a statewide, culturally
31 sensitive educational campaign on end-of-life
1
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1 care for the general public; creating s.
2 765.1103, F.S.; requiring certain health care
3 facilities, health care providers, and health
4 care practitioners to comply with patient
5 requests for pain management and palliative
6 care; amending s. 765.203, F.S.; revising the
7 suggested form for designating a health care
8 surrogate to include reference to
9 anatomical-gift declarations; amending s.
10 765.204, F.S.; providing a procedure for
11 determining a principal's capacity; revising
12 provisions; providing cross-references;
13 amending s. 765.205, F.S.; providing
14 responsibilities of a health care surrogate
15 with respect to medical records of the
16 principal; amending s. 765.303, F.S.; revising
17 the suggested form for a living will; amending
18 s. 765.305, F.S.; providing a procedure for
19 withholding or withdrawing medical treatment in
20 the absence of a living will; changing the
21 prerequisite circumstances on which a health
22 care surrogate must rely before authorizing
23 withholding or withdrawing of medical treatment
24 for another person; amending s. 765.306, F.S.,
25 relating to determination of patient condition;
26 changing the factors that must be evaluated for
27 determining whether a living will may take
28 effect; deleting the requirement for a
29 consulting physician to separately examine the
30 patient; amending s. 765.401, F.S.; providing a
31 proxy to make health care decisions on behalf
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1 of a patient; deleting the alternative
2 requirements that a proxy act in accordance
3 with a written declaration or that the patient
4 has certain specified medical conditions before
5 a proxy may consent to withholding or
6 withdrawing life-prolonging procedures;
7 providing cross-references; creating the
8 End-of-Life Care Workgroup; providing
9 membership of the workgroup; requiring a
10 report; providing an effective date.
11
12 Be It Enacted by the Legislature of the State of Florida:
13
14 Section 1. Paragraph (l) of subsection (3) of section
15 395.1041, Florida Statutes, is amended to read:
16 395.1041 Access to emergency services and care.--
17 (3) EMERGENCY SERVICES; DISCRIMINATION; LIABILITY OF
18 FACILITY OR HEALTH CARE PERSONNEL.--
19 (l) Hospital emergency services personnel may withhold
20 or withdraw cardiopulmonary resuscitation if presented with an
21 order not to resuscitate executed pursuant to s. 401.45.
22 Facility staff and facilities shall not be subject to criminal
23 prosecution or civil liability, nor be considered to have
24 engaged in negligent or unprofessional conduct, for
25 withholding or withdrawing cardiopulmonary resuscitation
26 pursuant to such an order. Nothing in this subsection shall
27 affect the authority of a physician to issue an order not to
28 resuscitate in the facility or the authority of facility staff
29 to act in accordance with such an order, as permitted by case
30 law and statutory law.
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1 Section 2. Subsection (3) of section 400.142, Florida
2 Statutes, is amended to read:
3 400.142 Emergency medication kits; orders not to
4 resuscitate.--
5 (3) Facility staff may withhold or withdraw
6 cardiopulmonary resuscitation if presented with an order not
7 to resuscitate executed pursuant to s. 401.45. The agency
8 shall adopt rules providing for the implementation of such
9 orders. Facility staff and facilities shall not be subject to
10 criminal prosecution or civil liability, nor be considered to
11 have engaged in negligent or unprofessional conduct, for
12 withholding or withdrawing cardiopulmonary resuscitation
13 pursuant to such an order and rules adopted by the agency.
14 Nothing in this subsection shall affect the authority of a
15 physician to issue an order not to resuscitate in the facility
16 or the authority of facility staff to act in accordance with
17 such an order, as permitted by case law and statutory law.
18 Section 3. Subsection (3) of section 400.4255, Florida
19 Statutes, is amended to read:
20 400.4255 Use of personnel; emergency care.--
21 (3) Facility staff may withhold or withdraw
22 cardiopulmonary resuscitation if presented with an order not
23 to resuscitate executed pursuant to s. 401.45. The department
24 shall adopt rules providing for the implementation of such
25 orders. Facility staff and facilities shall not be subject to
26 criminal prosecution or civil liability, nor be considered to
27 have engaged in negligent or unprofessional conduct, for
28 withholding or withdrawing cardiopulmonary resuscitation
29 pursuant to such an order and rules adopted by the department.
