BP BHEAD INT S [atlas:bill]

AN ACT Relating to recognizing and regulating the right of patients to their choice of end-of-life care; amending RCW 70.122.020 and 70.122.030; adding a new chapter to Title 70 RCW; and prescribing penalties.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:

NEW SECTION. Sec. 1. SHORT TITLE. This chapter may be known and cited as the end-of-life care act.

NEW SECTION. Sec. 2. LEGISLATIVE FINDINGS. The legislature finds that the historical, cultural, and legal traditions of our nation and of the state of Washington support and encourage the privacy of the physician-patient relationship, and the tradition of informed consent arising from the patient's right of self-determination.

The legislature further finds that modern medicine affords patients choices of end-of-life care that may include home care, hospice care, psychological and social counseling, palliative care, and a request to withhold cardiopulmonary resuscitation.

The legislature further finds that a dying patient or a patient in a permanent state of unconsciousness and his or her attending physician and other assisting health care providers may be uniquely confronted by circumstances in which curative treatment is no longer the goal but, instead, the relief of pain or suffering may predominate over all other considerations in order to achieve a dignified and serene death.

The legislature further finds that under such circumstances, a range of palliative care may be administered to a qualified patient even when the administration of medications to relieve pain or suffering may cause unconsciousness and may have the double effect of hastening death, so long as the patient chooses to receive it with that understanding.

The legislature further finds that although palliative sedation is a widely accepted ethical medical practice and is not unlawful in the state of Washington when consented to by an informed patient or an authorized representative, many physicians still under-prescribe controlled substances to relieve pain or suffering, fearing civil, criminal, or professional liability.

The legislature further finds that while the privacy of the physician-patient relationship and the patient's right to self-determination are protected, the state has an obligation to regulate end-of-life care in such a manner as to prevent abuse, to ensure that a qualified patient's choice of end-of-life care is voluntary, informed, and exercised by a patient with decisional capacity or in a legally executed health care directive or by an authorized representative who validly holds the person's durable power of attorney for health care, and to protect practitioners who prescribe, administer, or dispense controlled substances at the request of the patient in order to manage or relieve pain or suffering in good-faith compliance with the requirements of this chapter.

The legislature hereby declares that a qualified patient has the right to make voluntary and informed choices of care including a request for home care, hospice care, psychological and social counseling, palliative care, as well as a voluntary revocable recorded request for withholding cardiopulmonary resuscitation and/or for palliative sedation that may have the double effect of hastening death.

The legislature further declares that physicians, physician's assistants, nurses, pharmacists, and health care institutions have the right to participate voluntarily in end-of-life care in good-faith compliance with the requirements of this chapter without being subject to civil, criminal, or professional liability.

The legislature further declares that a withholding of cardiopulmonary resuscitation in good-faith compliance with the requirements of this chapter, or a hastened death resulting from palliative sedation administered or delivered in good-faith compliance with the requirements of this chapter, is not assisted suicide, euthanasia, or mercy killing.

NEW SECTION. Sec. 3. DEFINITIONS. Unless the context clearly requires otherwise, the definitions in this section apply throughout this chapter.

(1) "Attending physician" means a person licensed under chapter 18.71 or 18.57 RCW who is selected by, or assigned to, the patient and who has primary responsibility for the treatment and care of the patient, and:

(a) Is not related to the qualified patient by blood, marriage, or adoption;

(b) Does not hold power of attorney for the qualified patient;

(c) Is not entitled to any portion of the estate of the qualified patient upon his or her death by operation of then existing law or codicil of the qualified patient;

(d) Has no creditor's claim against the qualified patient, outside of a claim for professional services rendered to the qualified patient, nor anticipates making such a claim against any portion of the estate of the qualified patient upon his or her death.

(2) "Cardiopulmonary resuscitation" means measures to restore cardiac function or to support breathing in the event of cardiac or respiratory arrest or malfunction. These measures include cardiac compression, endotracheal intubation or other advanced airway management, artificial ventilation, defibrillation, administration of cardiac resuscitation medications, and related procedures.

