To amend sections 2133.02, 2133.21, 2133.211, 2133.23, 2133.24, 2133.25, 2133.26, 3795.03, and 4730.09; to amend, for the purpose of adopting new section numbers as indicated in parentheses, sections 2133.211 (2133.23), 2133.23 (2133.24), 2133.24 (2133.25), 2133.25 (2133.26), and 2133.26 (2133.27); to enact new section 2133.22 and sections 2133.28 to 2133.47; and to repeal section 2133.22 of the Revised Code to establish procedures for the use of medical orders for life-sustaining treatment and to make changes to the laws governing DNR identification and orders.

Section 1. That sections 2133.02, 2133.21, 2133.211, 2133.23, 2133.24, 2133.25, 2133.26, 3795.03, and 4730.09 be amended; sections 2133.211 (2133.23), 2133.23 (2133.24), 2133.24 (2133.25), 2133.25 (2133.26), and 2133.26 (2133.27) be amended for the purpose of adopting new section numbers as indicated in parentheses; and new section 2133.22 and sections 2133.28, 2133.29, 2133.30, 2133.31, 2133.32, 2133.33, 2133.34, 2133.35, 2133.36, 2133.37, 2133.38, 2133.39, 2133.40, 2133.41, 2133.42, 2133.43, 2133.44, 2133.45, 2133.46, and 2133.47 of the Revised Code be enacted to read as follows:

Sec. 2133.02.  (A)(1) An adult who is of sound mind voluntarily may execute at any time a declaration governing the use or continuation, or the withholding or withdrawal, of life-sustaining treatment. The declaration shall be signed at the end by the declarant or by another individual at the direction of the declarant, state the date of its execution, and either be witnessed as described in division (B)(1) of this section or be acknowledged by the declarant in accordance with division (B)(2) of this section. The declaration may include a designation by the declarant of one or more persons who are to be notified by the declarant's attending physician at any time that life-sustaining treatment would be withheld or withdrawn pursuant to the declaration. The declaration may include a specific authorization for the use or continuation or the withholding or withdrawal of CPR, but the failure to include a specific authorization for the withholding or withdrawal of CPR does not preclude the withholding or withdrawal of CPR in accordance with sections 2133.01 to 2133.15 or sections 2133.21 to 2133.26 2133.29 of the Revised Code.

(2) Depending upon whether the declarant intends the declaration to apply when the declarant is in a terminal condition, in a permanently unconscious state, or in either a terminal condition or a permanently unconscious state, the declarant's declaration shall use either or both of the terms "terminal condition" and "permanently unconscious state" and shall define or otherwise explain those terms in a manner that is substantially consistent with the provisions of section 2133.01 of the Revised Code.

(3)(a) If a declarant who has authorized the withholding or withdrawal of life-sustaining treatment intends that the declarant's attending physician withhold or withdraw nutrition or hydration when the declarant is in a permanently unconscious state and when the nutrition and hydration will not or no longer will serve to provide comfort to the declarant or alleviate the declarant's pain, then the declarant shall authorize the declarant's attending physician to withhold or withdraw nutrition or hydration when the declarant is in the permanently unconscious state by doing both of the following in the declaration:

(i) Including a statement in capital letters or other conspicuous type, including, but not limited to, a different font, bigger type, or boldface type, that the declarant's attending physician may withhold or withdraw nutrition and hydration if the declarant is in a permanently unconscious state and if the declarant's attending physician and at least one other physician who has examined the declarant determine, to a reasonable degree of medical certainty and in accordance with reasonable medical standards, that nutrition or hydration will not or no longer will serve to provide comfort to the declarant or alleviate the declarant's pain, or checking or otherwise marking a box or line that is adjacent to a similar statement on a printed form of a declaration;

(ii) Placing the declarant's initials or signature underneath or adjacent to the statement, check, or other mark described in division (A)(3)(a)(i) of this section.

(b) Division (A)(3)(a) of this section does not apply to the extent that a declaration authorizes the withholding or withdrawal of life-sustaining treatment when a declarant is in a terminal condition. The provisions of division (E) of section 2133.12 of the Revised Code pertaining to comfort care shall apply to a declarant in a terminal condition.

(B)(1) If witnessed for purposes of division (A) of this section, a declaration shall be witnessed by two individuals as described in this division in whose presence the declarant, or another individual at the direction of the declarant, signed the declaration. The witnesses to a declaration shall be adults who are not related to the declarant by blood, marriage, or adoption, who are not the attending physician of the declarant, and who are not the administrator of any nursing home in which the declarant is receiving care. Each witness shall subscribe the witness' signature after the signature of the declarant or other individual at the direction of the declarant and, by doing so, attest to the witness' belief that the declarant appears to be of sound mind and not under or subject to duress, fraud, or undue influence. The signatures of the declarant or other individual at the direction of the declarant under division (A) of this section and of the witnesses under this division are not required to appear on the same page of the declaration.

(2) If acknowledged for purposes of division (A) of this section, a declaration shall be acknowledged before a notary public, who shall make the certification described in section 147.53 of the Revised Code and also shall attest that the declarant appears to be of sound mind and not under or subject to duress, fraud, or undue influence.

(C) An attending physician, or other health care personnel acting under the direction of an attending physician, who is furnished a copy of a declaration shall make it a part of the declarant's medical record and, when section 2133.05 of the Revised Code is applicable, also shall comply with that section.

(D)(1) Subject to division (D)(2) of this section, an attending physician of a declarant or a health care facility in which a declarant is confined may refuse to comply or allow compliance with the declarant's declaration on the basis of a matter of conscience or on another basis. An employee or agent of an attending physician of a declarant or of a health care facility in which a declarant is confined may refuse to comply with the declarant's declaration on the basis of a matter of conscience.

