THE BILL ITSELF
HB 369
Patient-directed Medical Orders
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A bill to be entitled
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An act relating to patient-directed medical orders;
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amending s. 765.101, F.S.; revising definitions and
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defining the term "patient-directed medical order";
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amending s. 765.102, F.S.; revising legislative
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findings and intent; creating s. 765.3041, F.S.;
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authorizing the execution of a patient-directed
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medical order for a specified purpose; providing
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requirements for valid patient-directed medical
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orders; authorizing the use of telehealth for a
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specified purpose; requiring that certain health care
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services be provided to the principal regardless of
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the decision to withhold or withdraw life-prolonging
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procedures; authorizing physicians, physician
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assistants, and advanced practice registered nurses to
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withhold or withdraw life-prolonging procedures under
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certain circumstances without penalty; providing
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construction; amending ss. 395.1041, 400.142, 400.487,
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400.605, 400.6095, 400.611, 401.35, 401.45, 429.255,
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429.73, 744.4431, 752.001, 765.110, 765.204, 765.205,
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and 765.305, F.S.; conforming cross-references and
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provisions to changes made by the act; requiring the
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Agency for Health Care Administration to create and
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update a database for the storage of patient-directed
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medical orders; providing an effective date.
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Be It Enacted by the Legislature of the State of Florida:
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Section 1. Present subsections (15) through (22) of section 765.101, Florida Statutes, are redesignated as
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subsections (16) through (23), respectively, a new subsection
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(15) is added to that section, and subsections (1) and (7) of
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that section are amended, to read:
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765.101 Definitions.—As used in this chapter:
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(1) "Advance directive" means a witnessed written document
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or oral statement in which instructions are given by a principal
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or in which the principal's desires are expressed concerning any
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aspect of the principal's health care or health information, and
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includes, but is not limited to, the designation of a health
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care surrogate, a living will, or an anatomical gift made
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pursuant to part V of this chapter. An advance directive may
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also include a patient-directed medical order.
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(7) "Health care facility" means a hospital, nursing home,
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hospice, home health agency, or health maintenance organization
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licensed in this state; a, or any facility subject to part I of
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chapter 394; or an assisted living facility or adult family-care
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home licensed under chapter 429.
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(15) "Patient-directed medical order" means a medical
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order created by the principal in collaboration with a
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physician, a physician assistant, or an advanced practice
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registered nurse registered under s. 464.0123 which is portable
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across health care settings and accessible in a voluntary online
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registry.
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Section 2. Subsection (6) of section 765.102, Florida Statutes, is amended to read:
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765.102 Legislative findings and intent.—
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(6) For purposes of this chapter:
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(a) Palliative care is the comprehensive management of the
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physical, psychological, social, spiritual, and existential
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needs of patients. Palliative care is especially suited to the
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care of persons who have incurable or, progressive illnesses.
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(b) Palliative care may must include:
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1. An opportunity to discuss and plan for end-of-life
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care.
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2. Assurance that physical and mental suffering will be
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carefully attended to.
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3. Assurance that preferences for withholding and
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withdrawing life-sustaining interventions will be honored.
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4. Assurance that the personal goals of the dying person
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will be addressed.
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5. Assurance that the dignity of the dying person will be
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a priority.
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6. Assurance that health care providers will not abandon
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the dying person.
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7. Assurance that the burden to family and others will be
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addressed.
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8. Assurance that advance directives for care, orders not
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to resuscitate executed pursuant to s. 401.45, and patient-
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directed medical orders executed pursuant to s. 765.3041 will be
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respected regardless of the location of care.
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9. Assurance that organizational mechanisms are in place
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to evaluate the availability and quality of end-of-life,
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palliative, and hospice care services, including the evaluation
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of administrative and regulatory barriers.
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10. Assurance that necessary health care services will be
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provided and that relevant reimbursement policies are available.
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11. Assurance that the goals expressed in subparagraphs
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1.-10. will be accomplished in a culturally appropriate manner.
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Section 3. Section 765.3041, Florida Statutes, is created to read:
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765.3041 Patient-directed medical orders.—
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(1) To facilitate a principal's instructions concerning
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treatment preferences, a patient-directed medical order may be
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executed in advance to direct the actions of health care
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providers and health care facilities.
