S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                  7277--A
                                                         Cal. No. 245
 
                        2017-2018 Regular Sessions
 
                           I N  A S S E M B L Y
 
                              April 17, 2017
                                ___________
 
 Introduced  by  M.  of  A. GOTTFRIED, D'URSO, LUPARDO, McDONALD, LIFTON,
   HUNTER -- read once  and  referred  to  the  Committee  on  Health  --
   reported  from  committee,  advanced  to  a third reading, amended and
   ordered reprinted, retaining its place on the order of third reading

 AN ACT to amend the public health law, in relation to authorizing  nurse
   practitioners to execute orders not to resuscitate and orders pertain-
   ing to life sustaining treatments
 
   THE  PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
 BLY, DO ENACT AS FOLLOWS:
 
   Section 1. Section 2960 of the public health law, as added by  chapter
 818 of the laws of 1987, is amended to read as follows:
   §  2960. Legislative findings and purpose. The legislature finds that,
 although cardiopulmonary resuscitation  has  proved  invaluable  in  the
 prevention of sudden, unexpected death, it is appropriate for an attend-
 ing physician OR ATTENDING NURSE PRACTITIONER, in certain circumstances,
 to  issue  an  order  not  to attempt cardiopulmonary resuscitation of a
 patient where appropriate consent has  been  obtained.  The  legislature
 further  finds  that there is a need to clarify and establish the rights
 and obligations of patients, their families, and health  care  providers
 regarding  cardiopulmonary  resuscitation and the issuance of orders not
 to resuscitate.
   § 2. Subdivisions 2, 5 and 20 of section 2961  of  the  public  health
 law,  subdivisions  2 and 5 as amended by chapter 8 of the laws of 2010,
 and subdivision 20 as added by chapter 818 of the laws of  1987  and  as
 renumbered  by  chapter 370 of the laws of 1991, are amended and two new
 subdivisions 2-a and 16 are added to read as follows:
   2. "Attending physician" means the physician selected by  or  assigned
 to a patient in a hospital who has primary responsibility for the treat-
 ment and care of the patient. Where more than one physician AND/OR NURSE
 PRACTITIONER  shares  such  responsibility,  any such physician OR NURSE
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
              

                                                            LBD02551-02-7

 A. 7277--A                          2
 
 PRACTITIONER may act as the attending physician OR ATTENDING NURSE PRAC-
 TITIONER pursuant to this article.
   2-A.  "ATTENDING  NURSE  PRACTITIONER"  MEANS  THE  NURSE PRACTITIONER
 SELECTED BY OR ASSIGNED TO A PATIENT  IN  A  HOSPITAL  WHO  HAS  PRIMARY
 RESPONSIBILITY  FOR  THE  TREATMENT  AND CARE OF THE PATIENT. WHERE MORE
 THAN ONE PHYSICIAN AND/OR NURSE PRACTITIONER SHARES SUCH RESPONSIBILITY,
 ANY SUCH PHYSICIAN OR NURSE PRACTITIONER MAY ACT AS THE ATTENDING PHYSI-
 CIAN OR ATTENDING NURSE PRACTITIONER PURSUANT TO THIS ARTICLE.
   5. "Close friend" means any person, eighteen years of  age  or  older,
 who  is a close friend of the patient, or relative of the patient (other
 than a spouse, adult child, parent, brother or  sister)  who  has  main-
 tained  such regular contact with the patient as to be familiar with the
 patient's activities, health, and religious or  moral  beliefs  and  who
 presents a signed statement to that effect to the attending physician OR
 ATTENDING NURSE PRACTITIONER.
   16. "NURSE PRACTITIONER" MEANS A NURSE PRACTITIONER CERTIFIED PURSUANT
 TO SECTION SIXTY-NINE HUNDRED TEN OF THE EDUCATION LAW WHO IS PRACTICING
 IN  ACCORDANCE  WITH SUBDIVISION THREE OF SECTION SIXTY-NINE HUNDRED TWO
 OF THE EDUCATION LAW.
   20. "Reasonably available" means that a person to be contacted can  be
 contacted  with  diligent  efforts  by an attending physician, ATTENDING
 NURSE PRACTITIONER or another person acting on behalf of  the  attending
 physician, ATTENDING NURSE PRACTITIONER or the hospital.
   § 3. Subdivisions 2 and 3 of section 2962 of the public health law, as
 added  by  chapter  818  of  the  laws  of  1987, are amended to read as
 follows:
   2. It shall be lawful for the attending physician OR  ATTENDING  NURSE
 PRACTITIONER  to  issue  an order not to resuscitate a patient, provided
 that the order has been issued pursuant  to  the  requirements  of  this
 article.  The order shall be included in writing in the patient's chart.
 An order not to resuscitate shall be effective upon issuance.
   3. Before obtaining, pursuant to this  article,  the  consent  of  the
 patient, or of the surrogate of the patient, or parent or legal guardian
 of  the  minor  patient,  to  an order not to resuscitate, the attending
 physician OR ATTENDING NURSE PRACTITIONER shall provide  to  the  person
 giving  consent information about the patient's diagnosis and prognosis,
 the reasonably foreseeable risks and benefits of cardiopulmonary  resus-
 citation for the patient, and the consequences of an order not to resus-
 citate.
   § 4. Section 2963 of the public health law, as added by chapter 818 of
 the  laws  of  1987,  subdivision  1, paragraph (b) of subdivision 3 and
 subdivision 4 as amended by chapter 8 of the laws of 2010, paragraph (c)
 of subdivision 3 as amended by section 5 of part J of chapter 56 of  the
 laws of 2012, is amended to read as follows:
   §  2963.  Determination  of  capacity  to  make  a  decision regarding
 cardiopulmonary resuscitation.  1. Every adult shall be presumed to have
 the capacity to make a decision regarding cardiopulmonary  resuscitation
 unless  determined  otherwise  pursuant to this section or pursuant to a
 court order or unless a guardian is authorized to  decide  about  health
 care  for the adult pursuant to article eighty-one of the mental hygiene
 law or article seventeen-A of the surrogate's court procedure  act.  The
 attending  physician  OR  ATTENDING NURSE PRACTITIONER shall not rely on
 the presumption stated in this subdivision if clinical indicia of  inca-
 pacity are present.
   2.  A determination that an adult patient lacks capacity shall be made
 by the attending physician OR ATTENDING NURSE PRACTITIONER to a  reason-

 A. 7277--A                          3
 
 able  degree  of  medical  certainty. The determination shall be made in
 writing and shall contain such attending physician's OR ATTENDING  NURSE
 PRACTITIONER'S  opinion  regarding the cause and nature of the patient's
 incapacity  as  well  as  its extent and probable duration. The determi-
 nation shall be included in the patient's medical chart.
   3. (a) At least one other physician, selected by a  person  authorized
 by the hospital to make such selection, must concur in the determination
 that an adult lacks capacity. The concurring determination shall be made
 in  writing  after personal examination of the patient and shall contain
 the physician's opinion regarding the cause and nature of the  patient's
 incapacity  as well as its extent and probable duration. Each concurring
 determination shall be included in the patient's medical chart.
   (b) If the attending physician OR ATTENDING NURSE PRACTITIONER  deter-
 mines  that  a  patient  lacks  capacity  because of mental illness, the
 concurring determination required by paragraph (a) of  this  subdivision
 shall  be  provided  by a physician licensed to practice medicine in New
 York state, who is a diplomate or eligible to be certified by the Ameri-
 can Board of Psychiatry and Neurology or who is certified by the  Ameri-
 can  Osteopathic  Board of Neurology and Psychiatry or is eligible to be
 certified by that board.
   (c) If the attending physician OR ATTENDING NURSE PRACTITIONER  deter-
 mines that a patient lacks capacity because of a developmental disabili-
 ty,  the  concurring  determination  required  by  paragraph (a) of this
 subdivision shall be provided by a physician or psychologist employed by
 a developmental disabilities services office named in section  13.17  of
 the  mental  hygiene  law, or who has been employed for a minimum of two
 years to render care and service in a facility operated or  licensed  by
 the  office  for people with developmental disabilities, or who has been
 approved by the commissioner of developmental disabilities in accordance
 with regulations promulgated  by  such  commissioner.  Such  regulations
 shall  require  that  a  physician  or  psychologist possess specialized
 training or three years experience in treating  developmental  disabili-
 ties.
   4.  Notice  of  a  determination that the patient lacks capacity shall
 promptly be given (a) to the patient, where there is any  indication  of
 the patient's ability to comprehend such notice, together with a copy of
 a  statement  prepared  in  accordance  with section twenty-nine hundred
 seventy-eight of this article, and (b) to the person  on  the  surrogate
 list highest in order of priority listed, when persons in prior subpara-
 graphs  are  not reasonably available. Nothing in this subdivision shall
 preclude or require notice to more than  one  person  on  the  surrogate
 list.
   5.  A  determination  that a patient lacks capacity to make a decision
 regarding an order not to resuscitate pursuant to this section shall not
 be construed as a finding that the patient lacks capacity for any  other
 purpose.
   §  5. Subdivision 2 of section 2964 of the public health law, as added
 by chapter 818 of the laws of 1987, is amended to read as follows:
   2. (a) During hospitalization, an adult with capacity  may  express  a
 decision  consenting  to an order not to resuscitate orally in the pres-
 ence of at least two witnesses eighteen years of age or  older,  one  of
 whom  is  a physician OR NURSE PRACTITIONER affiliated with the hospital
 in which the patient is  being  treated.  Any  such  decision  shall  be
 recorded in the patient's medical chart.
   (b)  Prior  to  or  during hospitalization, an adult with capacity may
 express a decision consenting to an order not to resuscitate in writing,