(2) If an attending physician of a declarant or a health care facility in which a declarant is confined is not willing or not able to comply or allow compliance with the declarant's declaration, the physician or facility promptly shall so advise the declarant and comply with the provisions of section 2133.10 of the Revised Code, or, if the declaration has become operative as described in division (A) of section 2133.03 of the Revised Code, shall comply with the provisions of section 2133.10 of the Revised Code.

(E) As used in this section, "CPR" has the same meaning as in section 2133.21 of the Revised Code.

Sec. 2133.21.  As used in this section and sections 2133.21 2133.211 to 2133.26 2133.29 of the Revised Code, unless the context clearly requires otherwise:

(A) "Attending physician" means the physician to whom a person, or the family of a person, has assigned primary responsibility for the treatment or care of the person or, if the person or the person's family has not assigned that responsibility, the physician who has accepted that responsibility.

(B) "CPR" means cardiopulmonary resuscitation or a component of cardiopulmonary resuscitation, but it does not include clearing a person's airway for a purpose other than as a component of CPR.

(C) "Declaration," "health care facility," "life-sustaining treatment," "physician," "professional disciplinary action," and "tort action" have the same meanings as in section 2133.01 of the Revised Code means a document executed in accordance with section 2133.02 of the Revised Code.

(C)(D) "DNR identification" means a standardized identification card, form, necklace, or bracelet that is of uniform size and design, that has been approved by the department of health pursuant to former section 2133.25 of the Revised Code, and that signifies either at least one of the following:

(1) That the person who is named on and possesses the card, form, necklace, or bracelet has executed a declaration that authorizes the withholding or withdrawal of CPR and that has not been revoked pursuant to section 2133.04 of the Revised Code;

(2) That the attending physician of the person who is named on and possesses the card, form, necklace, or bracelet has issued a current do-not-resuscitate order, in accordance with the do-not-resuscitate protocol adopted by the department of health pursuant to section 2133.25 of the Revised Code, for that person and has documented the grounds for the order in that person's medical record.;

(3) That an issuing practitioner has completed a MOLST form that has not been revoked as described in section 2133.38 of the Revised Code.

(D)(E) "Do-not-resuscitate order" means a written directive issued by a physician prior to or not later than six months after the effective date of this amendment in accordance with the do-not-resuscitate protocol that identifies a person and specifies that CPR should not be administered to the person so identified.

(E)(F) "Do-not-resuscitate protocol" means the standardized method of procedure for the withholding of CPR by physicians, emergency medical service services personnel, and health care facilities that is was adopted in the rules of the department of health pursuant to former section 2133.25 of the Revised Code.

(F)(G) "Emergency medical services personnel" means paid or volunteer firefighters,; law enforcement officers,; medical technicians; any of the following, as defined in section 4765.01 of the Revised Code: first responders, emergency medical technicians-basic, emergency medical technicians-intermediate, or emergency medical technicians-paramedic, medical technicians,; or other emergency services personnel acting within the ordinary course of their profession.

(G) "CPR" means cardiopulmonary resuscitation or a component of cardiopulmonary resuscitation, but it does not include clearing a person's airway for a purpose other than as a component of CPR.

(H) "Health care facility," "life-sustaining treatment," "physician," "professional disciplinary action," and "tort action" have the same meanings as in section 2133.01 of the Revised Code.

(I) "Issuing practitioner" has the same meaning as in section 2133.30 of the Revised Code.

(J) "MOLST form" means the form specified in section 2133.31 of the Revised Code.

Sec. 2133.22.  Nothing in sections 2133.23 to 2133.29 of the Revised Code condones, authorizes, or approves of mercy killing, assisted suicide, or euthanasia.

Sec. 2133.211 2133.23.  A person who holds a certificate of authority to practice as a certified nurse practitioner or, clinical nurse specialist issued under section 4723.42 of the Revised Code, or physician assistant may take any action that may be taken by an attending physician under sections 2133.21 2133.22 to 2133.26 2133.29 of the Revised Code and has the immunity provided by section 2133.22 2133.29 of the Revised Code if, as applicable, the action is taken pursuant to a standard care arrangement with a collaborating physician, a physician supervisory plan approved under section 4730.17 of the Revised Code, or the policies of the health care facility in which the physician assistant is practicing.

Sec. 2133.23 2133.24.  (A) If emergency medical services personnel, other than physicians, are presented with DNR identification possessed by a person or are presented with a written do-not-resuscitate order for a person or if a physician directly issues to emergency medical services personnel, other than physicians, an oral do-not-resuscitate order for a person, the emergency medical services personnel shall comply with the do-not-resuscitate protocol for the person. If an oral do-not-resuscitate order is issued by a physician who is not present at the scene, the emergency medical services personnel shall verify the physician's identity instructions signified by the DNR identification or in the do-not-resuscitate order.

(B) If a person possesses DNR identification and if the person's attending physician or the health care facility in which the person is located is unwilling or unable to comply with the do-not-resuscitate protocol for the person instructions signified by the person's DNR identification or in the do-not-resuscitate order, the attending physician or the health care facility shall not prevent or attempt to prevent, or unreasonably delay or attempt to delay, the transfer of the person to a different physician who will follow the protocol instructions or to a different health care facility in which the protocol instructions will be followed.