30 Nothing in this subsection shall affect the authority of a
31 physician to issue an order not to resuscitate in the facility
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1 or the authority of facility staff to act in accordance with
2 such an order, as permitted by case law and statutory law.
3 Section 4. Subsection (8) of section 400.6095, Florida
4 Statutes, is amended to read:
5 400.6095 Patient admission; assessment; plan of care;
6 discharge; death.--
7 (8) The hospice care team may withhold or withdraw
8 cardiopulmonary resuscitation if presented with an order not
9 to resuscitate executed pursuant to s. 401.45. The department
10 shall adopt rules providing for the implementation of such
11 orders. Hospice staff shall not be subject to criminal
12 prosecution or civil liability, nor be considered to have
13 engaged in negligent or unprofessional conduct, for
14 withholding or withdrawing cardiopulmonary resuscitation
15 pursuant to such an order and rules adopted by the department.
16 Nothing in this subsection shall affect the authority of a
17 physician to issue an order not to resuscitate in a hospice
18 care site or the authority of hospice staff to act in
19 accordance with such an order, as permitted by case law and
20 statutory law.
21 Section 5. Paragraph (a) of subsection (3) of section
22 401.45, Florida Statutes, is amended to read:
23 401.45 Denial of emergency treatment; civil
24 liability.--
25 (3)(a) Resuscitation may be withheld or withdrawn from
26 a patient by an emergency medical technician or paramedic if
27 evidence of an order not to resuscitate by the patient's
28 physician is presented to the emergency medical technician or
29 paramedic. An order not to resuscitate, to be valid, must be
30 on the form adopted by rule of the department. The form must
31 be signed by the patient's physician and by the patient or, if
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1 the patient is incapable of giving informed consent, the
2 patient's health care surrogate or proxy, as provided under
3 chapter 765; a court-appointed guardian, as provided under
4 chapter 744; or a person acting pursuant to a durable power of
5 attorney, as provided under chapter 709.
6 Section 6. Section 455.597, Florida Statutes, is
7 amended to read:
8 455.597 Requirement for instruction on domestic
9 violence.--
10 (1)(a) The appropriate board shall require each person
11 licensed or certified under chapter 458, chapter 459, chapter
12 464, chapter 466, chapter 467, chapter 490, or chapter 491 to
13 complete a 1-hour continuing education course, approved by the
14 board, on domestic violence, as defined in s. 741.28, as part
15 of biennial relicensure or recertification. The course shall
16 consist of information on the number of patients in that
17 professional's practice who are likely to be victims of
18 domestic violence and the number who are likely to be
19 perpetrators of domestic violence, screening procedures for
20 determining whether a patient has any history of being either
21 a victim or a perpetrator of domestic violence, and
22 instruction on how to provide such patients with information
23 on, or how to refer such patients to, resources in the local
24 community, such as domestic violence centers and other
25 advocacy groups, that provide legal aid, shelter, victim
26 counseling, batterer counseling, or child protection services.
27 (b) Each such licensee or certificateholder shall
28 submit confirmation of having completed such course, on a form
29 provided by the board, when submitting fees for each biennial
30 renewal.
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1 (c) The board may approve additional equivalent
2 courses that may be used to satisfy the requirements of
3 paragraph (a). Each licensing board that requires a licensee
4 to complete an educational course pursuant to this subsection
5 may include the hour required for completion of the course in
6 the total hours of continuing education required by law for
7 such profession unless the continuing education requirements
8 for such profession consist of fewer than 30 hours biennially.
9 (d) Any person holding two or more licenses subject to
10 the provisions of this subsection shall be permitted to show
11 proof of having taken one board-approved course on domestic
12 violence, for purposes of relicensure or recertification for
13 additional licenses.
14 (e) Failure to comply with the requirements of this
15 subsection shall constitute grounds for disciplinary action
16 under each respective practice act and under s. 455.624(1)(k).
