1. (a) Purpose. The purpose of this section shall be to establish a statewide DNR protocol as required in the Health and Safety Code, Title 8, Chapter 674.
2. (b) DNR order. A DNR order may be issued by an attending physician for a patient who has been diagnosed as having a terminal condition. That attending physician has responsibility for ensuring that the form is filled out in its entirety and that the information regarding the existence of a DNR order is entered into the patient's medical record.

3. (c) Protocol development. A DNR protocol in accordance with this section, shall apply to all out-of-hospital settings including cardiac arrests which occur during interfacility transport. The protocol shall include the following:

   1. (1) a copy of the Texas Department of Health (department) standardized DNR form listing the designated procedures that shall be withdrawn or withheld. Those procedures shall be:

      1. (A) cardiopulmonary resuscitation;
      2. (B) endotracheal intubation or other advanced airway management;
      3. (C) artificial ventilation;
      4. (D) defibrillation;
      5. (E) transcutaneous cardiac pacing; and
      6. (F) administration of cardiac resuscitation medications;
   2. (2) an explanation of the patient identification process to include an option to use a department-standardized identification device such as a necklace or bracelet; and
   3. (3) an on-site DNR dispute resolution process which includes contacting an appropriate physician.

4. (d) Recordkeeping. Records shall be maintained on each incident in which an out-of-hospital DNR order or DNR identification device is encountered by responding healthcare professionals, and the number of cases where there is an on-site revocation of the DNR order shall be recorded.

   1. (1) The data documented should include:

      1. (A) an assessment of patient's physical condition;
      2. (B) whether an identification device or a DNR form was used to confirm DNR status and patient identification number;
      3. (C) any problems relating to the implementation of the DNR order;
      4. (D) the name of the patient's attending physician; and
      5. (E) the full name, address, telephone number, and relationship to patient of any witness used to identify the patient.
   2. (2) If the patient is transported, the original DNR order shall be kept with the patient.
   3. (3) Copies of the original DNR order may be put on file with concerned parties, and the original order shall remain in the possession of the patient, a legal guardian, or the healthcare facility responsible for the patient's care. The original DNR order shall be filed as a part of the permanent patient care record at the facility where the patient dies.

   4. (4) Annually, the out-of-hospital provider shall submit a report to the Bureau of Emergency Management with the following information:

      1. (A) number of times personnel have been presented with DNR documentation;
      2. (B) number of times there was a problem and the DNR order could not be honored; and
      3. (C) any problems that were encountered using the standardized form.
5. (e) Out-of-State DNR Orders. Personnel may accept an out-of-hospital DNR order that has been executed in any other state, if there is no reason to question the authenticity of the order. Personnel may not accept any out-of-state identifying devices to include bracelets or necklaces. If there is any question of validity of the DNR order, the responding healthcare professional shall attempt to contact medical control.
6. (f) Failure to honor a DNR order. If there are any indications of unnatural or suspicious circumstances, the provider shall begin resuscitation efforts until such time as a physician directs otherwise.
7. (g) Pregnant persons. A person may not withhold the designated procedures listed in subsection (c)(1) of this section from a person known by responding healthcare professionals to be pregnant.

8. (h) DNR Form. The Bureau of Emergency Management or their appointees shall furnish DNR forms to physicians, clinics, hospitals, nursing homes, hospices and home health agencies throughout the state upon request.

   1. (1) The form shall contain all the information as prescribed in the Health and Safety Code, Chapter 674.
   2. (2) The form shall be 8 1/2 inches by 14 inches, printed front and back, and in the format specified by the board as follows:

9. (i) Identification devices. A vendor under contract with the Texas Department of Health shall make the identification bracelet and necklace according to the following specifications:

   1. (1) The bracelet shall be made of stainless steel in eight-inch length with an engravable section which is 1 5/8-inch long, 5/8-inch wide and 1/32-inch thick, with an easy opening attachment clasp. The statewide standardized DNR logo will be on the front in red, white, and black colors as specified;
   2. (2) The necklace shall be made of stainless steel one inch in diameter and 1/32-inch thick. There will be a 16-inch to 18-inch stainless steel chain permanently attached without a clasp. The statewide standardized DNR logo will be on the front in red, white, and black colors as specified.

Source Note:The provisions of this §157.25 adopted to be effective October 16, 1996, 21 TexReg 9832.