(C) If a person who being transferred from one health care facility to another possesses DNR identification or for whom a current, has executed a declaration, or is the subject of a do-not-resuscitate order that has been issued is being transferred from one health care facility to another, before or at the time of the transfer, the transferring health care facility shall notify the receiving health care facility and the persons transporting the person of the existence of the DNR identification or the order, declaration, or do-not-resuscitate order. The notice shall be given before or at the time of the transfer. If a current do-not-resuscitate order was issued orally, it shall be reduced to writing before the time of the transfer. The DNR identification or the order, declaration, or do-not-resuscitate order shall accompany the person to the receiving health care facility and shall remain in effect unless it is revoked or unless, in the case of a do-not-resuscitate order, the order no longer is current.

(D) If emergency medical services personnel, a physician, or a health care facility is aware that a person's DNR identification signifies that the person is the subject of a MOLST form, the emergency medical services personnel, physician, or health care facility shall comply with sections 2133.30 to 2133.47 of the Revised Code.

Sec. 2133.24 2133.25.  (A) The death of a person resulting from the withholding or withdrawal of CPR for from the person pursuant to the do-not-resuscitate protocol and in the circumstances described in section 2133.22 of the Revised Code or in accordance with division (A) of section 2133.23 of the Revised Code instructions in a declaration executed by the person, a do-not-resuscitate order that has been issued for the person, or pursuant to instructions that form the basis of the person's DNR identification does not constitute for any purpose a suicide, aggravated murder, murder, or any other homicide.

(B)(1) If a person has executed a declaration, a do-not-resuscitate order has been issued for the person, or the person possesses DNR identification or if a current do-not-resuscitate order has been issued for a person, the existence of the declaration, do-not-resuscitate order, or the possession or order of the DNR identification shall not do either of the following:

(a) Affect in any manner the sale, procurement, issuance, or renewal of a policy of life insurance or annuity, notwithstanding any term of a policy or annuity to the contrary;

(b) Be deemed to modify in any manner or invalidate the terms of any policy of life insurance or annuity that is in effect on the effective date of this section.

(2) Notwithstanding any term of a policy of life insurance or annuity to the contrary, the withholding or withdrawal of CPR from a person who is insured or covered under the policy or annuity and who possesses DNR identification or for whom a current do-not-resuscitate order has been issued, in accordance with sections 2133.21 to 2133.26 of the Revised Code, who has executed a declaration, or for whom a do-not-resuscitate order has been issued shall not impair or invalidate any policy of life insurance or annuity.

(3) Notwithstanding any term of a policy or plan to the contrary, neither of the following shall impair or invalidate any policy of health insurance or other health care benefit plan:

(a) The withholding or withdrawal in accordance with sections 2133.21 to 2133.26 2133.29 of the Revised Code of CPR from a person who is insured or covered under the policy or plan and who possesses DNR identification or for whom a current do-not-resuscitate order has been issued, who has executed a declaration, or for whom a do-not-resuscitate order has been issued;

(b) The provision in accordance with sections 2133.21 to 2133.26 2133.29 of the Revised Code of CPR to a person of the nature described in division (B)(3)(a) of this section.

(4) No physician, health care facility, other health care provider, person authorized to engage in the business of insurance in this state under Title XXXIX of the Revised Code, health insuring corporation, other health care benefit plan, legal entity that is self-insured and provides benefits to its employees or members, or other person shall require an individual to possess DNR identification, execute a declaration, or have a do-not-resuscitate order issued, or shall require an individual to revoke or refrain from possessing DNR identification, as a condition of being insured or of receiving health care benefits or services.

(C)(1) Sections 2133.21 to 2133.26 2133.29 of the Revised Code do not create any presumption concerning the intent of an individual who does not possess DNR identification with respect to the use, continuation, withholding, or withdrawal of CPR.

(2) Sections 2133.21 to 2133.26 2133.29 of the Revised Code do not affect the right of a person to make informed decisions regarding the use, continuation, withholding, or withdrawal of CPR for the person as long as the person is able to make those decisions.

(3) Sections 2133.21 to 2133.26 2133.29 of the Revised Code are in addition to and independent of, and do not limit, impair, or supersede, any right or responsibility that a person has to effect the withholding or withdrawal of life-sustaining treatment to another pursuant to sections 2133.01 to 2133.15 or sections 2133.30 to 2133.47 of the Revised Code or in any other lawful manner.

(D) Nothing in sections 2133.21 to 2133.26 of the Revised Code condones, authorizes, or approves of mercy killing, assisted suicide, or euthanasia.

Sec. 2133.25 2133.26.  (A) The department of health, by rule adopted pursuant to Chapter 119. of the Revised Code, shall adopt a standardized method of procedure for the withholding of CPR by physicians, emergency medical services personnel, and health care facilities in accordance with sections 2133.21 to 2133.26 of the Revised Code. The standardized method shall specify criteria for determining when a do-not-resuscitate order issued by a physician is current. The standardized method so adopted shall be the "do-not-resuscitate protocol" for purposes of sections 2133.21 to 2133.26 of the Revised Code. The department also shall approve one or more standard forms of DNR identification to be used throughout this state and shall specify one or more procedures for revoking the forms of identification.

(B) The department of health shall adopt rules in accordance with Chapter 119. of the Revised Code for the administration of sections 2133.21 to 2133.26 of the Revised Code The do-not-resuscitate protocol adopted by the department in rules adopted under former section 2133.25 of the Revised Code are effective only for do-not-resuscitate orders issued on a date that is not later than six months after the effective date of this amendment. The criteria for determining when a do-not-resuscitate order is current apply only to orders issued before that date.