17 In addition to discipline by the board, the licensee shall be
18 required to complete such course.
19 (2) The board shall also require, as a condition of
20 granting a license under any chapter specified in paragraph
21 (1)(a), that each applicant for initial licensure under the
22 appropriate chapter complete an educational course acceptable
23 to the board on domestic violence which is substantially
24 equivalent to the course required in subsection (1). An
25 applicant who has not taken such course at the time of
26 licensure shall, upon submission of an affidavit showing good
27 cause, be allowed 6 months to complete such requirement.
28 (3) In lieu of completing a course as required in
29 subsection (1), a licensee or certificateholder may complete a
30 course in end-of-life care and palliative health care, if the
31 licensee or certificateholder has completed an approved
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1 domestic violence course in the immediately preceding
2 biennium.
3 (4)(3) Each board may adopt rules to carry out the
4 provisions of this section.
5 (5)(4) Each board shall report to the President of the
6 Senate, the Speaker of the House of Representatives, and the
7 chairs of the appropriate substantive committees of the
8 Legislature by March 1 of each year as to the implementation
9 of and compliance with the requirements of this section.
10 Section 7. Section 765.102, Florida Statutes, is
11 amended to read:
12 765.102 Legislative findings and intent.--
13 (1) The Legislature finds that every competent adult
14 has the fundamental right of self-determination regarding
15 decisions pertaining to his or her own health, including the
16 right to choose or refuse medical treatment. This right is
17 subject to certain interests of society, such as the
18 protection of human life and the preservation of ethical
19 standards in the medical profession.
20 (2) To ensure that such right is not lost or
21 diminished by virtue of later physical or mental incapacity,
22 the Legislature intends that a procedure be established to
23 allow a person to plan for incapacity by executing a document
24 or orally designating another person to direct the course of
25 his or her medical treatment upon his or her incapacity. Such
26 procedure should be less expensive and less restrictive than
27 guardianship and permit a previously incapacitated person to
28 exercise his or her full right to make health care decisions
29 as soon as the capacity to make such decisions has been
30 regained.
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1 (3) The Legislature recognizes that for some the
2 administration of life-prolonging medical procedures may
3 result in only a precarious and burdensome existence. In order
4 to ensure that the rights and intentions of a person may be
5 respected even after he or she is no longer able to
6 participate actively in decisions concerning himself or
7 herself, and to encourage communication among such patient,
8 his or her family, and his or her physician, the Legislature
9 declares that the laws of this state recognize the right of a
10 competent adult to make an advance directive instructing his
11 or her physician to provide, withhold, or withdraw
12 life-prolonging procedures, or to designate another to make
13 the treatment decision for him or her in the event that such
14 person should become incapacitated and unable to personally
15 direct his or her medical care.
16 (4) The Legislature recognizes the need for all health
17 care professionals to rapidly increase their understanding of
18 end-of-life and palliative health care. Therefore, the
19 Legislature encourages the professional regulatory boards to
20 adopt appropriate standards and guidelines regarding
21 end-of-life care and pain management and encourages
22 educational institutions established to train health care
23 professionals and allied health professionals to implement
24 curricula to train such professionals to provide end-of-life
25 care, including pain management and palliative care.
26 (5) The Department of Elderly Affairs, the Agency for
27 Health Care Administration, and the Department of Health shall
28 jointly create a campaign on end-of-life care for purposes of
29 educating the public. This campaign should include culturally
30 sensitive programs to improve understanding of end-of-life
31 care issues in minority communities.
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1 Section 8. Section 765.1103, Florida Statutes, is
2 created to read:
3 765.1103 Pain management and palliative care.--
4 (1) A patient shall be given information concerning
5 pain management and palliative care when he or she discusses
6 with the attending or treating physician, or such physician's
7 designee, the diagnosis, planned course of treatment,
8 alternatives, risks, or prognosis for his or her illness,
9 unless such information is medically inadvisable or impossible
10 to give, in which case the information must be given, when
11 appropriate, to the patient's surrogate, proxy, guardian, or
12 other designated representative.
