(a) Purpose. The purpose of this section shall be to establish a statewide OOH-DNR protocol as required in the Health and Safety Code, Title 2, Chapter 166.     
      (b) Out-of-Hospital DNR order. An OOH-DNR order may be issued by an attending physician for any patient. That attending physician has responsibility for ensuring that the form is filled out in its entirety and that the information regarding the existence of an OOH-DNR order is entered into the patient's medical record.     
      (c) Protocol development. An OOH-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) a copy of the Department of State Health Services (department) standardized OOH-DNR order form listing the designated treatments that shall be withdrawn or withheld. Those treatments shall be:                  (A) cardiopulmonary resuscitation;                   (B) advanced airway management;                   (C) artificial ventilation;                   (D) defibrillation; and                   (E) transcutaneous cardiac pacing.         
        (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) an on-site OOH-DNR dispute resolution process which includes contacting an appropriate physician.       
      (d) Recordkeeping. Records shall be maintained on each incident in which an OOH-DNR order or OOH-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) The data documented should include:                  (A) an assessment of patient's physical condition;                   (B) whether an identification device or an OOH-DNR form was used to confirm DNR status and patient identification number;                   (C) any problems relating to the implementation of the OOH-DNR order;                   (D) the name of the patient's attending physician; and                   (E) the full name, address, telephone number, and relationship to patient of any witness used to identify the patient.         
        (2) These records must be maintained and shall meet records retention requirements for each health care profession.       
        (3) If the patient is transported, the original OOH-DNR order or a copy of the original order will be kept with the patient.       
        (4) Copies of the original OOH-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.       
      (e) Out-of-state OOH-DNR Orders. Personnel may accept an OOH-DNR order or device that has been executed in any other state, if there is no reason to question the authenticity of the order or device.     
      (f) Failure to honor an OOH-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.     
      (g) Pregnant persons. A person may not withhold the designated treatments listed in subsection (c)(1) from a person known by responding healthcare professionals to be pregnant.     
      (h) Out-of-Hospital DNR Form. The executive commissioner or the commissioner's appointees shall furnish the department's OOH-DNR order forms to physicians, clinics, hospitals, nursing homes, hospices and home health agencies throughout the state upon request.      
        (1) The form shall contain all the information as prescribed in the Health and Safety Code, Chapter 166.       
        (2) The form shall be 8-1/2 inches by 11 inches, printed front and back, and in the format specified by the department as follows.        
          Attached Graphic         
      (i) Out-of-Hospital DNR Identification devices. As an optional means of identification, a patient may obtain, at patient's expense, an OOH-DNR device. An OOH-DNR device, as approved by the Department of State Health Services, must meet the following requirements:      
        (1) An intact, unaltered, easily identifiable plastic identification OOH-DNR bracelet, with the word "Texas" (or a representation of the geographical shape of Texas and the word "STOP" imposed over the shape) and the words "Do Not Resuscitate," shall be honored by qualified EMS personnel in lieu of an original OOH-DNR order form.       
        (2) An intact, unaltered, easily identifiable metal bracelet or necklace inscribed with the words, "Texas Do Not Resuscitate - OOH" shall be honored by qualified EMS personnel in lieu of an OOH-DNR order form.       
        (3) The person or entity who provides an OOH-DNR identification device to an individual shall send with the identification device a statement with the words, "Pursuant to Health and Safety Code, §166.090, this identification device may only be worn by a person who has executed a valid out-of-hospital DNR order."       
     Source Note:        The provisions of this §157.25 adopted to be effective June 15, 2000, 25 TexReg 5656; amended to be effective February 7, 2001, 26 TexReg 1143; amended to be effective July 29, 2004, 29 TexReg 7103; amended to be effective July 6, 2010, 35 TexReg 5888