(3) "Directive" means a written document voluntarily executed by the declarer generally consistent with the guidelines of RCW 70.122.030.

(4) "Do not attempt resuscitation identification" means a standardized identification card, form, necklace, or bracelet of uniform size and design, approved by the department of social and health services, that signifies:

(a) That the possessor has executed a health care directive that specifically addresses the cardiopulmonary resuscitation option of health care as provided in RCW 70.122.030, and that has not been revoked; or

(b) That the possessor has executed a recorded request as provided by section 15 of this act; and

(c) That the possessor's attending physician has issued an emergency medical services do not attempt resuscitation order at the possessor's request and has documented the grounds for the order in the possessor's medical file.

(5) "Double effect" means the process by which medication primarily intended to relieve the pain or suffering of a qualified patient may result in the known potential secondary effect of hastening death.

(6) "Health care facility" means a facility or agency licensed, certified, or otherwise authorized by the state of Washington to administer health care in the ordinary course of business.

(7) "Pain" means an unpleasant physical sensation that is caused by injury, disease, or other abnormal condition, and that is experienced in varying degrees of severity most reliably indicated by the patient himself or herself.

(8) "Palliative care" means care, including the administration of medication, intended to relieve pain or suffering.

(9) "Palliative sedation" means aggressive palliative care, even when sufficient dosage of medications to relieve pain or suffering may cause unconsciousness and may have the double effect of hastening death, so long as the patient chooses to receive it with that understanding.

(10) "Permanent unconscious condition" means an incurable and irreversible condition in which the patient is medically assessed within reasonable medical judgment as having no reasonable probability of recovery from an irreversible coma or a persistent vegetative state.

(11) "Physician" means a person licensed under chapter 18.71 or 18.57 RCW.

(12) "Qualified patient" means an adult person who is a patient diagnosed in writing to have a terminal condition by the patient's attending physician, who has personally examined the patient, or a patient who is diagnosed, in writing, to be in a permanent unconscious condition in accordance with accepted medical standards by two physicians, one of whom is the patient's attending physician, and both of whom have personally examined the patient.

(13) "Recorded request" means a voluntary revocable written or videotape recorded statement meeting the requirements of section 6 of this act, and in substantially the same form set forth in section 15 of this act if the recorded request is in writing.

(14) "Suffering" means physical or psychological distress, with or without pain, as a result of a patient's medical condition. Symptoms of suffering are most reliably indicated by the patient himself or herself and may include, but are not limited to, agonized breathing, agitated delirium or confusion, persistent vomiting, extreme fear, or panic.

(15) "Terminal condition" means an incurable and irreversible condition caused by injury, disease, or illness, that, within reasonable medical judgment, will cause death within a reasonable period of time in accordance with accepted medical standards, and where the application of life-sustaining treatment serves only to prolong the process of dying.

NEW SECTION. Sec. 4. CARDIOPULMONARY RESUSCITATION. (1) Every patient is presumed to consent to the administration of cardiopulmonary resuscitation in the event of cardiac or respiratory arrest, unless there is a request for an order not to attempt resuscitation. This presumption of consent does not mean that every patient shall be administered cardiopulmonary resuscitation, but rather every patient agrees to its administration unless such an administration is medically futile.

(2) A qualified patient with decision-making capacity may request orally or in writing an order not to attempt resuscitation and to its implementation at a present or future date, regardless of that person's mental or physical condition on that future date.

(3) In the event a qualified patient lacking decision-making capacity has made an earlier do not attempt resuscitation directive executed pursuant to section 15 of this act or RCW 70.122.030 and not previously revoked, or a request for a do not attempt resuscitation order has been made by the qualified patient's authorized representative who validly holds the patient's durable power of attorney for health care, such directive or request shall authorize issuance of an order not to attempt resuscitation.