13 (2) When the patient is receiving care as an admitted
14 patient of a facility or a provider or is a subscriber of a
15 health care facility, health care provider, or health care
16 practitioner regulated under chapter 395, chapter 400, chapter
17 458, chapter 459, chapter 464, or chapter 641, Florida
18 Statutes, such facility, provider, or practitioner must, when
19 appropriate, comply with a request for pain management or
20 palliative care from a capacitated patient or an incapacitated
21 patient's surrogate; proxy; representative appointed under
22 chapter 744, if delegated the authority to make medical
23 decisions on behalf of the patient; or a representative
24 designated under chapter 709, who has the authority to make
25 medical decisions on behalf of the patient.
26 Section 9. Section 765.203, Florida Statutes, is
27 amended to read:
28 765.203 Suggested form of designation.--A written
29 designation of a health care surrogate executed pursuant to
30 this chapter may, but need not be, in the following form:
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1 DESIGNATION OF HEALTH CARE SURROGATE
2
3 Name:....(Last)....(First)....(Middle Initial)....
4 In the event that I have been determined to be
5 incapacitated to provide informed consent for medical
6 treatment and surgical and diagnostic procedures, I wish to
7 designate as my surrogate for health care decisions:
8
9 Name:.........................................................
10 Address:......................................................
11 .......................................... Zip Code:......
12 Phone:................
13 If my surrogate is unwilling or unable to perform his
14 or her duties, I wish to designate as my alternate surrogate:
15 Name:.........................................................
16 Address:......................................................
17 .......................................... Zip Code:........
18 Phone:................
19 I fully understand that this designation will permit my
20 designee to make health care decisions, except for anatomical
21 gifts, unless I have executed an anatomical-gift declaration
22 pursuant to law, and to provide, withhold, or withdraw consent
23 on my behalf; to apply for public benefits to defray the cost
24 of health care; and to authorize my admission to or transfer
25 from a health care facility.
26 Additional instructions (optional):...........................
27 ..............................................................
28 ..............................................................
29 ..............................................................
30 I further affirm that this designation is not being
31 made as a condition of treatment or admission to a health care
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1 facility. I will notify and send a copy of this document to
2 the following persons other than my surrogate, so they may
3 know who my surrogate is.
4 Name:.........................................................
5 Name:.........................................................
6 ..............................................................
7 ..............................................................
8 Signed:.......................................................
9 Date:.........................................................
10 Witnesses: 1.................................................
11 2.................................................
12 Section 10. Subsection (2) of section 765.204, Florida
13 Statutes, is amended to read:
14 765.204 Capacity of principal; procedure.--
15 (2) If a principal's capacity to make health care
16 decisions for herself or himself or provide informed consent
17 is in question, the attending physician shall evaluate the
18 principal's capacity and, if the physician concludes that the
19 principal lacks capacity, enter that evaluation in the
20 principal's medical record. If the attending physician has a
21 question as to whether the principal lacks capacity, another
22 physician shall also evaluate the principal's capacity, and.
23 if the second physician agrees that the principal lacks the
24 capacity to make health care decisions or provide informed
25 consent, the health care facility shall enter both physician's
26 evaluations in the principal's medical clinical record. and,
27 If the principal has designated a health care surrogate, the
28 facility shall notify such surrogate in writing that her or
29 his authority under the instrument has commenced, as provided
30 in s. 765.203 or chapter 709.
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1 Section 11. Section 765.205, Florida Statutes, is
2 amended to read:
3 765.205 Responsibility of the surrogate.--
4 (1) The surrogate, in accordance with the principal's
5 instructions, unless such authority has been expressly limited
6 by the principal, shall:
7 (a) Have authority to act for the principal and to
8 make all health care decisions for the principal during the
9 principal's incapacity, in accordance with the principal's
10 instructions, unless such authority has been expressly limited
11 by the principal.
12 (b) Consult expeditiously with appropriate health care
13 providers to provide informed consent, and make only health
14 care decisions for the principal which he or she believes the
15 principal would have made under the circumstances if the
16 principal were capable of making such decisions.