 A. 7277--A                          4
 
 dated and signed in the presence of  at  least  two  witnesses  eighteen
 years of age or older who shall sign the decision.
   (c)  An  attending  physician  OR  ATTENDING NURSE PRACTITIONER who is
 provided with or informed of a decision  pursuant  to  this  subdivision
 shall  record  or include the decision in the patient's medical chart if
 the decision has not been recorded or included, and either:
   (i) promptly issue an order not to resuscitate the patient or issue an
 order at such time as the conditions, if any, specified in the  decision
 are  met,  and  inform  the hospital staff responsible for the patient's
 care of the order; or
   (ii) promptly make his or her objection to the  issuance  of  such  an
 order  and the reasons therefor known to the patient and either make all
 reasonable efforts to arrange for the transfer of the patient to another
 physician OR NURSE PRACTITIONER, if necessary, or  promptly  submit  the
 matter to the dispute mediation system.
   (d)  Prior  to  issuing  an order not to resuscitate a patient who has
 expressed a decision consenting to an order  not  to  resuscitate  under
 specified medical conditions, the attending physician OR ATTENDING NURSE
 PRACTITIONER  must  make  a  determination,  to  a  reasonable degree of
 medical certainty, that such conditions exist, and include the  determi-
 nation in the patient's medical chart.
   §  6. Subdivision 5 of section 2964 of the public health law is renum-
 bered subdivision 3.
   § 7. Subdivisions 3 and 4 of section 2965 of the public health law, as
 added by chapter 818 of the laws of 1987 and as  renumbered  by  chapter
 370  of  the  laws of 1991, paragraph (a) of subdivision 4 as amended by
 chapter 370 of the laws of 1991 and paragraph (c) of  subdivision  4  as
 amended  by  chapter  8  of  the  laws  of  2010, are amended to read as
 follows:
   3. (a) The surrogate shall make a decision  regarding  cardiopulmonary
 resuscitation  on  the  basis  of the adult patient's wishes including a
 consideration of the patient's religious and moral beliefs, or,  if  the
 patient's  wishes are unknown and cannot be ascertained, on the basis of
 the patient's best interests.
   (b) Notwithstanding any law to the contrary, the surrogate shall  have
 the same right as the patient to receive medical information and medical
 records.
   (c)  A  surrogate may consent to an order not to resuscitate on behalf
 of an adult patient only if there has been a determination by an attend-
 ing physician OR ATTENDING NURSE PRACTITIONER with  the  concurrence  of
 another  physician OR NURSE PRACTITIONER selected by a person authorized
 by the hospital to make such selection, given after personal examination
 of the patient that, to a reasonable degree of medical certainty:
   (i) the patient has a terminal condition; or
   (ii) the patient is permanently unconscious; or
   (iii) resuscitation would be medically futile; or
   (iv) resuscitation would impose an extraordinary burden on the patient
 in light of the patient's medical condition and the expected outcome  of
 resuscitation for the patient.
   Each determination shall be included in the patient's medical chart.
   4. (a) A surrogate shall express a decision consenting to an order not
 to  resuscitate either (i) in writing, dated, and signed in the presence
 of one witness eighteen years of age or older who shall sign  the  deci-
 sion, or (ii) orally, to two persons eighteen years of age or older, one
 of  whom is a physician OR NURSE PRACTITIONER affiliated with the hospi-

 A. 7277--A                          5
 
 tal in which the patient is being treated. Any such  decision  shall  be
 recorded in the patient's medical chart.
   (b)  The  attending  physician  OR ATTENDING NURSE PRACTITIONER who is
 provided with the decision of a surrogate shall include the decision  in
 the  patient's  medical chart and, if the surrogate has consented to the
 issuance of an order not to resuscitate, shall either:
   (i) promptly issue an order not to resuscitate the patient and  inform
 the hospital staff responsible for the patient's care of the order; or
   (ii)  promptly make the attending physician's OR ATTENDING NURSE PRAC-
 TITIONER'S objection to the issuance of  such  an  order  known  to  the
 surrogate  and  either  make  all  reasonable efforts to arrange for the
 transfer of the patient to another physician OR NURSE  PRACTITIONER,  if
 necessary, or promptly refer the matter to the dispute mediation system.
   (c)  If  the  attending  physician OR ATTENDING NURSE PRACTITIONER has
 actual notice of opposition to a surrogate's consent to an order not  to
 resuscitate  by any person on the surrogate list, the physician OR NURSE
 PRACTITIONER shall submit the matter to the dispute mediation system and
 such order shall not be issued or shall be revoked  in  accordance  with
 the  provisions  of  subdivision  three  of  section twenty-nine hundred
 seventy-two of this article.
   § 8. Section 2966 of the public health law, as added by chapter 818 of
 the laws of 1987, subdivision 3 as amended by chapter 8 of the  laws  of
 2010, is amended to read as follows:
   § 2966. Decision-making on behalf of an adult patient without capacity
 for  whom  no  surrogate  is available. 1. If no surrogate is reasonably
 available, willing to make a decision regarding issuance of an order not
 to resuscitate, and competent to make a decision regarding  issuance  of
 an  order  not  to  resuscitate  on behalf of an adult patient who lacks
 capacity and who had  not  previously  expressed  a  decision  regarding
 cardiopulmonary resuscitation, an attending physician OR ATTENDING NURSE
 PRACTITIONER  (a)  may  issue  an  order not to resuscitate the patient,
 provided that the attending physician OR  ATTENDING  NURSE  PRACTITIONER
 determines, in writing, that, to a reasonable degree of medical certain-
 ty,  resuscitation  would  be medically futile, and another physician OR
 NURSE PRACTITIONER selected by a person authorized by  the  hospital  to
 make  such selection, after personal examination of the patient, reviews
 and concurs in writing with such determination, or, (b) shall  issue  an
 order  not to resuscitate the patient, provided that, pursuant to subdi-
 vision one of section twenty-nine hundred seventy-six of this article, a
 court has granted a judgment directing the issuance of such an order.
   [3]  2.  Notwithstanding any other provision of this section, where  a
 decision to consent to an order not to resuscitate has been made, notice
 of  the  decision shall be given to the patient where there is any indi-
 cation of the patient's  ability  to  comprehend  such  notice.  If  the
 patient objects, an order not to resuscitate shall not be issued.
   § 9. Section 2967 of the public health law, as added by chapter 818 of
 the  laws  of  1987,  paragraph  (b) of subdivision 2, subdivision 3 and
 paragraphs (a) and (b) of subdivision 4 as amended by chapter 370 of the
 laws of 1991, is amended to read as follows:
   § 2967. Decision-making on behalf of a minor patient. 1. An  attending
 physician  OR  ATTENDING  NURSE  PRACTITIONER,  in  consultation  with a
 minor's parent or legal guardian, shall determine whether  a  minor  has
 the capacity to make a decision regarding resuscitation.
   2.  (a)  The  consent  of  a  minor's parent or legal guardian and the
 consent of the minor, if the minor has capacity, must be obtained  prior
 to issuing an order not to resuscitate the minor.

 A. 7277--A                          6

   (b)  Where the attending physician OR ATTENDING NURSE PRACTITIONER has
 reason to believe that there is another parent or a non-custodial parent
 who has not been informed of a decision to issue an order not to  resus-
 citate the minor, the attending physician OR ATTENDING NURSE PRACTITION-
 ER,  or someone acting on behalf of the attending physician OR ATTENDING
 NURSE PRACTITIONER, shall make reasonable efforts to  determine  if  the
 uninformed parent or non-custodial parent has maintained substantial and
 continuous  contact  with  the  minor  and,  if  so, shall make diligent
 efforts to notify that parent or non-custodial parent  of  the  decision
 prior to issuing the order.
   3.  A parent or legal guardian may consent to an order not to resusci-
 tate on behalf of a minor only if there has been a written determination
 by the attending physician OR ATTENDING  NURSE  PRACTITIONER,  with  the
 written  concurrence of another physician OR NURSE PRACTITIONER selected
 by a person authorized by the hospital to  make  such  selections  given
 after  personal examination of the patient, that, to a reasonable degree
 of medical certainty, the minor suffers from one of the  medical  condi-
 tions  set  forth in paragraph (c) of subdivision three of section twen-
 ty-nine hundred sixty-five of this article. Each determination shall  be
 included in the patient's medical chart.
   4.  (a)  A  parent  or legal guardian of a minor, in making a decision
 regarding  cardiopulmonary  resuscitation,  shall  consider  the   minor
 patient's wishes, including a consideration of the minor patient's reli-
 gious  and  moral  beliefs,  and  shall express a decision consenting to
 issuance of an order not to resuscitate either (i) in writing, dated and
 signed in the presence of one witness eighteen years of age or older who
 shall sign the decision, or (ii) orally, to two persons  eighteen  years
 of age or older, one of whom is a physician OR NURSE PRACTITIONER affil-
 iated  with the hospital in which the patient is being treated. Any such
 decision shall be recorded in the patient's medical chart.
   (b) The attending physician OR ATTENDING  NURSE  PRACTITIONER  who  is
 provided  with  the  decision  of  a  minor's  parent or legal guardian,
 expressed pursuant to this subdivision, and of the minor  if  the  minor
 has  capacity,  shall  include such decision or decisions in the minor's
 medical chart and shall comply with the provisions of paragraph  (b)  of
 subdivision four of section twenty-nine hundred sixty-five of this arti-
 cle.
   (c)  If  the  attending  physician OR ATTENDING NURSE PRACTITIONER has
 actual notice of the opposition of a parent or non-custodial  parent  to
 consent  by  another  parent to an order not to resuscitate a minor, the
 physician OR NURSE PRACTITIONER shall submit the matter to  the  dispute
 mediation  system and such order shall not be issued or shall be revoked
 in accordance with the provisions of subdivision three of section  twen-
 ty-nine hundred seventy-two of this article.
   §  10.  Section 2969 of the public health law, as added by chapter 818
 of the laws of 1987, subdivision 2 as amended by chapter 370 of the laws
 of 1991, is amended to read as follows:
   § 2969. Revocation of consent to order not to resuscitate. 1. A person
 may, at any time, revoke his or her consent to an order not to  resusci-
 tate  himself  or herself by making either a written or an oral declara-
 tion to a physician or member of the nursing staff at the hospital where
 he or she is being treated, or by any other act  evidencing  a  specific
 intent to revoke such consent.
   2. Any surrogate, parent, or legal guardian may at any time revoke his
 or her consent to an order not to resuscitate a patient by (a) notifying
 a  physician or member of the nursing staff of the revocation of consent