(4) The department of health, no later than one year after the effective date of this act, shall adopt rules and protocols for the implementation of cardiopulmonary resuscitation directives or orders for emergency medical personnel. The protocols adopted shall include uniform methods for rapid identification of persons who have executed a do not attempt resuscitation directive or for whom a do not attempt resuscitation order has been authorized. These methods shall include distribution of uniform do not attempt resuscitation forms and identification bracelets, necklaces, and cards.

(5) The visible presence of a do not attempt resuscitation identification bracelet, necklace, or card on one's person is conclusive evidence that the person has executed a valid cardiopulmonary directive or has a valid do not attempt resuscitation order issued on the person's behalf. Responding emergency medical personnel shall honor the do not attempt resuscitation identification bracelet, necklace, or card as a valid do not attempt resuscitation order form.

NEW SECTION. Sec. 5. PALLIATION OF PAIN OR SUFFERING. (1) A patient or the patient's authorized representative who validly holds the patient's durable power of attorney for health care may orally or in writing request medication intended to relieve pain or suffering.

(2) Upon such a request, and notwithstanding any other provision of law, an attending physician may prescribe, administer, or dispense a controlled substance in any dosage the attending physician deems medically indicated for the management or relief of pain or suffering.

(3) In prescribing or administering a controlled substance for the management or relief of pain or suffering, the attending physician shall observe department of health guidelines for the management of pain.

NEW SECTION. Sec. 6. PALLIATIVE SEDATION. (1) A qualified patient or the qualified patient's authorized representative who validly holds the patient's durable power of attorney for health care may voluntarily execute a revocable recorded request for palliative sedation to relieve pain or suffering, if:

(a) The request is repeated without self-contradiction on two separate occasions at least twenty-four hours apart, the second of which must constitute the recorded request and must comply with all requirements of this section; and

(b) The signing or videotape recording of the request is witnessed by two other adults who, at the time of witnessing, meet the following requirements:

(i) Are not related to the qualified patient by blood, marriage, or adoption;

(ii) Are not entitled to any portion of the estate of the qualified patient upon his or her death by operation of law in effect at the time of witnessing or under any will or codicil in effect at the time of witnessing;

(iii) Have no creditor's claim against the qualified patient, nor anticipate making such a claim against any portion of the estate of the qualified patient upon his or her death; or

(iv) Are not the attending physician or an employee of the attending physician.

(2) The recorded request may include the withdrawal or withholding of artificial nutrition and hydration if the patient or the qualified patient's authorized representative who validly holds the patient's durable power of attorney for health care so chooses.

(3) A completed and witnessed recorded request shall be delivered to the qualified patient's attending physician, who shall file the recorded request in the qualified patient's medical records. If the qualified patient is an inpatient at a health care facility, a copy of the recorded request shall also be delivered to the health care facility, where it shall become a part of the qualified patient's permanent record.

(4) In the event of a conflict between the qualified patient's recorded request and the qualified patient's lawful attorney-in-fact for health care or the qualified patient's lawful health care surrogate, the qualified patient's recorded request shall prevail.

(5) An attending physician who receives a recorded request from a qualified patient or from the qualified patient's authorized representative who validly holds the patient's durable power of attorney for health care shall make a personal examination of the qualified patient, including an evaluation of the patient's decision-making capacity, assuring that the request is not the result of impaired judgment or mental illness, and a review of the qualified patient's medical records, and shall apply independent reasonable medical judgment as to whether the qualified patient has a terminal condition. The attending physician shall engage in a consultation with the qualified patient or the patient's authorized representative who validly holds the patient's durable power of attorney for health care for the purpose of:

(a) Explaining the qualified patient's medical diagnosis and prognosis;

(b) Reviewing the feasible alternatives to palliative sedation, including other methods of pain control, hospice care, home care, and counseling, and the possible effects of such alternatives on the qualified patient; and

(6) If the attending physician finds that the qualified patient suffers from a terminal condition and that the patient's request is not the result of impaired judgment or mental illness, the recorded request for palliative sedation shall be granted and the attending physician may provide palliative sedation for the qualified patient.