(C) The department of health shall appoint an advisory committee to advise the department in the development of rules under this section. The advisory committee shall include, but shall not be limited to, representatives of each of the following organizations:

(1) The association for hospitals and health systems (OHA);

(2) The Ohio state medical association;

(3) The Ohio chapter of the American college of emergency physicians;

(4) The Ohio hospice organization;

(5) The Ohio council for home care;

(6) The Ohio health care association;

(7) The Ohio ambulance association;

(8) The Ohio medical directors association;

(9) The Ohio association of emergency medical services;

(10) The bioethics network of Ohio;

(11) The Ohio nurses association;

(12) The Ohio academy of nursing homes;

(13) The Ohio association of professional firefighters;

(14) The department of developmental disabilities;

(15) The Ohio osteopathic association;

(16) The association of Ohio philanthropic homes, housing and services for the aging;

(17) The catholic conference of Ohio;

(18) The department of aging;

(19) The department of mental health and addiction services;

(20) The Ohio private residential association;

(21) The northern Ohio fire fighters association.

Sec. 2133.26 2133.27.  (A)(1) No physician shall purposely prevent or attempt to prevent, or delay or unreasonably attempt to delay, the transfer of a patient in violation of division (B) of section 2133.23 2133.24 of the Revised Code.

(2) No person shall purposely conceal, cancel, deface, or obliterate the DNR identification of another person without the consent of the other person.

(3) No person shall purposely falsify or forge a revocation of a declaration that is the basis of the DNR identification of another person or purposely falsify or forge an order of a physician that purports to supersede a do-not-resuscitate order issued for another person.

(4) No person shall purposely falsify or forge the DNR identification of another person with the intent to cause the use, withholding, or withdrawal of CPR for the other person.

(5) No person who has personal knowledge that another person has revoked a declaration that is the basis of the other person's DNR identification or personal knowledge that a physician has issued an order that supersedes a do-not-resuscitate order that the physician issued for another person Neither of the following shall purposely conceal or withhold that personal knowledge with the intent to cause the use, withholding, or withdrawal of CPR for the other person:

(a) A person who has personal knowledge that another person has revoked a declaration that is the basis of the other person's DNR identification;

(b) A person who has personal knowledge that a physician has issued an order that supersedes a do-not-resuscitate order that the physician issued for another person.

(B)(1) Whoever violates division (A)(1) or (5) of this section is guilty of a misdemeanor of the third degree.

(2) Whoever violates division (A)(2), (3), or (4) of this section is guilty of a misdemeanor of the first degree.

Sec. 2133.28. (A) None of the following shall be subject to criminal prosecution, liability in damages in a tort or other civil action for injury, death, or loss to person or property, or professional disciplinary action arising out of or relating to the withholding or withdrawal of CPR from a person after DNR identification is discovered in the person's possession and reasonable efforts have been made to determine that the person in possession of the DNR identification is the person named on the identification, if the withholding or withdrawal is in accordance with the instructions signified by the DNR identification:

(1) The health care facility in which the person is present, the administrator of that facility, and any person who works for the facility as an employee or contractor, or who volunteers at the health care facility, and who participates under the direction of or with the authorization of a physician in the withholding or withdrawal of CPR from the person possessing the DNR identification;

(2) A physician who causes the withholding or withdrawal of CPR from a person who possesses DNR identification;

(3) Any emergency medical services personnel who cause or participate in the withholding or withdrawal of CPR from the person possessing the DNR identification.

(B) If, after DNR identification is discovered in the possession of a person, the person makes an oral or written request to receive CPR, any person who provides CPR pursuant to the request, any health care facility in which CPR is provided, and the administrator of any health care facility in which CPR is provided are not subject to criminal prosecution as a result of the provision of CPR, are not liable in damages in tort or other civil action for injury, death, or loss to person or property that arises out of or is related to the provision of CPR, and are not subject to professional disciplinary action as a result of the provision of CPR.

Sec. 2133.29. (A) In an emergency situation, emergency medical services personnel are not required to search a person to determine if the person possesses DNR identification. If emergency medical services personnel or emergency department personnel provide CPR to a person in possession of DNR identification in an emergency situation, and if, at that time, the personnel do not know and do not have reasonable cause to believe that the person possesses DNR identification, the emergency medical services personnel and emergency department personnel are not subject to criminal prosecution as a result of the provision of the CPR, are not liable in damages in tort or other civil action for injury, death, or loss to person or property that arises out of or is related to the provision of CPR, and are not subject to professional disciplinary action as a result of the provision of CPR.

(B) Nothing in this section or sections 2133.21 to 2133.29 of the Revised Code grants immunity to a physician for issuing a do-not-resuscitate order that is contrary to reasonable medical standards or that the physician knows or has reason to know is contrary to the wishes of the patient or of a person who is authorized to make informed medical decisions on the patient's behalf.

Sec. 2133.30. As used in this section and sections 2133.31 to 2133.47 of the Revised Code:

(A) "Attending physician" means the physician to whom a patient or patient's family has assigned primary responsibility for the medical treatment or care of the patient or, if the responsibility has not been assigned, the physician who has accepted that responsibility.

(B) "Certified nurse practitioner" and "clinical nurse specialist" have the same meanings as in section 4723.01 of the Revised Code.

(C) "Comfort care" means any of the following:

(1) Nutrition when administered to diminish pain or discomfort, but not to postpone death;

(2) Hydration when administered to diminish pain or discomfort, but not to postpone death;

(3) Any other medical or nursing procedure, treatment, intervention, or other measure that is taken to diminish pain or discomfort, but not to postpone death.

(D) "CPR" has the same meaning as in section 2133.21 of the Revised Code.

(E) "Declaration" means a document executed in accordance with section 2133.02 of the Revised Code.