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(2) A valid patient-directed medical order must:
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(a) Be on a form adopted by rule of the Department of
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Health and may be combined with an order not to resuscitate
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executed pursuant to s. 401.45. The form must:
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1. Address medical interventions to be withheld or
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withdrawn when the application of life-prolonging procedures
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would serve only to prolong artificially the process of dying.
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2. Be signed by the principal and the principal's
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physician, physician assistant, or advanced practice registered
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nurse registered under s. 464.0123.
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a. If the principal is physically unable to sign the form,
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the physician, physician assistant, or advanced practice
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registered nurse present at the discussion as required by
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subparagraph (b)1. may subscribe the principal's signature in
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the principal's presence and at the principal's direction. If
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telehealth is used, the physician, physician assistant, or
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advanced practice registered nurse may be present at either
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location where telehealth is being administered.
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b. If the principal is incapacitated, the form may be
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signed by the principal's health care surrogate or proxy, court-
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appointed guardian as provided in chapter 744, or attorney in
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fact under a durable power of attorney as provided in chapter
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709. The court-appointed guardian or attorney in fact must be
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delegated authority to make health care decisions on behalf of
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the principal.
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c. All signatures may be electronic signatures.
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(b) Clearly express the principal's preferences and
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instructions for care, which may include all treatments
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available, modified treatments that are not prolonged or
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burdensome, or comfort measures that do not pursue or continue
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interventions.
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1. The principal and a physician, a physician assistant,
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or an advanced practice registered nurse registered under s.
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464.0123 must discuss the principal's medical treatment wishes
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relating to medical interventions to be withheld or withdrawn
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based on the principal's values and preferences in the event the
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principal becomes unable to make her or his own decisions.
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2. The discussion must be in person and may be conducted
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using telehealth.
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(3) Regardless of the decision to withhold or withdraw
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life-prolonging procedures, necessary health care services must
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be provided for the care and comfort of the principal or to
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alleviate pain.
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(4) A physician, a physician assistant, or an advanced
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practice registered nurse registered under s. 464.0123 may
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withhold or withdraw cardiopulmonary resuscitation or other
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life-prolonging procedures if presented with an order not to
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resuscitate executed pursuant to s. 401.45 or a patient-directed
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medical order executed pursuant to this section which contains
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an order not to resuscitate or an order to withhold or withdraw
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life-prolonging procedures. A physician, a physician assistant,
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or an advanced practice registered nurse registered under s.
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464.0123 is not subject to any disciplinary action under s.
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456.072 or criminal prosecution or civil liability, or
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considered to have engaged in negligent or unprofessional
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conduct, for withholding or withdrawing cardiopulmonary
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resuscitation or other life-prolonging procedures pursuant to
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such orders. The absence of an order not to resuscitate executed
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pursuant to s. 401.45 or a patient-directed medical order
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executed pursuant to this section does not preclude a physician,
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a physician assistant, or an advanced practice registered nurse
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registered under s. 464.0123 from withholding or withdrawing
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cardiopulmonary resuscitation or other life-prolonging
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procedures as otherwise authorized by law.
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Section 4. Paragraph (l) of subsection (3) of section
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395.1041, Florida Statutes, is amended to read:
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395.1041 Access to and ensurance of emergency services;
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transfers; patient rights; diversion programs; reports of
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controlled substance overdoses.—
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(3) EMERGENCY SERVICES; DISCRIMINATION; LIABILITY OF
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FACILITY OR HEALTH CARE PERSONNEL.—
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(l) Hospital personnel may withhold or withdraw
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cardiopulmonary resuscitation or other life-prolonging
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procedures if presented with an order not to resuscitate
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executed pursuant to s. 401.45 or a patient-directed medical
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order executed pursuant to s. 765.3041 which contains an order
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not to resuscitate or an order to withhold or withdraw life-
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prolonging procedures. Facility staff and facilities are shall
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not be subject to criminal prosecution or civil liability, or
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nor be considered to have engaged in negligent or unprofessional
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conduct, for withholding or withdrawing cardiopulmonary
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resuscitation or other life-prolonging procedures pursuant to
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such orders an order. The absence of an order not to resuscitate
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executed pursuant to s. 401.45 or a patient-directed medical
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order executed pursuant to s. 765.3041 does not preclude a
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physician from withholding or withdrawing cardiopulmonary
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resuscitation or other life-prolonging procedures as otherwise
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authorized permitted by law.