 A. 7277--A                          7
 
 in writing, dated and signed, or  (b)  orally  notifying  the  attending
 physician  OR  ATTENDING NURSE PRACTITIONER in the presence of a witness
 eighteen years of age or older.
   3.  Any physician OR NURSE PRACTITIONER who is informed of or provided
 with a revocation of consent pursuant to this section shall  immediately
 include  the  revocation  in  the patient's chart, cancel the order, and
 notify the hospital staff responsible for  the  patient's  care  of  the
 revocation and cancellation. Any member of the nursing staff, OTHER THAN
 A  NURSE  PRACTITIONER, who is informed of or provided with a revocation
 of consent pursuant to this section shall immediately notify a physician
 OR NURSE PRACTITIONER of such revocation.
   § 11. Section 2970 of the public health law, as added by  chapter  818
 of  the  laws of 1987, subdivision 1 as amended by chapter 8 of the laws
 of 2010, paragraph (b) of subdivision 2 as amended by chapter 370 of the
 laws of 1991, is amended to read as follows:
   § 2970. Physician AND NURSE PRACTITIONER review of the  order  not  to
 resuscitate.    1. For each patient for whom an order not to resuscitate
 has been issued, the attending physician OR ATTENDING NURSE PRACTITIONER
 shall review the patient's chart to determine  if  the  order  is  still
 appropriate  in  light  of the patient's condition and shall indicate on
 the patient's chart that the order  has  been  reviewed  each  time  the
 patient  is  required to be seen by a physician but at least every sixty
 days.
   Failure to comply with this subdivision shall not render an order  not
 to resuscitate ineffective.
   2.  (a)  If  the  attending  physician OR ATTENDING NURSE PRACTITIONER
 determines at any time that an order not to  resuscitate  is  no  longer
 appropriate  because  the  patient's medical condition has improved, the
 physician OR NURSE PRACTITIONER shall immediately notify the person  who
 consented  to  the  order.  Except  as provided in paragraph (b) of this
 subdivision, if such person declines to revoke consent to the order, the
 physician OR NURSE  PRACTITIONER  shall  promptly  (i)  make  reasonable
 efforts  to arrange for the transfer of the patient to another physician
 or (ii) submit the matter to the dispute mediation system.
   (b) If the order not to resuscitate was entered upon the consent of  a
 surrogate,  parent,  or  legal  guardian  and the attending physician OR
 ATTENDING NURSE PRACTITIONER who issued the order, or,  if  unavailable,
 another  attending physician OR ATTENDING NURSE PRACTITIONER at any time
 determines that the patient does not suffer  from  one  of  the  medical
 conditions  set  forth  in paragraph (c) of subdivision three of section
 twenty-nine hundred sixty-five of this article, the attending  physician
 OR  ATTENDING NURSE PRACTITIONER shall immediately include such determi-
 nation in the patient's chart, cancel the order, and notify  the  person
 who  consented  to  the order and all hospital staff responsible for the
 patient's care of the cancellation.
   (c) If an order not to resuscitate was entered upon the consent  of  a
 surrogate  and  the  patient  at any time gains or regains capacity, the
 attending physician OR  ATTENDING  NURSE  PRACTITIONER  who  issued  the
 order,  or,  if  unavailable,  another  attending physician OR ATTENDING
 NURSE PRACTITIONER shall immediately cancel the  order  and  notify  the
 person  who  consented  to  the  order  and  all hospital staff directly
 responsible for the patient's care of the cancellation.
   § 12. The opening paragraph and subdivision 2 of section 2971  of  the
 public  health  law,  as amended by chapter 370 of the laws of 1991, are
 amended to read as follows:

 A. 7277--A                          8
 
   If a patient for whom an order not to resuscitate has been  issued  is
 transferred  from  a  hospital  to  a different hospital the order shall
 remain effective, unless revoked pursuant to  this  article,  until  the
 attending  physician  OR ATTENDING NURSE PRACTITIONER first examines the
 transferred  patient,  whereupon  the  attending  physician OR ATTENDING
 NURSE PRACTITIONER must either:
   2. Cancel the order not to resuscitate, provided the attending  physi-
 cian OR ATTENDING NURSE PRACTITIONER immediately notifies the person who
 consented  to  the order and the hospital staff directly responsible for
 the patient's care of  the  cancellation.  Such  cancellation  does  not
 preclude the entry of a new order pursuant to this article.
   §  13.  Subdivisions  1,  2 and 4 of section 2972 of the public health
 law, subdivisions 1 and 4 as added by chapter 818 of the laws  of  1987,
 paragraph  (b) of subdivision 1 as amended by chapter 370 of the laws of
 1991 and subdivision 2 as amended by chapter 8 of the laws of 2010,  are
 amended to read as follows:
   1.  (a)  Each  hospital  shall  establish  a  mediation system for the
 purpose of mediating disputes regarding the issuance of  orders  not  to
 resuscitate.
   (b)  The  dispute  mediation  system shall be described in writing and
 adopted by the hospital's governing authority. It may  utilize  existing
 hospital  resources,  such  as  a  patient advocate's office or hospital
 chaplain's office, or it may utilize a  body  created  specifically  for
 this  purpose,  but, in the event a dispute involves a patient deemed to
 lack capacity pursuant to (i) paragraph  (b)  of  subdivision  three  of
 section twenty-nine hundred sixty-three of this article, the system must
 include  a physician OR NURSE PRACTITIONER eligible to provide a concur-
 ring determination pursuant to such subdivision, or a family  member  or
 guardian  of the person of a person with a mental illness of the same or
 similar nature, or (ii) paragraph (c) of subdivision  three  of  section
 twenty-nine hundred sixty-three of this article, the system must include
 a  physician  OR  NURSE  PRACTITIONER  eligible  to provide a concurring
 determination pursuant to such subdivision, or a family member or guard-
 ian of the person of a person with a  developmental  disability  of  the
 same or similar nature.
   2.  The  dispute  mediation  system shall be authorized to mediate any
 dispute, including disputes regarding the determination of the patient's
 capacity, arising under this article between the patient and an  attend-
 ing  physician,  ATTENDING  NURSE  PRACTITIONER  or the hospital that is
 caring for the patient and, if the patient is  a  minor,  the  patient's
 parent,   or   among   an   attending   physician,  AN  ATTENDING  NURSE
 PRACTITIONER, a parent, non-custodial parent, or  legal  guardian  of  a
 minor  patient,  any person on the surrogate list, and the hospital that
 is caring for the patient.
   4. If a dispute between a patient who expressed a  decision  rejecting
 cardiopulmonary  resuscitation  and  an  attending  physician, ATTENDING
 NURSE PRACTITIONER or the hospital that is caring  for  the  patient  is
 submitted to the dispute mediation system, and either:
   (a)  the dispute mediation system has concluded its efforts to resolve
 the dispute, or
   (b) seventy-two hours have elapsed from the time of submission without
 resolution of the dispute, whichever shall occur  first,  the  attending
 physician  OR  ATTENDING  NURSE  PRACTITIONER shall either: (i) promptly
 issue an order not to resuscitate the patient or issue the order at such
 time as the conditions, if any, specified in the decision are  met,  and
 inform  the  hospital  staff  responsible  for the patient's care of the

 A. 7277--A                          9

 order; or (ii) promptly arrange for  the  transfer  of  the  patient  to
 another physician, NURSE PRACTITIONER or hospital.
   §  14.  Subdivision  1  of  section  2973 of the public health law, as
 amended by chapter 8 of the laws of 2010, is amended to read as follows:
   1. The patient, an attending physician, ATTENDING NURSE  PRACTITIONER,
 a  parent,  non-custodial  parent, or legal guardian of a minor patient,
 any person on the surrogate list, the hospital that is  caring  for  the
 patient  and  the  facility  director, may commence a special proceeding
 pursuant to article four of the civil practice law and rules, in a court
 of competent jurisdiction, with respect to  any  dispute  arising  under
 this  article,  except  that the decision of a patient not to consent to
 issuance of an order not to resuscitate may not be subjected to judicial
 review. In any proceeding brought pursuant to this subdivision challeng-
 ing a decision regarding issuance of an order not to resuscitate on  the
 ground  that  the  decision  is contrary to the patient's wishes or best
 interests, the person or entity challenging the decision must  show,  by
 clear  and  convincing  evidence,  that  the decision is contrary to the
 patient's wishes including consideration of the patient's religious  and
 moral  beliefs,  or, in the absence of evidence of the patient's wishes,
 that the decision is contrary to the patient's best  interests.  In  any
 other  proceeding  brought pursuant to this subdivision, the court shall
 make its determination based upon the applicable  substantive  standards
 and procedures set forth in this article.
   §  15.  Section 2976 of the public health law, as added by chapter 818
 of the laws of 1987, is amended to read as follows:
   § 2976. Judicially approved order not to resuscitate. 1. If no  surro-
 gate is reasonably available, willing to make a decision regarding issu-
 ance  of  an  order not to resuscitate, and competent to make a decision
 regarding issuance of an order not to resuscitate on behalf of an  adult
 patient  who lacks capacity and who had not previously expressed a deci-
 sion regarding cardiopulmonary resuscitation pursuant to  this  article,
 an  attending  physician OR ATTENDING NURSE PRACTITIONER or hospital may
 commence a special proceeding pursuant to  article  four  of  the  civil
 practice  law  and  rules,  in  a court of competent jurisdiction, for a
 judgment directing the physician OR NURSE PRACTITIONER to issue an order
 not to resuscitate where the patient has a terminal condition, is perma-
 nently unconscious,  or  resuscitation  would  impose  an  extraordinary
 burden  on  the  patient in light of the patient's medical condition and
 the expected outcome of resuscitation for the patient, and  issuance  of
 an  order  not  to  resuscitate  is consistent with the patient's wishes
 including a consideration of the patient's religious and  moral  beliefs
 or,  in  the  absence of evidence of the patient's wishes, the patient's
 best interests.
   2. Nothing in this article shall be construed to preclude a  court  of
 competent  jurisdiction  from  approving the issuance of an order not to
 resuscitate under circumstances other than those  under  which  such  an
 order may be issued pursuant to this article.
   § 16. Subdivisions 2 and 4 of section 2994-a of the public health law,
 as  added  by  chapter  8  of  the laws of 2010, are amended and two new
 subdivisions 2-a and 22-a are added to read as follows:
   2. "Attending physician" means a physician, selected by or assigned to
 a patient pursuant to hospital policy, who  has  primary  responsibility
 for the treatment and care of the patient. Where more than one physician
 AND/OR  NURSE PRACTITIONER shares such responsibility, or where a physi-
 cian OR NURSE PRACTITIONER is acting on  the  attending  physician's  OR
 ATTENDING NURSE PRACTITIONER'S behalf, any such physician OR NURSE PRAC-