(7) In the event a qualified patient lacking decision-making capacity has made an earlier palliative sedation directive pursuant to RCW 70.122.030 and not previously revoked, such directive shall authorize palliative sedation and the attending physician may provide palliative sedation for the qualified patient.

(8) Before providing palliative sedation to a qualified patient, the attending physician shall: (a) Review thoroughly the qualified patient's recorded request or advance directive and medical record; (b) take reasonable steps to ensure that the requirements of this chapter have been met; and (c) determine that the recorded request or the advance directive is in accord with the consistently expressed desires of the patient. Absent knowledge to the contrary, there is a rebuttable presumption that the recorded request or advance directive complies with this chapter and is valid.

(9) A recorded request may be revoked at any time by the qualified patient, without regard to his or her mental state or competency, or by the qualified patient's authorized representative who validly holds the patient's durable power of attorney for health care, by being canceled, defaced, obliterated, burned, torn, or otherwise destroyed by or at the direction of the qualified patient, or by oral expression or assertive conduct by the qualified patient of the patient's intent to revoke the recorded request. The time, date, and place of the revocation shall be confirmed by the attending physician and recorded by the physician in the patient's medical record.

(10) There is no criminal, civil, or administrative liability on the part of any person, firm, or organization for following a recorded request that has been revoked unless that person, firm, or organization had actual knowledge, or should reasonably have had knowledge, of the revocation.

NEW SECTION. Sec. 7. NO COMPULSION. A physician or health care professional is not required to provide or participate in any end-of-life care specified in this chapter to which he or she is opposed.

NEW SECTION. Sec. 8. TRANSFER OF PATIENT. If a physician declines to provide or a health care facility declines to participate in the qualified patient's choice of end-of-life care specified in this chapter, the physician or health care facility shall assist the patient in transferring his or her care, as soon as reasonably possible, to another physician or health care facility to enable the patient to receive his or her choice of end-of-life care. A copy of the patient's relevant medical records shall be transferred to the new physician or health care facility.

NEW SECTION. Sec. 9. FAMILY NOTIFICATION. A patient requesting end-of-life care specified under this chapter shall be encouraged to notify next of kin of the request. A patient who declines or cannot supply family details may not, for that reason, be denied his or her request.

NEW SECTION. Sec. 10. PROTECTION OF HEALTH CARE PROFESSIONALS. (1) A physician, health care professional, health care facility, or employee of a health care facility, who, acting in good-faith compliance with the requirements of this chapter, participates in, or is present at, adherence to a do not attempt resuscitation order at the time of cardiac or respiratory arrest of a qualified patient is not subject to civil, criminal, or administrative liability.

(2) A physician, health care professional, health care facility, employee of a health care facility, or licensed pharmacist, who, acting in good-faith compliance with the requirements of this chapter, participates in, or is present at, the palliative sedation of a qualified patient is not subject to civil, criminal, or administrative liability for the double effect of hastened death of the qualified patient.

(3) A health care facility is not barred under this section from disciplining an employee who acted contrary to the written policy of the health care facility and in furtherance of a patient's voluntary request.

NEW SECTION. Sec. 11. INSURANCE. (1) An insurer doing business in the state of Washington shall not cancel, refuse to insure, refuse to renew, reassess the risk of an insured, or raise premiums on the basis of whether or not the insured has considered or completed a do not attempt resuscitation directive or a health care directive or recorded request for palliative sedation. An insurer may not require or request the insured to disclose whether he or she has executed a do not attempt resuscitation directive or a health care directive or recorded request for palliative sedation.

(2) The making of a do not attempt resuscitation directive pursuant to section 4 of this act and/or the making of a health care directive or recorded request for palliative sedation pursuant to section 6 of this act does not restrict, inhibit, or impair in any manner the sale, procurement, issuance, or rates of any policy of life, health, or disability insurance. A policy of life, health, or disability insurance may not be legally impaired or invalidated in any manner by the provision of end-of-life care to an insured qualified patient under this chapter.