17 (c) Provide written consent using an appropriate form
18 whenever consent is required, including a physician's order
19 not to resuscitate.
20 (d) Be provided access to the appropriate medical
21 clinical records of the principal.
22 (e) Apply for public benefits, such as Medicare and
23 Medicaid, for the principal and have access to information
24 regarding the principal's income and assets and banking and
25 financial records to the extent required to make application.
26 A health care provider or facility may not, however, make such
27 application a condition of continued care if the principal, if
28 capable, would have refused to apply.
29 (2) The surrogate may authorize the release of
30 information and medical clinical records to appropriate
31 persons to ensure the continuity of the principal's health
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1 care and may authorize the admission, discharge, or transfer
2 of the principal to or from a health care facility or other
3 facility or program licensed under chapter 400.
4 (3) If, after the appointment of a surrogate, a court
5 appoints a guardian, the surrogate shall continue to make
6 health care decisions for the principal, unless the court has
7 modified or revoked the authority of the surrogate pursuant to
8 s. 744.3115. The surrogate may be directed by the court to
9 report the principal's health care status to the guardian.
10 Section 12. Subsection (1) of section 765.303, Florida
11 Statutes, is amended to read:
12 765.303 Suggested form of a living will.--
13 (1) A living will may, BUT NEED NOT, be in the
14 following form:
15 Living Will
16 Declaration made this .... day of ...., ...(year)...,
17 I, ........, willfully and voluntarily make known my desire
18 that my dying not be artificially prolonged under the
19 circumstances set forth below, and I do hereby declare that,
20 if at any time I am both mentally and physically incapacitated
21 and
22 ...(initial)... and I have a terminal condition
23 or ...(initial)... and I have an end-stage end-state
24 condition
25 or ...(initial)... and I am in a persistent vegetative
26 state
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28 and if my attending or treating physician and another
29 consulting physician have determined that there is no
30 reasonable medical probability of my recovery from such
31 condition, I direct that life-prolonging procedures be
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1 withheld or withdrawn when the application of such procedures
2 would serve only to prolong artificially the process of dying,
3 and that I be permitted to die naturally with only the
4 administration of medication or the performance of any medical
5 procedure deemed necessary to provide me with comfort care or
6 to alleviate pain.
7 It is my intention that this declaration be honored by
8 my family and physician as the final expression of my legal
9 right to refuse medical or surgical treatment and to accept
10 the consequences for such refusal.
11 In the event that I have been determined to be unable
12 to provide express and informed consent regarding the
13 withholding, withdrawal, or continuation of life-prolonging
14 procedures, I wish to designate, as my surrogate to carry out
15 the provisions of this declaration:
16
17 Name:.........................................................
18 Address:......................................................
19 .......................................... Zip Code:......
20 Phone:................
21 I understand the full import of this declaration, and I
22 am emotionally and mentally competent to make this
23 declaration.
24 Additional Instructions (optional):
25 ..............................................................
26 ..............................................................
27 ..............................................................
28 ....(Signed)....
29 ....Witness....
30 ....Address....
31 ....Phone....
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1 ....Witness....
2 ....Address....
3 ....Phone....
4
5 Section 13. Subsection (2) of section 765.305, Florida
6 Statutes, is amended to read:
7 765.305 Procedure in absence of a living will.--
8 (2) Before exercising the incompetent patient's right
9 to forego treatment, the surrogate must be satisfied that:
10 (a) The patient does not have a reasonable medical
11 probability of recovering capacity so that the right could be
12 exercised by the patient.
13 (b) The patient is both mentally and physically
14 incapacitated with no reasonable medical probability of
15 recovery, the patient has an end-stage condition, the patient
16 is in a persistent vegetative state, or the patient's physical
17 condition is terminal.
18 Section 14. Section 765.306, Florida Statutes, is
19 amended to read:
20 765.306 Determination of patient condition.--In
21 determining whether the patient has a terminal condition, has
22 an end-stage condition, or is in a persistent vegetative state
23 or may recover mental and physical capacity, or whether a
24 medical condition or limitation referred to in an advance
25 directive exists, the patient's attending or treating
26 physician and at least one other consulting physician must
27 separately examine the patient. The findings of each such
28 examination must be documented in the patient's medical record
29 and signed by each examining physician before life-prolonging
30 procedures may be withheld or withdrawn.