 A. 7277--A                         10
 
 TITIONER  may  act  as an attending physician OR ATTENDING NURSE PRACTI-
 TIONER pursuant to this article.
   2-A.  "ATTENDING  NURSE  PRACTITIONER"  MEANS  A  NURSE  PRACTITIONER,
 SELECTED BY OR ASSIGNED TO A PATIENT PURSUANT TO  HOSPITAL  POLICY,  WHO
 HAS  PRIMARY  RESPONSIBILITY  FOR THE TREATMENT AND CARE OF THE PATIENT.
 WHERE MORE THAN ONE PHYSICIAN  AND/OR  NURSE  PRACTITIONER  SHARES  SUCH
 RESPONSIBILITY,  OR WHERE A PHYSICIAN OR NURSE PRACTITIONER IS ACTING ON
 THE ATTENDING PHYSICIAN'S OR ATTENDING NURSE PRACTITIONER'S BEHALF,  ANY
 SUCH  PHYSICIAN  OR NURSE PRACTITIONER MAY ACT AS AN ATTENDING PHYSICIAN
 OR ATTENDING NURSE PRACTITIONER PURSUANT TO THIS ARTICLE.
   4. "Close friend" means any person, eighteen years of  age  or  older,
 who  is  a  close  friend  of  the patient, or a relative of the patient
 (other than a spouse, adult child, parent, brother or sister),  who  has
 maintained  such regular contact with the patient as to be familiar with
 the patient's activities, health, and religious or  moral  beliefs,  and
 who  presents  a signed statement to that effect to the attending physi-
 cian OR ATTENDING NURSE PRACTITIONER.
   22-A. "NURSE PRACTITIONER" MEANS A NURSE PRACTITIONER CERTIFIED PURSU-
 ANT TO SECTION SIXTY-NINE HUNDRED TEN OF THE EDUCATION LAW WHO IS  PRAC-
 TICING  IN  ACCORDANCE  WITH  SUBDIVISION  THREE  OF  SECTION SIXTY-NINE
 HUNDRED TWO OF THE EDUCATION LAW.
   § 17. Subdivisions 2 and 3 of section 2994-b of the public health law,
 as added by chapter 8 of the laws  of  2010,  are  amended  to  read  as
 follows:
   2. Prior to seeking or relying upon a health care decision by a surro-
 gate  for  a  patient  under  this  article,  the attending physician OR
 ATTENDING NURSE PRACTITIONER shall make reasonable efforts to  determine
 whether  the patient has a health care agent appointed pursuant to arti-
 cle twenty-nine-C of this chapter. If so, health care decisions for  the
 patient  shall be governed by such article, and shall have priority over
 decisions by any  other  person  except  the  patient  or  as  otherwise
 provided in the health care proxy.
   3. Prior to seeking or relying upon a health care decision by a surro-
 gate  for  a  patient  under this article, if the attending physician OR
 ATTENDING NURSE PRACTITIONER has reason to believe that the patient  has
 a  history  of  receiving  services for mental retardation or a develop-
 mental disability; it reasonably appears to the attending  physician  OR
 ATTENDING  NURSE PRACTITIONER that the patient has mental retardation or
 a developmental disability; or  the  attending  physician  OR  ATTENDING
 NURSE  PRACTITIONER  has  reason  to  believe  that the patient has been
 transferred from a mental hygiene facility operated or licensed  by  the
 office of mental health, then such physician OR NURSE PRACTITIONER shall
 make  reasonable efforts to determine whether paragraphs (a), (b) or (c)
 of this subdivision are applicable:
   (a) If the patient has a guardian appointed by  a  court  pursuant  to
 article  seventeen-A of the surrogate's court procedure act, health care
 decisions for the patient shall be governed by section seventeen hundred
 fifty-b of the surrogate's court [proceedure] PROCEDURE act and  not  by
 this article.
   (b)  If a patient does not have a guardian appointed by a court pursu-
 ant to article seventeen-A of the surrogate's court  procedure  act  but
 falls within the class of persons described in paragraph (a) of subdivi-
 sion  one of section seventeen hundred fifty-b of such act, decisions to
 withdraw or withhold life-sustaining treatment for the patient shall  be
 governed  by  section seventeen hundred fifty-b of the surrogate's court
 procedure act and not by this article.

 A. 7277--A                         11
 
   (c) If a health care decision for a patient cannot be made under para-
 graphs (a) or (b) of this subdivision, but consent for the decision  may
 be  provided  pursuant  to  the mental hygiene law or regulations of the
 office of mental health or the office [of mental  retardation  and]  FOR
 PEOPLE  WITH  developmental  disabilities,  then  the  decision shall be
 governed by such statute or regulations and not by this article.
   § 18. Subdivisions 2, 3 and 7 of section 2994-c of the  public  health
 law,  as added by chapter 8 of the laws of 2010, paragraph (b) of subdi-
 vision 3 as amended by chapter 167 of the laws of 2011 and  subparagraph
 (ii) of paragraph (c) of subdivision 3 as amended by section 8 of part J
 of chapter 56 of the laws of 2012, are amended to read as follows:
   2.  Initial  determination  by  attending physician OR ATTENDING NURSE
 PRACTITIONER. An attending physician  OR  ATTENDING  NURSE  PRACTITIONER
 shall  make  an  initial determination that an adult patient lacks deci-
 sion-making capacity to a reasonable degree of medical certainty.   Such
 determination shall include an assessment of the cause and extent of the
 patient's  incapacity  and  the  likelihood that the patient will regain
 decision-making capacity.
   3. Concurring determinations. (a)  An  initial  determination  that  a
 patient  lacks decision-making capacity shall be subject to a concurring
 determination, independently made, where required by this subdivision. A
 concurring determination shall include an assessment of  the  cause  and
 extent  of  the patient's incapacity and the likelihood that the patient
 will regain decision-making capacity,  and  shall  be  included  in  the
 patient's medical record. Hospitals shall adopt written policies identi-
 fying  the training and credentials of health or social services practi-
 tioners qualified to provide concurring determinations of incapacity.
   (b) (i) In a residential health care  facility,  a  health  or  social
 services  practitioner employed by or otherwise formally affiliated with
 the facility must independently determine whether an adult patient lacks
 decision-making capacity.
   (ii) In a general hospital a health or  social  services  practitioner
 employed  by  or  otherwise  formally  affiliated with the facility must
 independently determine whether an adult patient  lacks  decision-making
 capacity  if  the  surrogate's decision concerns the withdrawal or with-
 holding of life-sustaining treatment.
   (iii) With respect to decisions regarding hospice care for  a  patient
 in a general hospital or residential health care facility, the health or
 social  services  practitioner must be employed by or otherwise formally
 affiliated with the general hospital or residential health care  facili-
 ty.
   (c)  (i)  If  the  attending physician OR ATTENDING NURSE PRACTITIONER
 makes an initial determination  that  a  patient  lacks  decision-making
 capacity  because of mental illness, either such physician must have the
 following qualifications, or another physician with the following quali-
 fications must independently determine whether the patient  lacks  deci-
 sion-making  capacity:  a physician licensed to practice medicine in New
 York state, who is a diplomate or eligible to be certified by the Ameri-
 can Board of Psychiatry and Neurology or who is certified by the  Ameri-
 can  Osteopathic  Board of Neurology and Psychiatry or is eligible to be
 certified by that board. A record of such consultation shall be included
 in the patient's medical record.
   (ii) If the attending physician OR ATTENDING NURSE PRACTITIONER  makes
 an  initial  determination that a patient lacks decision-making capacity
 because of a developmental disability, either such  physician  OR  NURSE
 PRACTITIONER  must have the following qualifications, or another profes-