(F) "DNR identification" and "do-not-resuscitate order" have the same meanings as in section 2133.21 of the Revised Code.

(G) "Durable power of attorney for health care" means a document created pursuant to sections 1337.11 to 1337.17 of the Revised Code.

(H) "Emergency medical services person" is the singular of "emergency medical services personnel," as defined in section 2133.21 of the Revised Code.

(I) "Form preparer" means the issuing practitioner who completes and signs a medical orders for life-sustaining treatment form or the individual who completes the form pursuant to the practitioner's delegation and for the practitioner's signature.

(J) "Guardian" has the same meaning as in section 2133.01 of the Revised Code.

(K) "Health care facility" means any of the following:

(1) A health care facility, as defined in section 1337.11 of the Revised Code;

(2) An ambulatory surgical facility, as defined in section 3702.30 of the Revised Code;

(3) A residential care facility, as defined in section 3721.01 of the Revised Code;

(4) A freestanding dialysis center.

(L) "Issuing practitioner" means a physician, physician assistant, certified nurse practitioner, or clinical nurse specialist who issues medical orders for life-sustaining treatment for a patient by signing as the issuing practitioner the medical orders for life-sustaining treatment form for the patient.

(M) "Life-sustaining treatment" means any medical procedure, treatment, intervention, or other measure that, when administered to a patient, is intended to serve principally to prolong the process of dying.

(N) "Medical orders for life-sustaining treatment" means instructions, issued by a physician, physician assistant, certified nurse practitioner, or clinical nurse specialist, regarding how a patient should be treated with respect to hospitalization, administration or withdrawal of life-sustaining treatment and comfort care, administration of CPR, and other treatment prescribed by the Revised Code.

(O) "Medical orders for life-sustaining treatment form," "MOLST form," or "form" means the form specified in section 2133.31 of the Revised Code.

(P) "Medically administered hydration" means fluids that are technologically administered.

(Q) "Medically administered nutrition" means sustenance that is technologically administered.

(R) "Physician" means an individual authorized under Chapter 4731. of the Revised Code to practice medicine and surgery or osteopathic medicine and surgery.

(S) "Physician assistant" means an individual who holds a valid certificate to practice as a physician assistant issued under Chapter 4730. of the Revised Code.

Sec. 2133.31. A medical orders for life-sustaining treatment form shall be substantially in the following form. It is recommended that the patient's name and date of birth, as shown below with the form's title, appear on a page separate from the remaining pages of the form.

Patient's Name (printed): .....................................

Patient's Date of Birth: ......................................

There is no requirement that a patient or the patient's parent, guardian, legal custodian, or representative execute a medical orders for life-sustaining treatment form (MOLST form).

These medical orders are based on the patient's medical condition and advance directives or preferences at the time the orders were issued. An incomplete section does not invalidate the form and implies full treatment for that section.

Each patient shall be treated with dignity and respect and attention shall be given to the patient's needs. The duty of medicine is to care for the patient even when the patient cannot be cured. Moral judgments about the use of technology to maintain life shall reflect the inherent dignity of human life and the duty of medical care.

The instructions in this form shall be followed in accordance with Ohio law, including restrictions in Ohio Revised Code section 2133.09 governing the removal of life-sustaining treatment from an adult who currently is, and for at least the immediately preceding twelve months has been, in a permanently unconscious state.

This form may be revoked at any time and in any manner that communicates the intent to revoke.

When signed, this form supersedes all previously signed MOLST forms.

A. CARDIOPULMONARY RESUSCITATION (CPR): Individual has no pulse and is not breathing. Check only one:

[ ] Attempt resuscitation/CPR. With full treatment and intervention including intubation, advanced airway interventions, mechanical ventilation, defibrillation, and cardioversion as indicated. Transfer to intensive care if indicated.

[ ] Do NOT attempt resuscitation/DNR (no CPR).

When patient is not in cardiopulmonary arrest, follow the orders in sections B, C, and D.

B. MEDICAL INTERVENTIONS: Patient has a pulse, is breathing, or both. Check only one:

[ ] Full intervention. Includes all care described in this subsection. Use intubation, advanced airway interventions, mechanical ventilation, and cardioversion as indicated. Transfer to intensive care if indicated.

Additional order/instructions: ...............................

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

[ ] Limited additional interventions. Includes all care described in this subsection. Use medical treatment, intravenous fluids, and cardiac monitor as indicated. Do not use intubation, advanced airway interventions, or mechanical ventilation. May consider airway support (e.g., CPAP, BiPAP). Avoid intensive care.

Additional order/instructions: ...............................

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

[ ] Comfort measures only. Use medication by any route, positioning, wound care, and other measures to relieve pain and suffering. Use oxygen, suction, and manual treatment of airway obstruction as needed for comfort. Do not transfer to higher level of care for life-sustaining treatment.

Additional order/instructions: ...............................

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

C. ANTIBIOTICS. Check only one:

[ ] Use antibiotics if medically indicated.

[ ] Determine use or limitation of antibiotics when infection occurs.

[ ] Do not use antibiotics. Use other measures to relieve symptoms.

Additional order/instructions: ...............................

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

D. MEDICALLY ADMINISTERED NUTRITION/HYDRATION

The administration of nutrition or hydration, or both, whether orally or by invasive means, shall occur except in the event that another condition arises which is life-limiting or irreversible in which the nutrition or hydration becomes a greater burden than benefit to the patient.

Always offer by mouth, if feasible. Check only one in each column:

Additional order/instructions: ...............................