(3) A physician, health care facility, insurer, self-insured employee benefit plan, or nonprofit hospital service plan may not require any person to execute or prohibit any person from executing a do not attempt resuscitation directive, or a health care directive or recorded request, as a condition for receiving insurance coverage or health care services. Violation of this subsection is a misdemeanor.

(4) A life insurer in the state of Washington may not refuse to pay sums due upon death of an insured because the insured received palliative sedation in accordance with this chapter.

(5) An insurer doing business in the state of Washington may not exclude from coverage any fair and reasonable fees charged for palliative care.

(6) This section does not change existing law regarding the availability of insurance coverage to a person deemed to have a preexisting condition.

NEW SECTION. Sec. 12. UNLAWFUL ACTS. (1) Any person who unduly influences another to execute a do not attempt resuscitation clause or palliative sedation clause of a health care directive, a do not attempt resuscitation directive, or a recorded request for palliative sedation, including through persuasion that the patient is a financial, emotional, or other burden to his or her family, other persons, or the state, is guilty of a misdemeanor; or, if death occurs as a result of such undue influence, is guilty of a felony.

(2) Any person who fraudulently influences another to execute a do not attempt resuscitation clause or palliative sedation clause of a health care directive, a do not attempt resuscitation directive, or a recorded request for palliative sedation is guilty of a misdemeanor; or, if death occurs as a result of such undue influence, is guilty of a felony.

(3) Any person who thwarts, conceals, cancels, defaces, obliterates, or damages the do not attempt resuscitation clause or palliative sedation clause of a health care directive, a do not attempt resuscitation directive, or a recorded request for palliative sedation is guilty of a misdemeanor.

(4) Any person who falsifies or forges the do not attempt resuscitation clause or palliative sedation clause of a health care directive, a do not attempt resuscitation directive, or a recorded request for palliative sedation of another, or willfully conceals or withholds personal knowledge of a revocation as provided in section 6(9) of this act, with the intent to hasten death contrary to the wishes of the qualified patient, and thereby directly causes hastening of death, is guilty of the crime of murder.

NEW SECTION. Sec. 13. OTHER RIGHTS. (1) This chapter does not impair or supersede any right that any person may have to seek judicial redress for any violations of this chapter.

(2) This chapter does not impair or supersede any right or legal responsibility that any person may have regarding the withholding or withdrawal of life-sustaining procedures in any lawful manner.

(3) This chapter does not impair or supersede any right or legal responsibility that any person may have as a result of a validly executed durable power of attorney.

NEW SECTION. Sec. 14. RECOGNITION OF DO NOT ATTEMPT RESUSCITATION DIRECTIVE OR RECORDED REQUEST EXECUTED IN ANOTHER STATE. A do not attempt resuscitation directive or an advance directive or recorded request for palliative sedation that has been executed in another state in compliance with the law of that state and that substantially complies with this chapter is valid for the purpose of this chapter.

NEW SECTION. Sec. 15. FORM OF DO NOT ATTEMPT RESUSCITATION DIRECTIVE. A written do not attempt resuscitation directive by a qualified patient under this chapter or by the qualified patient's authorized representative who validly holds the patient's durable power of attorney for health care must contain substantially the following form, or, if orally given, shall be in substantially the following words:

DO NOT ATTEMPT RESUSCITATION DIRECTIVE

(side one)

In the event of cardiac or respiratory arrest, I [the patient] wish[es] to be allowed to die naturally, and I [he or she] therefore refuse[s] any resuscitation measures including cardiac compression, endotracheal intubation and other advanced airway management, artificial ventilation, defibrillation, administration of advanced cardiac life support drugs, and related emergency procedures.

Patient [Surrogate]: ................. Date: .................

(Signature or mark)

Attach recent photograph here or provide all of the following information below:

Date of Birth........... Sex..............

Eye Color............... Hair Color............ Race........

Any Other Distinguishing Marks...................................

Name and telephone number of patient's physician.................

.................................................................

Name and telephone number of lawful health care surrogate........

.................................................................