 A. 7277--A                         12
 
 sional with the following qualifications  must  independently  determine
 whether the patient lacks decision-making capacity: a physician or clin-
 ical psychologist who either is employed by a developmental disabilities
 services office named in section 13.17 of the mental hygiene law, or who
 has  been employed for a minimum of two years to render care and service
 in a facility operated or licensed by the office for people with  devel-
 opmental  disabilities,  or  has  been  approved  by the commissioner of
 developmental disabilities in accordance with regulations promulgated by
 such commissioner. Such regulations shall require that  a  physician  or
 clinical  psychologist possess specialized training or three years expe-
 rience in treating developmental disabilities. A record of such  consul-
 tation shall be included in the patient's medical record.
   (d)  If  an  attending  physician  OR ATTENDING NURSE PRACTITIONER has
 determined that the patient lacks decision-making capacity  and  if  the
 health or social services practitioner consulted for a concurring deter-
 mination disagrees with the attending physician's OR THE ATTENDING NURSE
 PRACTITIONER'S determination, the matter shall be referred to the ethics
 review committee if it cannot otherwise be resolved.
   7.  Confirmation  of  continued  lack  of decision-making capacity. An
 attending physician OR ATTENDING NURSE PRACTITIONER  shall  confirm  the
 adult  patient's  continued  lack  of  decision-making  capacity  before
 complying with health care decisions  made  pursuant  to  this  article,
 other  than  those  decisions  made  at or about the time of the initial
 determination. A concurring determination  of  the  patient's  continued
 lack  of  decision-making  capacity  shall be required if the subsequent
 health care decision concerns the withholding or withdrawal of life-sus-
 taining treatment. Health care providers shall not be required to inform
 the patient or surrogate of the confirmation.
   § 19. Subdivisions 2, 3 and 5 of section 2994-d of the  public  health
 law,  as added by chapter 8 of the laws of 2010, the subdivision heading
 and the opening paragraph of subdivision 5 as amended by chapter 167  of
 the laws of 2011, are amended to read as follows:
   2. Restrictions on who may be a surrogate. An operator, administrator,
 or  employee  of  a hospital or a mental hygiene facility from which the
 patient was transferred, or a physician OR NURSE  PRACTITIONER  who  has
 privileges at the hospital or a health care provider under contract with
 the  hospital  may  not  serve  as  the surrogate for any adult who is a
 patient of such hospital, unless  such  individual  is  related  to  the
 patient  by  blood, marriage, domestic partnership, or adoption, or is a
 close friend of the patient whose friendship with the  patient  preceded
 the patient's admission to the facility. If a physician OR NURSE PRACTI-
 TIONER  serves  as  surrogate, the physician OR NURSE PRACTITIONER shall
 not act as the patient's attending physician OR ATTENDING NURSE  PRACTI-
 TIONER after his or her authority as surrogate begins.
   3. Authority and duties of surrogate. (a) Scope of surrogate's author-
 ity.
   (i)  Subject  to  the  standards  and limitations of this article, the
 surrogate shall have the authority to make any and all health care deci-
 sions on the adult patient's behalf that the patient could make.
   (ii) Nothing in this article shall obligate health care  providers  to
 seek  the  consent of a surrogate if an adult patient has already made a
 decision about the proposed health care, expressed orally or in  writing
 or,  with  respect to a decision to withdraw or withhold life-sustaining
 treatment expressed either orally during hospitalization in the presence
 of two witnesses eighteen years of age or older, at least one of whom is
 a health or social services practitioner affiliated with  the  hospital,

 A. 7277--A                         13
 
 or in writing. If an attending physician OR ATTENDING NURSE PRACTITIONER
 relies  on  the patient's prior decision, the physician OR NURSE PRACTI-
 TIONER shall record the prior decision in the patient's medical  record.
 If  a surrogate has already been designated for the patient, the attend-
 ing physician OR ATTENDING  NURSE  PRACTITIONER  shall  make  reasonable
 efforts  to  notify  the  surrogate  prior to implementing the decision;
 provided that in the case of a decision to withdraw  or  withhold  life-
 sustaining treatment, the attending physician OR ATTENDING NURSE PRACTI-
 TIONER  shall  make  diligent  efforts  to  notify the surrogate and, if
 unable to notify the surrogate, shall document  the  efforts  that  were
 made to do so.
   (b)  Commencement  of surrogate's authority. The surrogate's authority
 shall commence upon a determination, made pursuant  to  section  twenty-
 nine hundred ninety-four-c of this article, that the adult patient lacks
 decision-making capacity and upon identification of a surrogate pursuant
 to  subdivision one of this section. In the event an attending physician
 OR NURSE PRACTITIONER determines that the  patient  has  regained  deci-
 sion-making capacity, the authority of the surrogate shall cease.
   (c)  Right  and  duty  to  be informed. Notwithstanding any law to the
 contrary, the surrogate shall have the right to receive medical informa-
 tion and medical records necessary to make informed decisions about  the
 patient's  health  care.  Health  care  providers  shall provide and the
 surrogate shall seek information necessary to make an informed decision,
 including information about  the  patient's  diagnosis,  prognosis,  the
 nature  and  consequences  of proposed health care, and the benefits and
 risks of and alternative to proposed health care.
   5. Decisions to withhold or  withdraw  life-sustaining  treatment.  In
 addition to the standards set forth in subdivision four of this section,
 decisions  by  surrogates to withhold or withdraw life-sustaining treat-
 ment (including decisions to accept a hospice plan of care that provides
 for the withdrawal or withholding of life-sustaining treatment) shall be
 authorized only if the following conditions are satisfied,  as  applica-
 ble:
   (a)(i)  Treatment  would be an extraordinary burden to the patient and
 an attending physician OR ATTENDING NURSE PRACTITIONER determines,  with
 the  independent concurrence of another physician OR NURSE PRACTITIONER,
 that, to a reasonable degree of medical certainty  and  in  accord  with
 accepted  medical  standards,  (A)  the patient has an illness or injury
 which can be expected to cause death within six months, whether  or  not
 treatment is provided; or (B) the patient is permanently unconscious; or
   (ii)  The provision of treatment would involve such pain, suffering or
 other burden that it would reasonably be  deemed  inhumane  or  extraor-
 dinarily burdensome under the circumstances and the patient has an irre-
 versible or incurable condition, as determined by an attending physician
 OR  ATTENDING  NURSE  PRACTITIONER  with  the independent concurrence of
 another physician OR  NURSE  PRACTITIONER  to  a  reasonable  degree  of
 medical certainty and in accord with accepted medical standards.
   (b)  In a residential health care facility, a surrogate shall have the
 authority to refuse life-sustaining treatment under subparagraph (ii) of
 paragraph (a) of this subdivision only if the ethics  review  committee,
 including  at  least  one  physician  OR  NURSE  PRACTITIONER who is not
 directly responsible for the patient's care, or  a  court  of  competent
 jurisdiction,  reviews  the  decision  and  determines that it meets the
 standards set forth in this article. This requirement shall not apply to
 a decision to withhold cardiopulmonary resuscitation.

 A. 7277--A                         14
 
   (c) In a general hospital, if the  attending  physician  OR  ATTENDING
 NURSE PRACTITIONER objects to a surrogate's decision, under subparagraph
 (ii)  of  paragraph  (a)  of  this  subdivision, to withdraw or withhold
 nutrition and hydration provided by  means  of  medical  treatment,  the
 decision  shall  not  be  implemented until the ethics review committee,
 including at least one  physician  OR  NURSE  PRACTITIONER  who  is  not
 directly  responsible  for  the  patient's care, or a court of competent
 jurisdiction, reviews the decision and  determines  that  it  meets  the
 standards  set  forth  in  this subdivision and subdivision four of this
 section.
   (d) Providing nutrition and  hydration  orally,  without  reliance  on
 medical  treatment,  is  not  health  care under this article and is not
 subject to this article.
   (e) Expression of decisions. The surrogate shall express a decision to
 withdraw or withhold  life-sustaining  treatment  either  orally  to  an
 attending physician OR ATTENDING NURSE PRACTITIONER or in writing.
   § 20. Subdivisions 2 and 3 of section 2994-e of the public health law,
 as  added  by  chapter  8  of  the  laws of 2010, are amended to read as
 follows:
   2. Decision-making standards and procedures for minor patient. (a) The
 parent or guardian of a minor patient shall make decisions in accordance
 with the minor's best interests, consistent with the standards set forth
 in subdivision four of section twenty-nine hundred ninety-four-d of this
 article, taking into account the minor's wishes as appropriate under the
 circumstances.
   (b) An attending physician OR ATTENDING NURSE PRACTITIONER, in consul-
 tation with a minor's parent or  guardian,  shall  determine  whether  a
 minor patient has decision-making capacity for a decision to withhold or
 withdraw  life-sustaining  treatment.  If the minor has such capacity, a
 parent's or guardian's decision to withhold or withdraw  life-sustaining
 treatment  for  the  minor  may  not  be implemented without the minor's
 consent.
   (c) Where a parent or guardian of a minor patient has made a  decision
 to  withhold  or  withdraw  life-sustaining  treatment  and an attending
 physician OR ATTENDING NURSE PRACTITIONER has reason to believe that the
 minor patient has a parent or guardian who has not been informed of  the
 decision,  including  a  non-custodial  parent or guardian, an attending
 physician,ATTENDING NURSE PRACTITIONER or someone acting on his  or  her
 behalf,  shall  make  reasonable  efforts to determine if the uninformed
 parent or guardian has maintained  substantial  and  continuous  contact
 with  the  minor  and, if so, shall make diligent efforts to notify that
 parent or guardian prior to implementing the decision.
   3. Decision-making standards  and  procedures  for  emancipated  minor
 patient.  (a)  If an attending physician OR ATTENDING NURSE PRACTITIONER
 determines that a patient is an emancipated  minor  patient  with  deci-
 sion-making  capacity,  the  patient  shall have the authority to decide
 about life-sustaining treatment. Such authority shall include a decision
 to withhold or withdraw life-sustaining treatment if an attending physi-
 cian OR ATTENDING NURSE PRACTITIONER and  the  ethics  review  committee
 determine  that  the  decision  accords with the standards for surrogate
 decisions for adults, and the ethics review committee approves the deci-
 sion.
   (b) If the hospital can with reasonable efforts ascertain the identity
 of the parents or guardian of an emancipated minor patient, the hospital
 shall notify such persons prior to withholding or withdrawing  life-sus-
 taining treatment pursuant to this subdivision.