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

E. AUTHORIZATION BY PATIENT OR DECISION MAKER

Patient possesses the following prior to execution of this form:

[ ] Declaration (living will) – Attach copy if available

[ ] Durable power of attorney for health care – Attach copy if available

Authorization name and signature belongs to (check only one):

[ ] Patient

[ ] Guardian appointed by a probate court pursuant to Ohio Revised Code Chapter 2111.

[ ] Attorney in fact under patient's durable power of attorney for health care

[ ] Next of kin as specified in Ohio Revised Code section 2133.08(B)(2) – (6)

[ ] Parent, guardian, or legal custodian of a minor

[ ] Other representative (print name and relationship to patient): ..............................................

Name (printed): ..............................................

Phone Contact: ...............................................

Signature (mandatory): .......................................

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

F. SIGNATURE OF PRACTITIONER

My signature in this section indicates, to the best of my knowledge, that these orders are consistent with the patient's current medical condition and preferences as indicated by the patient's advance directive, previous discussions with the person identified in Section E, above, or both.

Name of Physician, Physician Assistant, Certified Nurse Practitioner, or Clinical Nurse Specialist:

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

Signature of Physician, Physician Assistant, Certified Nurse Practitioner, or Clinical Nurse Specialist (mandatory):

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

G. REVIEW OF MOLST FORM

This form should be reviewed periodically, such as when the patient is transferred from one care setting or care level to another or there is a substantial change in the patient's health status. A new MOLST form should be completed if the patient wishes to make a substantive change to his or her treatment goal (e.g., reversal of a prior directive). When completing a new form, the old form must be properly revoked and retained in the medical chart.

To revoke the MOLST form, draw a line through the heading of this form, MEDICAL ORDERS FOR LIFE-SUSTAINING TREATMENT FORM ("MOLST FORM") and write "VOID" next to it in large letters. The "VOID" designation should be signed and dated.

Sec. 2133.32.  The department of health shall make a version of the MOLST form available on the department's internet web site. The form shall be made available in a format that can be downloaded free of charge and reproduced.

Sec. 2133.33.  A physician, physician assistant, certified nurse practitioner, or clinical nurse specialist may at any time issue medical orders for life-sustaining treatment for a patient by completing a MOLST form. Patients for whom medical orders for life-sustaining treatment are suggested, but not required, include those who are suffering from an illness that is in its advanced stages.

Once completed and signed in accordance with sections 2133.34 and 2133.35 of the Revised Code, a MOLST form is valid and the instructions in it become operative and govern how the patient who is the subject of the form is to be treated with respect to hospitalization, administration or withdrawal of life-sustaining treatment and comfort care, administration of CPR, and any other medical treatment specified on the form.

At all times, the issuance of medical orders for life-sustaining treatment shall be guided by prudent medical practice and standards.

Sec. 2133.34.  (A) Both of the following persons shall participate in completion of a MOLST form:

(1) The issuing practitioner, who shall sign and date the form in the space designated for the practitioner's signature and who may complete the form or delegate to another person the responsibility of the form's completion other than signing the form;

(2) The patient, who shall sign and date the form in the space designated for the patient's signature, unless either of the following is the case:

(a) A circumstance described in division (B) applies;

(b) The patient, in a separate written document, has authorized a representative, including an attorney in fact under the patient's durable power of attorney for health care, to revoke a MOLST form and complete a new form on the patient's behalf.

(B)(1) If the patient is at least eighteen years of age, incapacitated, has a legally effective durable power of attorney for health care, and is not already the subject of a valid MOLST form, the patient's attorney in fact under the patient's durable power of attorney for health care shall sign and date the form in the space designated for such signature and indicate the person's status as the patient's attorney in fact.

(2) If the patient is at least eighteen years of age, incapacitated, does not have a legally effective durable power of attorney for health care, and is not the subject of a valid MOLST form, the individual or class of individuals specified in the descending order of priority in division (B) of section 2133.08 of the Revised Code, subject to division (C) of that section, shall sign and date the form in the space designated for such signature or signatures and indicate the relationship to the patient.

(3) If the patient is under eighteen years of age, the parent, guardian, or legal custodian of the patient shall sign and date the form in the space designated for such signature and indicate the relationship to the patient.

Sec. 2133.35. (A) When completing a MOLST form, the form preparer shall discuss the instructions in the form with the patient or the individual or class of individuals who participate in the form's completion on the patient's behalf in accordance with division (A)(2) or (B) of section 2133.34 of the Revised Code. The instructions the form preparer lists on the form shall be consistent with the desires of that person or persons, except that if the patient is under eighteen years of age, the patient's parent, guardian, or legal custodian may not indicate instructions that would result in the withholding of medically indicated treatment, as defined in section 14 of the "Child Abuse Prevention, Adoption, and Family Services Act of 1988," 102 Stat. 117 (1988), 42 U.S.C. 5106g, as amended.

(B) A declaration or durable power of attorney for health care, or both, if a copy of one or both documents is furnished to the form preparer, may guide the discussion between the form preparer and the patient or other person or persons who participate in the form's completion.

Sec. 2133.36.  A completed MOLST form shall be placed in the paper or electronic medical record of the patient to whom it pertains. Whether maintained as part of a paper or electronic medical record, the form shall be readily available and retrievable.

Sec. 2133.37. (A) If a patient with a MOLST form is transferred from one health care facility to another health care facility, the health care facility initiating the transfer shall communicate the existence of, and send a copy of, the form to the receiving facility prior to the transfer. The copy may be sent by regular mail or by facsimile or other electronic means. A copy of the form is the same as the original.