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Section 5. Subsection (3) of section 400.142, Florida
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Statutes, is amended to read:
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400.142 Emergency medication kits; orders not to
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resuscitate and patient-directed medical orders.—
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(3) Facility staff may withhold or withdraw
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cardiopulmonary resuscitation or other life-prolonging
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procedures if presented with an order not to resuscitate
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executed pursuant to s. 401.45 or a patient-directed medical
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order executed pursuant to s. 765.3041 which contains an order
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not to resuscitate or an order to withhold or withdraw life-
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prolonging procedures. Facility staff and facilities are not
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subject to criminal prosecution or civil liability, or
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considered to have engaged in negligent or unprofessional
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conduct, for withholding or withdrawing cardiopulmonary
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resuscitation or other life-prolonging procedures pursuant to
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such orders order. The absence of an order not to resuscitate
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executed pursuant to s. 401.45 or a patient-directed medical
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order executed pursuant to s. 765.3041 does not preclude a
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physician from withholding or withdrawing cardiopulmonary
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resuscitation or other life-prolonging procedures as otherwise
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authorized permitted by law. Section 6. Subsection (7) of section 400.487, Florida
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Statutes, is amended to read:
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400.487 Home health service agreements; physician's,
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physician assistant's, and advanced practice registered nurse's
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treatment orders; patient assessment; establishment and review
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of plan of care; provision of services; orders not to
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resuscitate and patient-directed medical orders.—
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(7) Home health agency personnel may withhold or withdraw
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cardiopulmonary resuscitation or other life-prolonging
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procedures if presented with an order not to resuscitate
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executed pursuant to s. 401.45 or a patient-directed medical
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order executed pursuant to s. 765.3041 which contains an order
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not to resuscitate or an order to withhold or withdraw life-
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prolonging procedures. The agency shall adopt rules providing
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for the implementation of such orders. Home health personnel and
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agencies are shall not be subject to criminal prosecution or
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civil liability, or nor be considered to have engaged in
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negligent or unprofessional conduct, for withholding or
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withdrawing cardiopulmonary resuscitation or other life-
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prolonging procedures pursuant to such orders an order and rules
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adopted by the agency. The absence of an order not to
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resuscitate executed pursuant to s. 401.45 or a patient-directed
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medical order executed pursuant to s. 765.3041 does not preclude
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a physician from withholding or withdrawing cardiopulmonary
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resuscitation or other life-prolonging procedures as otherwise
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authorized by law.
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Section 7. Paragraph (e) of subsection (1) of section
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400.605, Florida Statutes, is amended to read:
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400.605 Administration; forms; fees; rules; inspections;
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fines.—
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(1) The agency shall by rule establish minimum standards
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and procedures for a hospice pursuant to this part. The rules
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must include:
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(e) Procedures relating to the implementation of advance
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advanced directives, patient-directed medical orders executed
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pursuant to s. 765.3041, and do-not-resuscitate orders not to
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resuscitate executed pursuant to s. 401.45.
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Section 8. Subsection (8) of section 400.6095, Florida
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Statutes, is amended to read:
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400.6095 Patient admission; assessment; plan of care;
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discharge; death.—
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(8) The hospice care team may withhold or withdraw
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cardiopulmonary resuscitation or other life-prolonging
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procedures if presented with an order not to resuscitate
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executed pursuant to s. 401.45 or a patient-directed medical
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order executed pursuant to s. 765.3041 which contains an order
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not to resuscitate or an order to withhold or withdraw life-
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prolonging procedures. The agency shall adopt rules providing
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for the implementation of such orders. Hospice staff are shall
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not be subject to criminal prosecution or civil liability, or
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nor be considered to have engaged in negligent or unprofessional
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conduct, for withholding or withdrawing cardiopulmonary
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resuscitation or other life-prolonging procedures pursuant to
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such orders an order and applicable rules. The absence of an
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order not to resuscitate executed pursuant to s. 401.45 or a
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patient-directed medical order executed pursuant to s. 765.3041
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does not preclude a physician from withholding or withdrawing
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cardiopulmonary resuscitation or other life-prolonging
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procedures as otherwise authorized permitted by law.
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Section 9. Paragraph (b) of subsection (4) of section 400.611, Florida Statutes, is amended to read:
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400.611 Interdisciplinary records of care;
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confidentiality; release of records.—
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(4) A hospice may not release a patient's
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interdisciplinary record or any portion thereof, unless the
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person requesting the information provides to the hospice:
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(b) In the case of an incapacitated patient, a patient
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authorization executed before prior to the patient's death by
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the patient's then acting legal guardian, health care surrogate
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as defined in s. 765.101 s. 765.101(21), health care proxy as
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defined in s. 765.101 s. 765.101(19), or agent under power of
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attorney;
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Section 10. Subsection (4) of section 401.35, Florida
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Statutes, is amended to read:
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401.35 Rules.—The department shall adopt rules, including
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definitions of terms, necessary to carry out the purposes of
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this part.