 A. 7277--A                         15
 
   §  21.  Section 2994-f of the public health law, as added by chapter 8
 of the laws of 2010, is amended to read as follows:
   §  2994-f. Obligations of attending physician OR ATTENDING NURSE PRAC-
 TITIONER. 1. An attending  physician  OR  ATTENDING  NURSE  PRACTITIONER
 informed of a decision to withdraw or withhold life-sustaining treatment
 made pursuant to the standards of this article shall record the decision
 in  the patient's medical record, review the medical basis for the deci-
 sion, and shall either: (a) implement the decision, or (b) promptly make
 his or her objection to the decision and the reasons for  the  objection
 known  to  the decision-maker, and either make all reasonable efforts to
 arrange for the transfer of the patient to another  physician  OR  NURSE
 PRACTITIONER,  if  necessary, or promptly refer the matter to the ethics
 review committee.
   2. If an attending physician OR ATTENDING NURSE PRACTITIONER has actu-
 al notice of the following objections or disagreements, he or she  shall
 promptly  refer  the  matter  to  the  ethics  review  committee  if the
 objection or disagreement cannot otherwise be resolved:
   (a) A health or social services practitioner consulted for  a  concur-
 ring  determination that an adult patient lacks decision-making capacity
 disagrees with the attending physician's OR ATTENDING NURSE  PRACTITION-
 ER'S determination; or
   (b) Any person on the surrogate list objects to the designation of the
 surrogate  pursuant  to  subdivision  one of section twenty-nine hundred
 ninety-four-d of this article; or
   (c) Any person on the surrogate list objects to  a  surrogate's  deci-
 sion; or
   (d) A parent or guardian of a minor patient objects to the decision by
 another parent or guardian of the minor; or
   (e) A minor patient refuses life-sustaining treatment, and the minor's
 parent  or  guardian  wishes  the treatment to be provided, or the minor
 patient objects to an attending physician's OR ATTENDING  NURSE  PRACTI-
 TIONER'S  determination about decision-making capacity or recommendation
 about life-sustaining treatment.
   3. Notwithstanding the provisions of this section or  subdivision  one
 of  section  twenty-nine  hundred  ninety-four-q  of  this article, if a
 surrogate directs the provision of life-sustaining treatment, the denial
 of which in reasonable medical judgment would be likely to result in the
 death of the patient, a hospital or individual health care provider that
 does not wish to provide such treatment shall  nonetheless  comply  with
 the  surrogate's  decision  pending  either transfer of the patient to a
 willing hospital or individual health care provider, or judicial  review
 in  accordance  with  section  twenty-nine hundred ninety-four-r of this
 article.
   § 22. Subdivisions 3,4,5, 5-a and 6 of section 2994-g  of  the  public
 health law, subdivisions 3, 4, 5 and 6 as added by chapter 8 of the laws
 of 2010, subparagraph (iii) of paragraph (b) of subdivision 4 as amended
 by chapter 167 of the laws of 2011 and subdivision 5-a as added by chap-
 ter 107 of the laws of 2015, are amended to read as follows:
   3.  Routine  medical  treatment. (a) For purposes of this subdivision,
 "routine medical treatment" means any treatment, service,  or  procedure
 to  diagnose or treat an individual's physical or mental condition, such
 as the administration of medication, the extraction of bodily fluids for
 analysis, or dental care performed with a local  anesthetic,  for  which
 health  care  providers ordinarily do not seek specific consent from the
 patient or authorized representative. It shall not include the long-term
 provision of treatment such as ventilator support or a nasogastric  tube

 A. 7277--A                         16
 
 but shall include such treatment when provided as part of post-operative
 care  or  in  response  to  an  acute illness and recovery is reasonably
 expected within one month or less.
   (b)  An  attending  physician OR ATTENDING NURSE PRACTITIONER shall be
 authorized to decide  about  routine  medical  treatment  for  an  adult
 patient  who has been determined to lack decision-making capacity pursu-
 ant to section twenty-nine hundred ninety-four-c of this article.  Noth-
 ing  in  this  subdivision shall require health care providers to obtain
 specific consent for treatment where specific consent is  not  otherwise
 required by law.
   4.  Major  medical  treatment.  (a)  For purposes of this subdivision,
 "major medical treatment" means any treatment, service or  procedure  to
 diagnose  or  treat  an  individual's  physical or mental condition: (i)
 where general anesthetic is used; or (ii) which involves any significant
 risk; or (iii) which involves any significant invasion of bodily  integ-
 rity  requiring  an  incision,  producing  substantial pain, discomfort,
 debilitation or having a significant  recovery  period;  or  (iv)  which
 involves  the  use  of  physical restraints, as specified in regulations
 promulgated by the commissioner, except in an emergency;  or  (v)  which
 involves  the  use  of psychoactive medications, except when provided as
 part of post-operative care or in  response  to  an  acute  illness  and
 treatment  is  reasonably  expected  to be administered over a period of
 forty-eight hours or less, or when provided in an emergency.
   (b) A decision to provide major medical treatment, made in  accordance
 with  the  following  requirements,  shall  be  authorized  for an adult
 patient who has been determined to lack decision-making capacity  pursu-
 ant to section twenty-nine hundred ninety-four-c of this article.
   (i)  An attending physician OR ATTENDING NURSE PRACTITIONER shall make
 a recommendation in consultation with hospital staff directly  responsi-
 ble for the patient's care.
   (ii)  In  a  general  hospital,  at least one other physician OR NURSE
 PRACTITIONER designated by the  hospital  must  independently  determine
 that he or she concurs that the recommendation is appropriate.
   (iii) In a residential health care facility, and for a hospice patient
 not  in  a  general  hospital,  the  medical director of the facility or
 hospice, or a physician OR NURSE PRACTITIONER designated by the  medical
 director,  must  independently determine that he or she concurs that the
 recommendation is appropriate; provided that if the medical director  is
 the  patient's  attending  physician  OR ATTENDING NURSE PRACTITIONER, a
 different physician OR NURSE PRACTITIONER designated by the  residential
 health  care  facility  or  hospice  must make this independent determi-
 nation. Any health or social services practitioner employed by or other-
 wise formally affiliated with the facility  or  hospice  may  provide  a
 second  opinion for decisions about physical restraints made pursuant to
 this subdivision.
   5. Decisions to withhold or withdraw life-sustaining treatment. (a)  A
 court of competent jurisdiction may make a decision to withhold or with-
 draw  life-sustaining treatment for an adult patient who has been deter-
 mined to lack decision-making capacity pursuant to  section  twenty-nine
 hundred  ninety-four-c of this article if the court finds that the deci-
 sion accords with standards for decisions for adults set forth in subdi-
 visions four and five of section twenty-nine  hundred  ninety-four-d  of
 this article.
   (b)  If  the attending physician OR ATTENDING NURSE PRACTITIONER, with
 independent concurrence of a  second  physician  OR  NURSE  PRACTITIONER

 A. 7277--A                         17
 
 designated by the hospital, determines to a reasonable degree of medical
 certainty that:
   (i)  life-sustaining  treatment  offers the patient no medical benefit
 because the patient will  die  imminently,  even  if  the  treatment  is
 provided; and
   (ii) the provision of life-sustaining treatment would violate accepted
 medical standards, then such treatment may be withdrawn or withheld from
 an adult patient who has been determined to lack decision-making capaci-
 ty  pursuant  to section twenty-nine hundred ninety-four-c of this arti-
 cle, without judicial approval. This paragraph shall not  apply  to  any
 treatment necessary to alleviate pain or discomfort.
   5-a.  Decisions  regarding  hospice  care.  An  attending physician OR
 ATTENDING NURSE PRACTITIONER  shall  be  authorized  to  make  decisions
 regarding  hospice care and execute appropriate documents for such deci-
 sions (including a hospice election form) for  an  adult  patient  under
 this  section  who  is hospice eligible in accordance with the following
 requirements.
   (a) The attending physician OR ATTENDING NURSE PRACTITIONER shall make
 decisions under this section in consultation with staff directly respon-
 sible for the patient's care, and shall base his or her decisions on the
 standards for surrogate decisions set forth  in  subdivisions  four  and
 five of section twenty-nine hundred ninety-four-d of this article;
   (b) There is a concurring opinion as follows:
   (i) in a general hospital, at least one other physician OR NURSE PRAC-
 TITIONER designated by the hospital must independently determine that he
 or she concurs that the recommendation is consistent with such standards
 for surrogate decisions;
   (ii)  in  a  residential health care facility, the medical director of
 the facility, or a physician OR NURSE  PRACTITIONER  designated  by  the
 medical  director,  must  independently determine that he or she concurs
 that the recommendation is consistent with such standards for  surrogate
 decisions;  provided  that  if  the  medical  director  is the patient's
 attending physician OR ATTENDING NURSE PRACTITIONER, a different  physi-
 cian  OR  NURSE  PRACTITIONER  designated by the residential health care
 facility must make this independent determination; or
   (iii) in settings other than a general hospital or residential  health
 care  facility,  the  medical  director  of  the hospice, or a physician
 designated by the medical director, must independently determine that he
 or she concurs that the  recommendation  is  medically  appropriate  and
 consistent with such standards for surrogate decisions; provided that if
 the  medical  director is the patient's attending physician, a different
 physician designated by the hospice must make this independent  determi-
 nation; and
   (c)  The  ethics review committee of the general hospital, residential
 health care facility or hospice, as applicable, including at  least  one
 physician  OR  NURSE  PRACTITIONER  who  is  not the patient's attending
 physician OR ATTENDING NURSE  PRACTITIONER,  or  a  court  of  competent
 jurisdiction, must review the decision and determine that it is consist-
 ent with such standards for surrogate decisions.
   6.  Physician OR NURSE PRACTITIONER objection. If a physician OR NURSE
 PRACTITIONER consulted for a concurring opinion objects to an  attending
 physician's OR ATTENDING NURSE PRACTITIONER'S recommendation or determi-
 nation  made pursuant to this section, or a member of the hospital staff
 directly responsible for the patient's  care  objects  to  an  attending
 physician's OR ATTENDING NURSE PRACTITIONER'S recommendation about major
 medical treatment or treatment without medical benefit, the matter shall