(B) Consistent with section 2133.36 of the Revised Code, the copy of the MOLST form shall be placed in the patient's medical record immediately on receipt by the receiving facility. After admission, the attending physician shall review the MOLST form.

Sec. 2133.38.  The patient, the patient's authorized representative described in division (A)(2) or (B) of section 2133.34 of the Revised Code, or, if the patient is under eighteen years of age, the patient's parent, guardian, or legal custodian, may revoke a MOLST form at any time and in any manner that communicates the intent to revoke. A revoked MOLST form shall be retained in the patient's medical record.

Sec. 2133.39.  Unless revoked in accordance with section 2133.38 of the Revised Code, a MOLST form does not expire.

Sec. 2133.40. If an emergency medical services person determines in an emergency situation that either of the following applies, the emergency medical services person shall proceed to treat the patient as directed, verbally or in writing, by a physician, or, if applicable, the cooperating physician advisory board of the emergency medical service organization with which the emergency medical services person is affiliated:

(A) An instruction in the patient's MOLST form is inconsistent with an instruction in any of the following:

(1) A do-not-resuscitate order that applies to the patient;

(2) A general consent to treatment form signed by or on behalf of the patient;

(3) A declaration executed by the patient;

(4) A durable power of attorney for health care executed by the patient.

(B) The section of the MOLST form that relates to the patient's treatment in that emergency situation has not been completed.

Sec. 2133.41. (A) Subject to division (B) of this section, no health care facility, health care professional, emergency medical services person, or other individual who works for or volunteers at a health care facility as an employee, contractor, or volunteer and who is or who works or volunteers under the direction of or with the authorization of a physician, physician assistant, certified nurse practitioner, or clinical nurse specialist shall be subject to criminal prosecution, liable in damages in tort or other civil action, or subject to professional disciplinary action for acting in good faith and in accordance with, or otherwise being in compliance with, a valid MOLST form or sections 2133.31 to 2133.47 of the Revised Code.

(B) Division (A) of this section does not grant immunity from criminal or civil liability or from professional disciplinary action to a health care professional or emergency medical service person for actions that are outside the professional's or person's scope of authority.

Sec. 2133.42.  The death of an individual that occurs as a result of actions taken consistent with instructions in a MOLST form does not constitute for any purpose a suicide, aggravated murder, murder, or any other homicide.

Sec. 2133.43.  The issuance or non-issuance of a MOLST form shall not do any of the following:

(A) Affect in any manner the sale, procurement, issuance, or renewal of a policy of life insurance or annuity, notwithstanding any term of a policy or annuity to the contrary;

(B) Modify in any manner or invalidate the terms of a policy of life insurance or annuity that is in effect on the effective date of this section;

(C) Impair or invalidate a policy of life insurance or annuity or any health benefit plan.

Sec. 2133.44.  No physician, health care facility, other health care provider, person authorized to engage in the business of insurance in this state under Title XXXIX of the Revised Code, health insuring corporation, other health care benefit plan, legal entity that is self-insured and provides benefits to its employees or members, governmental entity, or other person shall require that an individual be the subject of a MOLST form, or require an individual to revoke or refrain from being the subject of a MOLST form, as a condition of being insured or of receiving health care benefits or services.

Sec. 2133.45.  (A) Subject to divisions (B) and (C) of this section, an attending physician of a patient or a health care facility in which a patient is located may refuse to comply or allow compliance with one or more instructions in a MOLST form on the basis of conscience or on another basis. An employee of an attending physician or of a health care facility in which a patient is located may refuse to comply with one or more instructions in a MOLST form on the basis of a matter of conscience.

(B) An attending physician of a patient who, or a health care facility in which a patient is confined that, is not willing or not able to comply or allow compliance with one or more instructions in a MOLST form shall immediately notify the patient or person who has signed the MOLST form on the patient's behalf under section 2133.34 of the Revised Code, and shall not prevent or attempt to prevent, or unreasonably delay or attempt to unreasonably delay, the transfer of the patient to the care of a physician who, or a health care facility that, is willing and able to so comply or allow compliance.

Sec. 2133.46. In the absence of actual knowledge to the contrary and if acting in good faith, an attending physician, other health care professional, emergency medical services person, or health care facility may assume that a MOLST form complies with sections 2133.31 to 2133.45 of the Revised Code and is valid.

Sec. 2133.47. Not later than sixty months after the effective date of this section, the director of health shall appoint a MOLST task force to perform a five-year review of medical orders for life-sustaining treatment and the MOLST form. Task force members shall be, or represent, persons or government entities that have experience with medical orders for life-sustaining treatment or the MOLST form. Not later than seventy-two months after the effective date of this section, the task force shall submit a report of its findings to the general assembly in accordance with section 101.68 of the Revised Code.

Members of the task force shall serve without compensation, but may be reimbursed for necessary expenses.

Sec. 3795.03. Nothing in section 3795.01 or 3795.02 of the Revised Code shall do any of the following:

(A) Prohibit or preclude a physician, certified nurse practitioner, certified nurse-midwife, or clinical nurse specialist who carries out the responsibility to provide comfort care to a patient in good faith and while acting within the scope of the physician's or nurse's authority from prescribing, dispensing, administering, or causing to be administered any particular medical procedure, treatment, intervention, or other measure to the patient, including, but not limited to, prescribing, personally furnishing, administering, or causing to be administered by judicious titration or in another manner any form of medication, for the purpose of diminishing the patient's pain or discomfort and not for the purpose of postponing or causing the patient's death, even though the medical procedure, treatment, intervention, or other measure may appear to hasten or increase the risk of the patient's death;