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(4) The rules must establish circumstances and procedures
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under which emergency medical technicians and paramedics may
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honor orders not to resuscitate executed pursuant to s. 401.45
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or patient-directed medical orders executed pursuant to s.
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765.3041 which contain an order not to resuscitate or an order
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to withhold or withdraw life-prolonging procedures by the
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patient's physician, physician assistant, or advanced practice
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registered nurse registered under s. 464.0123 not to resuscitate
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and the documentation and reporting requirements for handling
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such orders requests.
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Section 11. Paragraphs (a) and (b) of subsection (3) of
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section 401.45, Florida Statutes, are amended to read:
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401.45 Denial of emergency treatment; civil liability.—
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(3)(a) Resuscitation may be withheld or withdrawn from a
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patient by An emergency medical technician or paramedic may
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withhold or withdraw cardiopulmonary resuscitation or other
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life-prolonging procedures if presented with evidence of an
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order not to resuscitate executed pursuant to this subsection or
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a patient-directed medical order executed pursuant to s.
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765.3041 which contains an order not to resuscitate or an order
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to withhold or withdraw life-prolonging procedures by the
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patient's physician or physician assistant is presented to the
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emergency medical technician or paramedic. An order not to
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resuscitate executed pursuant to this subsection or a patient-
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directed medical order executed pursuant to s. 765.3041 which
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contains an order not to resuscitate or an order to withhold or
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withdraw life-prolonging procedures, to be valid, must be on the
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form adopted by rule of the department. The form must be signed
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by the patient's physician, or physician assistant, or advanced
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practice registered nurse registered under s. 464.0123 and by
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the patient or, if the patient is incapacitated, the patient's
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health care surrogate or proxy as provided in chapter 765,
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court-appointed guardian as provided in chapter 744, or attorney
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in fact under a durable power of attorney as provided in chapter
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709. The court-appointed guardian or attorney in fact must have
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been delegated authority to make health care decisions on behalf
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of the patient.
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(b) Any licensee, physician, medical director, or
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emergency medical technician or paramedic who acts under the
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direction of a medical director is not subject to criminal
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prosecution or civil liability, and has not engaged in negligent
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or unprofessional conduct, as a result of the withholding or
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withdrawal of cardiopulmonary resuscitation or other life-
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prolonging procedures from a patient pursuant to this subsection
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and rules adopted by the department.
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Section 12. Subsection (4) of section 429.255, Florida
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Statutes, is amended to read:
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429.255 Use of personnel; emergency care.—
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(4) Facility staff may withhold or withdraw
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cardiopulmonary resuscitation, or the use of an automated
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external defibrillator, or other life-prolonging procedures if
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presented with an order not to resuscitate executed pursuant to
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s. 401.45 or a patient-directed medical order executed pursuant
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to s. 765.3041 which contains an order not to resuscitate or an
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order to withhold or withdraw life-prolonging procedures. The
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agency shall adopt rules providing for the implementation of
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such orders. Facility staff and facilities are may not be
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subject to criminal prosecution or civil liability, or nor be
340
considered to have engaged in negligent or unprofessional
341
conduct, for withholding or withdrawing cardiopulmonary
342
resuscitation, the or use of an automated external
343
defibrillator, or other life-prolonging procedures pursuant to
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such orders an order and rules adopted by the agency. The
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absence of an order not to resuscitate executed pursuant to s.
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401.45 or a patient-directed medical order executed pursuant to
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s. 765.3041 does not preclude a physician from withholding or
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withdrawing cardiopulmonary resuscitation, the or use of an
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automated external defibrillator, or other life-prolonging
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procedures as otherwise authorized permitted by law.