 A. 7277--A                         18
 
 be  referred  to  the  ethics review committee if it cannot be otherwise
 resolved.
   §  23.  Section 2994-j of the public health law, as added by chapter 8
 of the laws of 2010, is amended read as follows:
   § 2994-j. Revocation of consent. 1. A patient, surrogate, or parent or
 guardian of a minor patient may at any time revoke his or her consent to
 withhold or withdraw life-sustaining treatment by informing an attending
 physician, ATTENDING NURSE PRACTITIONER or a member of  the  medical  or
 nursing staff of the revocation.
   2.  An attending physician OR ATTENDING NURSE PRACTITIONER informed of
 a revocation of consent made pursuant to this section shall immediately:
   (a) record the revocation in the patient's medical record;
   (b) cancel any orders implementing the decision to withhold  or  with-
 draw treatment; and
   (c)  notify  the hospital staff directly responsible for the patient's
 care of the revocation and any cancellations.
   3. Any member of the medical or nursing  staff,  OTHER  THAN  A  NURSE
 PRACTITIONER,  informed  of  a  revocation made pursuant to this section
 shall immediately notify an attending physician OR ATTENDING NURSE PRAC-
 TITIONER of the revocation.
   § 24. The opening paragraph of subdivision 2 of section 2994-k of  the
 public health law, as added by chapter 8 of the laws of 2010, is amended
 to read as follows:
   If  a  decision  to withhold or withdraw life-sustaining treatment has
 been made pursuant to  this  article,  and  an  attending  physician  OR
 ATTENDING NURSE PRACTITIONER determines at any time that the decision is
 no  longer  appropriate  or  authorized because the patient has regained
 decision-making capacity or because the patient's condition  has  other-
 wise improved, the physician OR NURSE PRACTITIONER shall immediately:
   §  25.  Section 2994-l of the public health law, as added by chapter 8
 of the laws of 2010, is amended to read as follows:
   § 2994-l. Interinstitutional transfers. If a patient with an order  to
 withhold  or  withdraw  life-sustaining  treatment is transferred from a
 mental hygiene facility to a hospital or from a hospital to a  different
 hospital, any such order or plan shall remain effective until an attend-
 ing  physician OR ATTENDING NURSE PRACTITIONER first examines the trans-
 ferred patient, whereupon an  attending  physician  OR  ATTENDING  NURSE
 PRACTITIONER must either:
   1.  Issue appropriate orders to continue the prior order or plan. Such
 orders may be issued without obtaining another consent  to  withhold  or
 withdraw life-sustaining treatment pursuant to this article; or
   2.  Cancel  such  order, if the attending physician OR ATTENDING NURSE
 PRACTITIONER determines that the  order  is  no  longer  appropriate  or
 authorized.  Before  canceling  the  order  the  attending  physician OR
 ATTENDING NURSE PRACTITIONER shall make reasonable efforts to notify the
 person who made the decision to withhold or withdraw treatment  and  the
 hospital  staff  directly responsible for the patient's care of any such
 cancellation. If such notice cannot reasonably be made prior to  cancel-
 ing  the order or plan, the attending physician OR ATTENDING NURSE PRAC-
 TITIONER shall make such notice as soon as reasonably practicable  after
 cancellation.
   § 26. Subdivisions 3 and 4 of section 2994-m of the public health law,
 as  added by chapter 8 of the laws of 2010 and paragraph (c) of subdivi-
 sion 4 as added by chapter 167 of the laws of 2011, are amended to  read
 as follows:

 A. 7277--A                         19
 
   3.  Committee  membership.  The membership of ethics review committees
 must be interdisciplinary and must include at  least  five  members  who
 have demonstrated an interest in or commitment to patient's rights or to
 the  medical,  public  health,  or social needs of those who are ill. At
 least  three  ethics  review  committee members must be health or social
 services practitioners, at least one of whom must be a registered  nurse
 and one of whom must be a physician OR NURSE PRACTITIONER.  At least one
 member must be a person without any governance, employment or contractu-
 al relationship with the hospital. In a residential health care facility
 the  facility  must  offer the residents' council of the facility (or of
 another facility that participates in the committee) the opportunity  to
 appoint  up  to two persons to the ethics review committee, none of whom
 may be a resident of or a family member of a resident of such  facility,
 and  both  of  whom  shall  be persons who have expertise in or a demon-
 strated commitment to patient rights or to the care and treatment of the
 elderly or nursing home  residents  through  professional  or  community
 activities, other than activities performed as a health care provider.
   4.  Procedures  for  ethics review committee. (a) These procedures are
 required only when: (i) the  ethics  review  committee  is  convened  to
 review a decision by a surrogate to withhold or withdraw life-sustaining
 treatment  for:  (A)  a  patient  in  a residential health care facility
 pursuant to paragraph (b) of subdivision  five  of  section  twenty-nine
 hundred ninety-four-d of this article; (B) a patient in a general hospi-
 tal pursuant to paragraph (c) of subdivision five of section twenty-nine
 hundred  ninety-four-d  of  this  article;  or  (C) an emancipated minor
 patient pursuant to subdivision three  of  section  twenty-nine  hundred
 ninety-four-e  of this article; or (ii) when a person connected with the
 case requests the ethics  review  committee  to  provide  assistance  in
 resolving  a  dispute about proposed care. Nothing in this section shall
 bar health care  providers  from  first  striving  to  resolve  disputes
 through  less  formal  means,  including  the  informal  solicitation of
 ethical advice from any source.
   (b)(i) A person connected with the case  may  not  participate  as  an
 ethics review committee member in the consideration of that case.
   (ii)  The  ethics review committee shall respond promptly, as required
 by the circumstances, to any  request  for  assistance  in  resolving  a
 dispute or consideration of a decision to withhold or withdraw life-sus-
 taining treatment pursuant to paragraphs (b) and (c) of subdivision five
 of  section  twenty-nine hundred ninety-four-d of this article made by a
 person connected with the  case.  The  committee  shall  permit  persons
 connected  with the case to present their views to the committee, and to
 have the option of being accompanied by an advisor when participating in
 a committee meeting.
   (iii) The ethics review committee shall promptly provide the  patient,
 where there is any indication of the patient's ability to comprehend the
 information, the surrogate, other persons on the surrogate list directly
 involved  in  the  decision or dispute regarding the patient's care, any
 parent or guardian of a minor patient directly involved in the  decision
 or  dispute  regarding the minor patient's care, an attending physician,
 AN ATTENDING NURSE PRACTITIONER, the hospital,  and  other  persons  the
 committee deems appropriate, with the following:
   (A)  notice  of any pending case consideration concerning the patient,
 including, for patients, persons on  the  surrogate  list,  parents  and
 guardians,  information  about the ethics review committee's procedures,
 composition and function; and

 A. 7277--A                         20
 
   (B) the committee's response to the case, including a  written  state-
 ment  of  the  reasons  for approving or disapproving the withholding or
 withdrawal of life-sustaining treatment for decisions considered  pursu-
 ant to subparagraph (ii) of paragraph (a) of subdivision five of section
 twenty-nine  hundred  ninety-four-d  of  this  article.  The committee's
 response to the case shall be included in the patient's medical record.
   (iv)  Following  ethics  review  committee  consideration  of  a  case
 concerning  the  withdrawal or withholding of life-sustaining treatment,
 treatment shall not be withdrawn or withheld until the  persons  identi-
 fied  in  subparagraph (iii) of this paragraph have been informed of the
 committee's response to the case.
   (c) When an ethics review committee is convened  to  review  decisions
 regarding  hospice  care for a patient in a general hospital or residen-
 tial health care facility, the responsibilities of this section shall be
 carried out by the ethics review committee of the  general  hospital  or
 residential  health  care  facility,  provided that such committee shall
 invite a representative from hospice to participate.
   § 27. Paragraph (b) of subdivision 4 of section 2994-r of  the  public
 health  law,  as  added  by chapter 8 of the laws of 2010, is amended to
 read as follows:
   (b) The following persons may commence a special proceeding in a court
 of competent jurisdiction to seek appointment as the health care guardi-
 an of a minor patient solely for the purpose of deciding about life-sus-
 taining treatment pursuant to this article:
   (i) the hospital administrator;
   (ii) an attending physician OR ATTENDING NURSE PRACTITIONER;
   (iii) the local commissioner of social services or the  local  commis-
 sioner of health, authorized to make medical treatment decisions for the
 minor  pursuant  to  section  three hundred eighty-three-b of the social
 services law; or
   (iv) an individual, eighteen years of age or older,  who  has  assumed
 care of the minor for a substantial and continuous period of time.
   §  28.  Subdivision  1  of section 2994-s of the public health law, as
 added by chapter 8 of the laws of 2010, is amended to read as follows:
   1. Any hospital [or], attending physician OR NURSE  PRACTITIONER  that
 refuses  to honor a health care decision by a surrogate made pursuant to
 this article and in accord with the standards set forth in this  article
 shall not be entitled to compensation for treatment, services, or proce-
 dures  refused  by the surrogate, except that this subdivision shall not
 apply:
   (a) when a hospital [or], physician OR  NURSE  PRACTITIONER  exercises
 the  rights granted by section twenty-nine hundred ninety-four-n of this
 article, provided that the physician,  NURSE  PRACTITIONER  or  hospital
 promptly  fulfills  the  obligations  set  forth  in section twenty-nine
 hundred ninety-four-n of this article;
   (b) while a matter is under consideration by the ethics review commit-
 tee, provided that the matter is promptly referred to and considered  by
 the committee;
   (c)  in  the  event  of a dispute between individuals on the surrogate
 list; or
   (d) if the physician, NURSE PRACTITIONER or hospital prevails  in  any
 litigation  concerning the surrogate's decision to refuse the treatment,
 services or procedure.   Nothing in  this  section  shall  determine  or
 affect  how  disputes  among  individuals  on  the  surrogate  list  are
 resolved.