(B) Prohibit or preclude health care personnel acting under the direction of a person authorized to prescribe a patient's treatment and who carry out the responsibility to provide comfort care to the patient in good faith and while acting within the scope of their authority from dispensing, administering, or causing to be administered any particular medical procedure, treatment, intervention, or other measure to the patient, including, but not limited to, personally furnishing, administering, or causing to be administered by judicious titration or in another manner any form of medication, for the purpose of diminishing the patient's pain or discomfort and not for the purpose of postponing or causing the patient's death, even though the medical procedure, treatment, intervention, or other measure may appear to hasten or increase the risk of the patient's death;

(C) Prohibit or affect the use or continuation, or the withholding or withdrawal, of life-sustaining treatment, CPR, or comfort care under Chapter 2133. of the Revised Code;

(D) Prohibit or affect the provision or withholding of health care, life-sustaining treatment, or comfort care to a principal under a durable power of attorney for health care or any other health care decision made by an attorney in fact under sections 1337.11 to 1337.17 of the Revised Code;

(E) Affect or limit the authority of a physician, a health care facility, a person employed by or under contract with a health care facility, or emergency service medical services personnel to provide or withhold health care to a person in accordance with reasonable medical standards applicable in an emergency situation;

(F) Affect or limit the authority of a person to refuse to give informed consent to health care, including through the execution of a durable power of attorney for health care under sections 1337.11 to 1337.17 of the Revised Code, the execution of a declaration under sections 2133.01 to 2133.15 of the Revised Code, the completion of a MOLST form under sections 2133.30 to 2133.47 of the Revised Code, or authorizing the withholding or withdrawal of CPR under sections 2133.21 to 2133.26 2133.29 of the Revised Code.

Sec. 4730.09. (A) Under a physician supervisory plan approved under section 4730.17 of the Revised Code, a physician assistant may provide any or all of the following services without approval by the state medical board as special services:

(1) Obtaining comprehensive patient histories;

(2) Performing physical examinations, including audiometry screening, routine visual screening, and pelvic, rectal, and genital-urinary examinations, when indicated;

(3) Ordering, performing, or ordering and performing routine diagnostic procedures, as indicated;

(4) Identifying normal and abnormal findings on histories, physical examinations, and commonly performed diagnostic studies;

(5) Assessing patients and developing and implementing treatment plans for patients;

(6) Monitoring the effectiveness of therapeutic interventions;

(7) Exercising physician-delegated prescriptive authority pursuant to a certificate to prescribe issued under this chapter;

(8) Carrying out or relaying the supervising physician's orders for the administration of medication, to the extent permitted by law;

(9) Providing patient education;

(10) Instituting and changing orders on patient charts;

(11) Performing developmental screening examinations on children with regard to neurological, motor, and mental functions;

(12) Performing wound care management, suturing minor lacerations and removing the sutures, and incision and drainage of uncomplicated superficial abscesses;

(13) Removing superficial foreign bodies;

(14) Administering intravenous fluids;

(15) Inserting a foley or cudae catheter into the urinary bladder and removing the catheter;

(16) Performing biopsies of superficial lesions;

(17) Making appropriate referrals as directed by the supervising physician;

(18) Performing penile duplex ultrasound;

(19) Changing of a tracheostomy;

(20) Performing bone marrow aspirations from the posterior iliac crest;

(21) Performing bone marrow biopsies from the posterior iliac crest;

(22) Performing cystograms;

(23) Performing nephrostograms after physician placement of nephrostomy tubes;

(24) Fitting, inserting, or removing birth control devices;

(25) Removing cervical polyps;

(26) Performing nerve conduction testing;

(27) Performing endometrial biopsies;

(28) Inserting filiform and follower catheters;

(29) Performing arthrocentesis of the knee;

(30) Performing knee joint injections;

(31) Performing endotracheal intubation with successful completion of an advanced cardiac life support course;

(32) Performing lumbar punctures;

(33) In accordance with rules adopted by the board, using light-based medical devices for the purpose of hair removal;

(34) Administering, monitoring, or maintaining local anesthesia, as defined in section 4730.091 of the Revised Code;

(35) Applying or removing a cast or splint;

(36) Inserting or removing chest tubes;

(37) Prescribing physical therapy or referring a patient to a physical therapist for the purpose of receiving physical therapy;

(38) Ordering occupational therapy or referring a patient to an occupational therapist for the purpose of receiving occupational therapy;

(39) Taking any action that may be taken by an attending physician under sections 2133.21 to 2133.26 2133.29 of the Revised Code, as specified in section 2133.211 2133.23 of the Revised Code;

(40) Determining and pronouncing death in accordance with section 4730.092 of the Revised Code;

(41) Admitting patients to hospitals in accordance with section 3727.06 of the Revised Code;

(42) Performing other services that are within the supervising physician's normal course of practice and expertise, if the services are included in any model physician supervisory plan approved under section 4730.06 of the Revised Code or the services are designated by the board by rule or other means as services that are not subject to approval as special services.

(B) Under the policies of a health care facility, the services a physician assistant may provide are limited to the services the facility has authorized the physician assistant to provide for the facility. The services a health care facility may authorize a physician assistant to provide for the facility include the following:

(1) Any or all of the services specified in division (A) of this section;

(2) Assisting in surgery in the health care facility;

(3) Any other services permitted by the policies of the health care facility, except that the facility may not authorize a physician assistant to perform a service that is prohibited by this chapter.

Section 2. That existing sections 2133.02, 2133.21, 2133.211, 2133.23, 2133.24, 2133.25, 2133.26, 3795.03, and 4730.09 and section 2133.22 of the Revised Code are hereby repealed.