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Section 13. Subsection (3) of section 429.73, Florida
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Statutes, is amended to read:
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429.73 Rules and standards relating to adult family-care
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homes.—
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(3) The agency shall adopt rules providing for the
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implementation of orders not to resuscitate and patient-directed
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medical orders. The provider may withhold or withdraw
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cardiopulmonary resuscitation or other life-prolonging
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procedures if presented with an order not to resuscitate
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executed pursuant to s. 401.45 or a patient-directed medical
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order executed pursuant to s. 765.3041 which contains an order
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not to resuscitate or an order to withhold or withdraw life-
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prolonging procedures. The provider is shall not be subject to
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criminal prosecution or civil liability, or nor be considered to
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have engaged in negligent or unprofessional conduct, for
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withholding or withdrawing cardiopulmonary resuscitation or
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other life-prolonging procedures pursuant to such orders an
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order and applicable rules. The absence of an order not to
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resuscitate executed pursuant to s. 401.45 or a patient-directed
370
medical order executed pursuant to s. 765.3041 does not preclude
371
a physician from withholding or withdrawing cardiopulmonary
372
resuscitation or other life-prolonging procedures as otherwise
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authorized by law.
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Section 14. Subsections (1), (7), and (8) of section
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744.4431, Florida Statutes, are amended to read:
376
744.4431 Guardianship power regarding life-prolonging
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procedures.—
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(1) Except as provided in this section, decisions by a
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professional guardian, as defined in s. 744.102, to withhold or
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withdraw life-prolonging procedures from, or to execute an order
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not to resuscitate pursuant to s. 401.45 or a patient-directed
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medical order pursuant to s. 765.3041 which contains an order
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not to resuscitate or an order to withhold or withdraw life-
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prolonging procedures for, a ward must be approved by the court.
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A professional guardian appointed to act on behalf of a ward's
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person must petition the court pursuant to the Florida Probate
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Rules for authority to consent to withhold or withdraw life-
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prolonging procedures or to execute an order not to resuscitate
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pursuant to s. 401.45 or a patient-directed medical order
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pursuant to s. 765.3041. Court approval must be obtained before
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taking such action, except as provided in subsection (7).
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(7) Court approval is not required for the following
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decisions:
394
(a) A decision to withhold or withdraw life-prolonging
395
procedures made by a professional guardian to whom authority has
396
been granted by the court under s. 744.3115 to carry out the
397
instructions in or to take actions consistent with the ward's
398
advance directive, order not to resuscitate executed pursuant to
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s. 401.45, or patient-directed medical order executed pursuant
400
to s. 765.3041 which contains an order not to resuscitate or an
401
order to withhold or withdraw life-prolonging procedures, as
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long as there are no known objections from the ward; the ward's
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attorney; the ward's next of kin, if known; and any other
404
interested persons as the court may direct based on s.
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765.105(1).
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(b) A decision by a professional guardian who has been
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delegated health care decisionmaking authority to execute an
408
order not to resuscitate pursuant to s. 401.45 or a patient-
409
directed medical order pursuant to s. 765.3041, as described in
410
s. 401.45(3)(a), if the ward is in a hospital and the following
411
conditions are met:
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1. The ward's primary treating physician and at least one
413
other consulting physician document in the ward's medical record
414
that:
415
a. There is no reasonable medical probability for recovery
416
from or a cure of the ward's underlying medical condition;
417
b. The ward is in an end-stage condition, a terminal
418
condition, or a persistent vegetative state as those terms are
419
defined in s. 765.101, and that the ward's death is imminent;
420
and
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c. Resuscitation will cause the ward physical harm or
422
additional pain.
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2. The professional guardian has notified the ward's next
424
of kin, if known, and any interested persons as the court may
425
direct and the decision is not contrary to the ward's expressed
426
wishes and there are no known objections from the ward; the
427
ward's attorney; the ward's next of kin, if known; or any other
428
interested persons as the court may direct on the basis of s.
429
765.105(1).
430
(8) Within 2 business days after executing an order not to
431
resuscitate pursuant to s. 401.45 or a patient-directed medical
432
order pursuant to s. 765.3041 which contains an order not to
433
resuscitate or an order to withhold or withdraw life-prolonging
434
procedures under paragraph (7)(b), a professional guardian must
435
notify the court in writing of all of the following:
436
(a) The date the order not to resuscitate or patient-
437
directed medical order was executed.
438
(b) The location of the ward when the order not to
439
resuscitate or patient-directed medical order was executed.
440
(c) The names of the physicians who documented the ward's
441
condition in the ward's medical record.
442
Section 15. Subsection (3) of section 752.001, Florida
443
Statutes, is amended to read:
444
752.001 Definitions.—As used in this chapter, the term:
445
(3) "Persistent vegetative state" has the same meaning as
446
provided in s. 765.101 s. 765.101(15).