 A. 7277--A                         21
 
   § 29. Subdivision 2 of section 2994-aa of the public  health  law,  as
 added  by chapter 8 of the laws of 2010, is amended and two new subdivi-
 sions 2-a and 13-a are added to read as follows:
   2. "Attending physician" means the physician who has primary responsi-
 bility  for  the  treatment and care of the patient. Where more than one
 physician OR NURSE PRACTITIONER shares  such  responsibility,  any  such
 physician  OR  NURSE  PRACTITIONER may act as the attending physician OR
 ATTENDING NURSE PRACTITIONER pursuant to this article.
   2-A. "ATTENDING NURSE PRACTITIONER" MEANS THE NURSE  PRACTITIONER  WHO
 HAS  PRIMARY  RESPONSIBILITY  FOR THE TREATMENT AND CARE OF THE PATIENT.
 WHERE MORE THAN ONE PHYSICIAN  AND/OR  NURSE  PRACTITIONER  SHARES  SUCH
 RESPONSIBILITY,  ANY SUCH PHYSICIAN OR NURSE PRACTITIONER MAY ACT AS THE
 ATTENDING PHYSICIAN OR ATTENDING NURSE  PRACTITIONER  PURSUANT  TO  THIS
 ARTICLE.
   13-A. "NURSE PRACTITIONER" MEANS A NURSE PRACTITIONER CERTIFIED PURSU-
 ANT  TO SECTION SIXTY-NINE HUNDRED TEN OF THE EDUCATION LAW WHO IS PRAC-
 TICING IN  ACCORDANCE  WITH  SUBDIVISION  THREE  OF  SECTION  SIXTY-NINE
 HUNDRED TWO OF THE EDUCATION LAW.
   §  30. Section 2994-cc of the public health law, as added by chapter 8
 of the laws of 2010, subdivision 4 as amended by section 131 of  subpart
 B  of  part  C  of chapter 62 of the laws of 2011, is amended to read as
 follows:
   § 2994-cc. Consent to a nonhospital order not to  resuscitate.  1.  An
 adult with decision-making capacity, a health care agent, or a surrogate
 may  consent  to  a  nonhospital  order not to resuscitate orally to the
 attending physician OR ATTENDING NURSE PRACTITIONER or in writing. If  a
 patient  consents  to  a nonhospital order not to resuscitate while in a
 correctional facility, notice of the patient's consent shall be given to
 the facility director and reasonable efforts shall be made to notify  an
 individual designated by the patient to receive such notice prior to the
 issuance  of  the  nonhospital order not to resuscitate. Notification to
 the facility director or the individual designated by the patient  shall
 not delay issuance of a nonhospital order not to resuscitate.
   2.  Consent  by a health care agent shall be governed by article twen-
 ty-nine-C of this chapter.
   3. Consent by a surrogate shall be governed by article  twenty-nine-CC
 of  this  chapter,  except  that: (a) a second determination of capacity
 shall be made by a health or social services practitioner; and  (b)  the
 authority   of   the  ethics  review  committee  set  forth  in  article
 twenty-nine-CC of this chapter shall apply only  to  nonhospital  orders
 issued in a hospital.
   4. (a) When the concurrence of a second physician OR NURSE PRACTITION-
 ER is sought to fulfill the requirements for the issuance of a nonhospi-
 tal  order  not  to resuscitate for patients in a correctional facility,
 such second physician OR NURSE PRACTITIONER shall  be  selected  by  the
 chief  medical  officer  of  the department of corrections and community
 supervision or his or her designee.
   (b) When the concurrence of a second physician OR  NURSE  PRACTITIONER
 is  sought to fulfill the requirements for the issuance of a nonhospital
 order not to resuscitate for hospice and home care patients, such second
 physician OR NURSE PRACTITIONER shall be selected by the hospice medical
 director or hospice nurse coordinator designated by the medical director
 or by the home care services agency director of patient  care  services,
 as appropriate to the patient.

 A. 7277--A                         22

   5.  Consent  by  a  patient  or  a surrogate for a patient in a mental
 hygiene facility shall be governed  by  article  twenty-nine-B  of  this
 chapter.
   §  31. Section 2994-dd of the public health law, as added by chapter 8
 of the laws of 2010, subdivision 6 as amended by section 10 of part J of
 chapter 56 of the laws of 2012, is amended to read as follows:
   § 2994-dd. Managing a nonhospital order not  to  resuscitate.  1.  The
 attending  physician  OR  ATTENDING  NURSE PRACTITIONER shall record the
 issuance of a nonhospital order not  to  resuscitate  in  the  patient's
 medical record.
   2. A nonhospital order not to resuscitate shall be issued upon a stan-
 dard  form  prescribed  by the commissioner. The commissioner shall also
 develop a standard bracelet that may be worn by a patient with a nonhos-
 pital order not to resuscitate to identify that status; provided, howev-
 er, that no person may require a patient to wear  such  a  bracelet  and
 that no person may require a patient to wear such a bracelet as a condi-
 tion  for honoring a nonhospital order not to resuscitate or for provid-
 ing health care services.
   3. An attending physician OR  ATTENDING  NURSE  PRACTITIONER  who  has
 issued a nonhospital order not to resuscitate, and who transfers care of
 the patient to another physician OR NURSE PRACTITIONER, shall inform the
 physician OR NURSE PRACTITIONER of the order.
   4.  For  each  patient for whom a nonhospital order not to resuscitate
 has been issued, the attending physician OR ATTENDING NURSE PRACTITIONER
 shall review whether the order is still  appropriate  in  light  of  the
 patient's condition each time he or she examines the patient, whether in
 the hospital or elsewhere, but at least every ninety days, provided that
 the review need not occur more than once every seven days. The attending
 physician OR ATTENDING NURSE PRACTITIONER shall record the review in the
 patient's  medical  record  provided,  however, that a registered nurse,
 OTHER THAN THE ATTENDING NURSE PRACTITIONER, who provides direct care to
 the patient may record the review in the medical record at the direction
 of the physician. In such case, the  attending  physician  OR  ATTENDING
 NURSE  PRACTITIONER  shall  include  a confirmation of the review in the
 patient's medical record within fourteen days of such review.    Failure
 to comply with this subdivision shall not render a nonhospital order not
 to resuscitate ineffective.
   5.  A  person who has consented to a nonhospital order not to resusci-
 tate may at any time revoke his or her consent to the order by  any  act
 evidencing  a  specific  intent  to revoke such consent. Any health care
 professional, OTHER THAN THE  ATTENDING  PHYSICIAN  OR  ATTENDING  NURSE
 PRACTITIONER, informed of a revocation of consent to a nonhospital order
 not  to  resuscitate  shall  notify the attending physician OR ATTENDING
 NURSE PRACTITIONER of the revocation. An attending physician OR  ATTEND-
 ING  NURSE  PRACTITIONER who is informed that a nonhospital order not to
 resuscitate  has  been  revoked  shall  record  the  revocation  in  the
 patient's  medical record, cancel the order and make diligent efforts to
 retrieve the form issuing the order, and the standard bracelet, if any.
   6. The commissioner may authorize the use of one or  more  alternative
 forms  for  issuing  a nonhospital order not to resuscitate (in place of
 the standard form prescribed by the commissioner under  subdivision  two
 of  this  section).  Such  alternative form or forms may also be used to
 issue a non-hospital do not intubate order. Any such  alternative  forms
 intended  for use for persons with developmental disabilities or persons
 with mental illness who are incapable of making their  own  health  care
 decisions  or  who  have  a guardian of the person appointed pursuant to

 A. 7277--A                         23
 
 article eighty-one of the mental hygiene law or article  seventeen-A  of
 the surrogate's court procedure act must also be approved by the commis-
 sioner  of  developmental  disabilities  or  the  commissioner of mental
 health, as appropriate. An alternative form under this subdivision shall
 otherwise  conform  with applicable federal and state law. This subdivi-
 sion does not limit, restrict or impair the use of an  alternative  form
 for  issuing  an order not to resuscitate in a general hospital or resi-
 dential health care facility under article twenty-eight of this  chapter
 or  a  hospital  under  subdivision  ten  of  section 1.03 of the mental
 hygiene law.
   § 32. Subdivision 2 of section 2994-ee of the public  health  law,  as
 added by chapter 8 of the laws of 2010, is amended to read as follows:
   2.  Hospital  emergency  services  physicians  AND  HOSPITAL EMERGENCY
 SERVICES NURSE PRACTITIONERS may direct that the order be disregarded if
 other significant and exceptional medical circumstances  warrant  disre-
 garding the order.
   §  33.  This  act  shall  take effect on the one hundred eightieth day
 after it shall have become a law; provided that, effective  immediately,
 any  rules and regulations necessary to implement the provisions of this
 act on its effective date are authorized and  directed  to  be  amended,
 repealed and/or promulgated on or before such date.