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1 Section 15. Subsection (3) of section 765.401, Florida
2 Statutes, is amended to read:
3 765.401 The proxy.--
4 (3) Before exercising the incapacitated patient's
5 rights to select or decline health care, the proxy must comply
6 with the pertinent provisions of ss. 765.205 and 765.305
7 applicable to surrogates under this chapter, except that a
8 proxy's decision to withhold or withdraw life-prolonging
9 procedures must either:
10 (a) Be supported by a written declaration; or
11 (b) If there is no written declaration, the patient
12 must have a terminal condition, have an end-stage condition,
13 or be in a persistent vegetative state, and the proxy's
14 decision must be supported by clear and convincing evidence
15 that the decision would have been the one the patient would
16 have chosen had the patient been competent.
17 Section 16. End-of-Life Care Workgroup.--
18 (1) There is created within the Department of Elderly
19 Affairs the End-of-Life Care Workgroup. The workgroup shall:
20 (a) Examine reimbursement methodologies for
21 end-of-life care;
22 (b) Identify end-of-life care standards that will
23 enable all health care providers along the health-care
24 continuum to participate in an excellent system of delivering
25 end-of-life care; and
26 (c) Develop recommendations for incentives for
27 appropriate end-of-life care.
28 (2) The workgroup is composed of the Secretary of
29 Elderly Affairs or his or her designee; the Secretary of
30 Health or his or her designee; the Director of Health Care
31 Administration or his or her designee; a member of the Senate,
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1 appointed by the President of the Senate; a member of the
2 House of Representatives, appointed by the Speaker of the
3 House of Representatives; and one representative from each of
4 the following organizations: the Florida Hospital Association,
5 the Florida Medical Association, the Florida Osteopathic
6 Medical Association, the Florida Nurses Association, the
7 Florida Acupuncture Association, the Florida Pharmacy
8 Association, Florida Hospices and Palliative Care, Inc., the
9 Florida Health Care Association, the Florida Assisted Living
10 Association, the Florida Association of Homes for the Aging,
11 the Florida Life Care Residents Association, the Florida
12 Association of Insurance and Financial Advisors, and the
13 Florida Association of Health Maintenance Organizations.
14 (3) The workgroup shall exist for 1 year and shall
15 meet as often as necessary to carry out its duties and
16 responsibilities. Within existing resources, the Department of
17 Elderly Affairs shall provide support services to the
18 workgroup. Workgroup members shall serve without compensation.
19 (4) The workgroup shall submit a report of its
20 findings and recommendations to the Governor, the President of
21 the Senate, and the Speaker of the House of Representatives by
22 December 31, 2000.
23 (5) This section expires May 1, 2001.
24 Section 17. This act shall take effect upon becoming a
25 law.
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1 STATEMENT OF SUBSTANTIAL CHANGES CONTAINED IN
COMMITTEE SUBSTITUTE FOR
2 SB 1890
3
4 Deletes changes to the Florida Patient's Bill of Rights and
Responsibilities. Clarifies that authority to recognize and
5 act on a prehospital order not to resuscitate does not affect
the authority of a physician to issue an order not to
6 resuscitate or the authority of nursing home, assisted living
facility, or hospice staff to act in accordance with such a
7 physician order. Requires certain health care facilities,
health care providers, and health care practitioners to comply
8 with a patient's request for pain management or palliative
care, when appropriate. Revises requirements for designating a
9 health care surrogate so that determination of incapacity,
instead of both mental and physical incapacity, is a
10 prerequisite for such surrogate's authority to commence.
Revises the statutory form for designation of a health care
11 surrogate and the statutory living will form. Reinstates
current law, and conforms the related statutory form, that
12 requires a consulting physician to evaluate a patient
separately from the attending or treating physician when
13 determining a patient's condition for purposes of activating a
living will or withholding or withdrawing life-prolonging
14 procedures.
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