447
Section 16. Subsections (1) and (4) of section 765.110,
448
Florida Statutes, are amended to read:
449
765.110 Health care facilities and providers; discipline.—
450
(1) A health care facility, pursuant to Pub. L. No. 101-
451
508, ss. 4206 and 4751, shall provide to each patient written
452
information concerning the individual's rights concerning
453
advance directives, orders not to resuscitate executed pursuant
454
to s. 401.45, or patient-directed medical orders executed
455
pursuant to s. 765.3041 which contain an order not to
456
resuscitate or an order to withhold or withdraw life-prolonging
457
procedures and the health care facility's policies respecting
458
the implementation of such rights, and shall document in the
459
patient's medical records whether or not the individual has
460
executed an advance directive, an order not to resuscitate
461
pursuant to s. 401.45, or a patient-directed medical order
462
pursuant to s. 765.3041 which contains an order not to
463
resuscitate or an order to withhold or withdraw life-prolonging
464
procedures.
465
(4) The Department of Health, in consultation with the
466
Department of Elderly Affairs, for health care providers; the
467
Agency for Health Care Administration for hospitals, hospices,
468
nursing homes, home health agencies, assisted living facilities,
469
adult family-care homes, and health maintenance organizations;
470
and the Department of Children and Families for facilities
471
subject to part I of chapter 394 shall adopt rules to implement
472
this section.
473
Section 17. Subsection (3) of section 765.204, Florida
474
Statutes, is amended to read:
475
765.204 Capacity of principal; procedure.—
476
(3) The surrogate's authority commences either upon a
477
determination under subsection (2) that the principal lacks
478
capacity or upon a stipulation of such authority pursuant to s.
479
765.101 s. 765.101(21). Such authority remains in effect until a
480
determination that the principal has regained such capacity, if
481
the authority commenced as a result of incapacity, or until the
482
authority is revoked, if the authority commenced immediately
483
pursuant to s. 765.101 s. 765.101(21). Upon commencement of the
484
surrogate's authority, a surrogate who is not the principal's
485
spouse shall notify the principal's spouse or adult children of
486
the principal's designation of the surrogate. Except if the
487
principal provided immediately exercisable authority to the
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surrogate pursuant to s. 765.101 s. 765.101(21), in the event
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that the primary or attending physician determines that the
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principal has regained capacity, the authority of the surrogate
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shall cease, but recommences if the principal subsequently loses
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capacity as determined pursuant to this section. A health care
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provider is not liable for relying upon health care decisions
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made by a surrogate while the principal lacks capacity. At any
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time when a principal lacks capacity, a health care decision
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made on the principal's behalf by a surrogate is effective to
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the same extent as a decision made by the principal. If a
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principal possesses capacity, health care decisions of the
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principal take precedence over decisions made by the surrogate
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that present a material conflict.
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Section 18. Paragraph (c) of subsection (1) of section
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765.205, Florida Statutes, is amended to read:
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765.205 Responsibility of the surrogate.—
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(1) The surrogate, in accordance with the principal's
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instructions, unless such authority has been expressly limited
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by the principal, shall:
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(c) Provide written consent using an appropriate form
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whenever consent is required, including the execution of an a
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physician's order not to resuscitate pursuant to s. 401.45 or a
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patient-directed medical order pursuant to s. 765.3041 which
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contains an order not to resuscitate or an order to withhold or
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withdraw life-prolonging procedures.
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Section 19. Subsection (2) of section 765.305, Florida
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Statutes, is amended to read:
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765.305 Procedure in absence of a living will.—
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(2) Before exercising the incompetent patient's right to
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forego treatment, including the execution of an order not to
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resuscitate pursuant to s. 401.45 or a patient-directed medical
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order pursuant to s. 765.3041 which contains an order not to
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resuscitate or an order to withhold or withdraw life-prolonging
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procedures, the surrogate must be satisfied that:
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(a) The patient does not have a reasonable medical
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probability of recovering capacity so that the right could be
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exercised by the patient.
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(b) The patient has an end-stage condition, the patient is
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in a persistent vegetative state, or the patient's physical
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condition is terminal.
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Section 20. The Agency for Health Care Administration
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shall create and update a database for the storage of patient-
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directed medical orders, which shall be stored solely at the
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option of the patient in electronic form by the agency.
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Section 21. This act shall take effect July 1, 2026.