(side two)

I have explained this form and its consequences to the signer and obtained assurance that the signer understands that death may result from any refused care listed above.

...................................... Date: ...................

(Licensed health care provider)

I was present when this was signed (or marked). The patient then appeared to be of sound mind and free from duress.

...................................... Date: ...................

(Witness)

FORM OF RECORDED REQUEST. A written recorded request for palliative sedation by a qualified patient under this chapter or by the qualified patient's authorized representative who validly holds the patient's durable power of attorney for health care shall be in substantially the following form, or, if videotape recorded must contain substantially the following words:

VOLUNTARY REQUEST BY A QUALIFIED PATIENT FOR PALLIATIVE SEDATION

This recorded request is made on . . . . . . . . . .19 . . . I, . . . . . . . . . . . . ., being a mentally competent adult eighteen years of age or older, do voluntarily make known my desire that my pain or suffering be relieved by the full range of palliative care available, including palliative sedation, even when sufficient dosage of medications to relieve my pain or suffering may cause unconsciousness and may have the double effect of hastening my death.

[Optional] I hereby voluntarily request that upon my receiving palliative sedation, artificial nutrition and hydration be withheld and any necessary additional comfort care be provided until I die peacefully, in a painless, humane, and dignified manner.

I understand that I have a condition that qualifies me for palliative sedation under the End-of-life Care Act, and I ask my attending physician to prescribe or deliver medication appropriate for this purpose. I trust and hope that he or she will comply. If he or she declines, which is his or her right, then I urge that he or she assist in transferring my care to a colleague who will comply.

This recorded request shall remain valid until revoked by me and only me. I may revoke this request at any time.

It is solely my option, and not my physician's, to inform my family of my intentions.

I have given full consideration to other options for end-of-life care that have been discussed with me by my attending physician and I understand the full import of this recorded request. I accept the moral and legal responsibility for receiving palliative sedation.

Signed:........................... Date: ........................

(Patient's signature or mark)

City and State of Residence......................................

NOTICE - This recorded request is not valid unless it is signed by two qualified witnesses who are present when you sign or acknowledge your signature. The witnesses must not be related to you by blood, marriage, or adoption; they must not be entitled to any part of your estate, or, at the time of execution of the recorded request, have any claim against any portion of your estate; and they must not include your attending physician or an employee of your attending physician.

If you have attached any additional pages to this form, you must sign and date each of the additional pages at the same time you date and sign this recorded request.

STATEMENT OF WITNESSES

TO VOLUNTARY RECORDED REQUEST

I declare under penalty of perjury under the laws of the state of Washington that the person who signed or acknowledged this document is personally known to me (or proved to me on the basis of satisfactory evidence to be the qualified patient or lawful surrogate of the qualified patient of this recorded request); that he or she signed or acknowledged this recorded request in my presence; that he or she appears to be of sound mind and under no duress, fraud, or undue influence; that I am not the attending physician or an employee of the attending physician.

I further declare under penalty of perjury under the laws of the state of Washington that I am not related to the qualified patient by blood, marriage, or adoption; and, to the best of my knowledge, I am not entitled to any part of the estate of the qualified patient upon the death of the qualified patient under a will now existing or by operation of law; and have no claim nor anticipate making a claim against any portion of the estate of the qualified patient upon his or her death.

Dated: .........................................................

Witness's Signature: ...........................................

Print Name: ....................................................

Residence Address: .............................................

Dated: .........................................................

Witness's Signature: ...........................................

Print Name: ....................................................

Residence Address: .............................................

Sec. 16. RCW 70.122.020 and 1992 c 98 s 2 are each amended to read as follows:

Unless the context clearly requires otherwise, the definitions contained in this section shall apply throughout this chapter.

(1) "Adult person" means a person who has attained the age of majority as defined in RCW 26.28.010 and 26.28.015, and who has the capacity to make health care decisions.

(2) "Attending physician" means the physician selected by, or assigned to, the patient who has primary responsibility for the treatment and care of the patient.

(3) "Cardiopulmonary resuscitation" means measures to restore cardiac function or to support breathing in the event of cardiac or respiratory arrest or malfunction. These measures include cardiac compression, endotracheal intubation or other advanced airway management, artificial ventilation, defibrillation, administration of cardiac resuscitation medications, and related procedures.

(4) "Directive" means a written document voluntarily executed by the declarer generally consistent with the guidelines of RCW 70.122.030.

((~~(4)~~)) (5) "Double effect" means the process by which medication primarily intended to relieve the pain or suffering of a qualified patient may result in the known potential secondary effect of hastening death.

(6) "Health facility" means a hospital as defined in RCW 70.41.020(2) or a nursing home as defined in RCW 18.51.010, a home health agency or hospice agency as defined in RCW 70.126.010, or a boarding home as defined in RCW 18.20.020.

((~~(5)~~)) (7) "Life-sustaining treatment" means any medical or surgical intervention that uses mechanical or other artificial means, including artificially provided nutrition and hydration, to sustain, restore, or replace a vital function, which, when applied to a qualified patient, would serve only to prolong the process of dying. "Life-sustaining treatment" shall not include the administration of medication or the performance of any medical or surgical intervention deemed necessary solely to alleviate pain or suffering.

((~~(6)~~)) (8) "Pain" means an unpleasant physical sensation that is caused by injury, disease, or other abnormal condition, and that is experienced in varying degrees of severity most reliably indicated by the patient himself or herself.

(9) "Palliative care" means care, including the administration of medication, intended to relieve pain or suffering.

(10) "Palliative sedation" means aggressive palliative care even when sufficient dosage of medications to relieve pain or suffering may cause unconsciousness and may have the double effect of hastening death, so long as the patient chooses to receive it with that understanding.

(11) "Permanent unconscious condition" means an incurable and irreversible condition in which the patient is medically assessed within reasonable medical judgment as having no reasonable probability of recovery from an irreversible coma or a persistent vegetative state.

((~~(7)~~)) (12) "Physician" means a person licensed under chapters 18.71 or 18.57 RCW.

((~~(8)~~)) (13) "Qualified patient" means an adult person who is a patient diagnosed in writing to have a terminal condition by the patient's attending physician, who has personally examined the patient, or a patient who is diagnosed in writing to be in a permanent unconscious condition in accordance with accepted medical standards by two physicians, one of whom is the patient's attending physician, and both of whom have personally examined the patient.

((~~(9)~~)) (14) "Suffering" means physical or psychological distress, with or without pain, as a result of a patient's medical condition. Symptoms of suffering are most reliably indicated by the patient himself or herself and may include, but are not limited to, agonized breathing, agitated delirium or confusion, persistent vomiting, extreme fear, or panic.

Sec. 17. RCW 70.122.030 and 1992 c 98 s 3 are each amended to read as follows:

(1) Any adult person may execute a directive directing the withholding or withdrawal of life-sustaining treatment and the administration of aggressive palliative care for the relief of pain or suffering in a terminal condition or permanent unconscious condition. The directive shall be signed by the declarer in the presence of two witnesses not related to the declarer by blood or marriage and who would not be entitled to any portion of the estate of the declarer upon declarer's decease under any will of the declarer or codicil thereto then existing or, at the time of the directive, by operation of law then existing. In addition, a witness to a directive shall not be the attending physician, an employee of the attending physician or a health facility in which the declarer is a patient, or any person who has a claim against any portion of the estate of the declarer upon declarer's decease at the time of the execution of the directive. The directive, or a copy thereof, shall be made part of the patient's medical records retained by the attending physician, a copy of which shall be forwarded by the custodian of the records to the health facility when the withholding or withdrawal of life-support treatment or the administration of aggressive palliative care is contemplated. The directive may be in the following form, but in addition may include other specific directions:

Health Care Directive

Directive made this . . . . day of . . . . . . (month, year).

I . . . . . ., having the capacity to make health care decisions, willfully, and voluntarily make known my desire that my dying shall not be artificially prolonged, and my pain or suffering shall be relieved, under the circumstances set forth below, and do hereby declare that:

(a) If at any time I should be diagnosed in writing to be in a terminal condition by the attending physician, or in a permanent unconscious condition by two physicians, and where the application of life-sustaining treatment would serve only to artificially prolong the process of my dying, I direct that such treatment be withheld or withdrawn, and that I be permitted to die naturally. I further direct that if I indicate by word or physical expression that I am experiencing pain or suffering as a result of my medical condition, palliative care be administered that will relieve my pain or suffering even if such palliative care may have the double effect of hastening my death. I understand by using this form that a terminal condition means an incurable and irreversible condition caused by injury, disease, or illness, that would within reasonable medical judgment cause death within a reasonable period of time in accordance with accepted medical standards, and where the application of life-sustaining treatment would serve only to prolong the process of dying. I further understand in using this form that a permanent unconscious condition means an incurable and irreversible condition in which I am medically assessed within reasonable medical judgment as having no reasonable probability of recovery from an irreversible coma or a persistent vegetative state.

(b) In the absence of my ability to give directions regarding the use of such life-sustaining treatment and the administration of such palliative care, it is my intention that this directive shall be honored by my family and physician(s) as the final expression of my legal right to refuse medical or surgical treatment and my right to request the full range of palliative care available, including palliative sedation, to relieve pain or suffering and I accept the consequences of such refusal and request. If another person is appointed to make these decisions for me, whether through a durable power of attorney or otherwise, I request that the person be guided by this directive and any other clear expressions of my desires.

I DO want to have artificially provided nutrition and hydration.

I DO NOT want to have artificially provided nutrition and hydration.

(d) If I am diagnosed to be in a terminal condition or in a permanent unconscious condition and by word or expression I indicate that I am experiencing pain or suffering as a result of my medical condition (check one):

I DO want the full range of palliative care available, including palliative sedation, even when sufficient dosage of medications to relieve my pain or suffering may cause unconsciousness and may have the double effect of hastening my death.

I DO NOT want palliative sedation.

(e) If I am diagnosed to be in a terminal condition or in a permanent unconscious condition (check one):

I DO want cardiopulmonary resuscitation attempted in the event of cardiac or respiratory arrest.

I DO NOT want cardiopulmonary resuscitation attempted in the event of cardiac or respiratory arrest.

(f) If I have been diagnosed as pregnant and that diagnosis is known to my physician, this directive shall have no force or effect during the course of my pregnancy.

((~~(e)~~)) (g) I understand the full import of this directive and I am emotionally and mentally capable to make the health care decisions contained in this directive.

((~~(f)~~)) (h) I understand that before I sign this directive, I can add to or delete from or otherwise change the wording of this directive and that I may add to or delete from this directive at any time and that any changes shall be consistent with Washington state law or federal constitutional law to be legally valid.

((~~(g)~~)) (i) It is my wish that every part of this directive be fully implemented. If for any reason any part is held invalid it is my wish that the remainder of my directive be implemented.

Signed.............................

City, County, and State of Residence

The declarer has been personally known to me and I believe him or her to be capable of making health care decisions.

Witness............................

(2) Prior to withholding or withdrawing life-sustaining treatment, implementing a do not attempt resuscitation order, or administering palliative sedation, the diagnosis of a terminal condition by the attending physician or the diagnosis of a permanent unconscious state by two physicians shall be entered in writing and made a permanent part of the patient's medical records.

(3) A directive executed in another political jurisdiction is valid to the extent permitted by Washington state law and federal constitutional law.

NEW SECTION. Sec. 18. CODIFICATION. Sections 1 through 15 and 19 of this act constitute a new chapter in Title 70 RCW.

NEW SECTION. Sec. 19. CAPTIONS NOT LAWS. Captions as used in this act constitute no part of the law.

NEW SECTION. Sec. 20. SEVERABILITY. If any provision of this act or its application to any person or circumstance is held invalid, the remainder of the act or the application of the provision to other persons or circumstances is not affected.