Attachment 15 BMX 6031.01.24D Inmate Serious Illness.pdf

COMPLEX

SUPPLEMENT

U.S. Department of Justice

Federal Bureau of Prisons

Federal Correctional Complex

Beaumont, Texas 77720-6015

OP!: Medical

NUMBER: BMX 6031.01.24D

DATE: October 5, 2009 SUBJECT: Inmate Serious Illness and

Death; Advanced Directives;

Do Not Resuscitate Orders

DISTRIBUTION: General

1. PURPOSE AND SCOPE: To establish policies and procedures regarding Inmate Serious Illness and Death, Advanced Directives, and Do Not Resuscitate (DNR) orders at the Federal Correctional Complex (FCC), Beaumont, Texas.

2. PROGRAM OBJECTIVES: To provide a uniformed approach and opportunity for individual inmate patients to express their wishes for medical treatment to be followed in the event they become unable to make known their desires. To provide an approach for situations of inmate serious illness, critical illness, homicide, or death which require notification to the next of kin, investigation, and reporting.

3. DIRECTIVES AFFECTED:

a. Directives Rescinded: Complex Supplement BMX 603 1 .01 .24C, Inmate Serious Illness and Death; Advanced Directives; Do Not Resuscitate Orders, dated July 25, 2008.

b. Directives Referenced: Program Statement 603 1 .0 1 , Section 24, Patient Care, dated January 1 5, 2005; JCAHO Accreditation Manual for Hospitals, 1 996 standards;

Vernon's Texas Statutes and Codes Annotated Currentness, Tex. Health & Safety Code Ann. §§ 1 66.00 1 - 1 66. 1 6 1 .

4. CORRECTIONAL STANDARDS REFERENCED: American Correctional Association Standards for Adult Correctional Institutions, 4th Edition, 4-4425, 4-4395, and 4-4396.

5. APPLICABILITY: This supplement will apply to inmates in the custody of the Federal Bureau of Prisons, to include inmates housed at FCC Beaumont and local community hospitals. Inmates under the care of a community contract facility will be subject to the policies and regulations of that facility.

6. DEFINITIONS:

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a. Serious Illness is an illness which threatens an inmate's life. Determination that an illness is "serious" is a medical determination made only by a physician.

b. Critical Illness is an illness of such a degree or severity and of such nature that death is considered imminent, being but a matter of days away at most, as contrasted with a serious illness, which may persist for weeks or months.

c. Death is the irreversible cessation of the following: ( 1 ) total cerebral function;

(2) spontaneous function of the respiratory system; and (3) spontaneous function of the circulatory system.

d. Competent is possessing the ability, based on reasonable medical judgment, to understand and appreciate the nature and consequences of a treatment decision, including the significant benefits and harms of and reasonable alternatives to a proposed treatment decision.

e. Declarant is a person who has executed or issued a directive under these guidelines.

f. Advanced Directives are defmed due to inmate and health care providers are confronted with difficult and sensitive decisions regarding health care, including the decision to have extraordinary means of care and life support withheld or withdrawn in cases of a terminal condition or irreversible illness. Inmates may direct, in advance, to withhold or withdraw certain medical treatments when recovery or cure is not possible.

Inmates may appoint, in advance, a proxy decision maker (excluding staff members or another inmate) who will make critical health care decisions for them should they become incapacitated and unable to make such decisions for themselves.

FCC Beaumont's withholding or withdrawal of resuscitative or life-support services pursuant to an Advance Directive or DNR order, is consistent with sound medical practice and is not associated with assisting suicide, voluntary euthanasia, or expediting the inmate's death.

The patient's right to refuse medical treatment is not absolute and, in all cases, will be weighed against legitimate governmental interests, including the security and orderly operation of correctional institutions.

When an inmate is unconscious or otherwise unable or incompetent to participate in the decision, every reasonable effort will be undertaken to obtain written concurrence of one or several immediate family members. The attending physician must document these efforts in the medical record.

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g. Do Not Resuscitate (DNR) Order: A DNR order indicates that resuscitative measures or advanced cardiac life support techniques will be withheld in the event of cardiac or pulmonary arrest.

h. Full Disclosure: In order to make full disclosure, the attending physician will disclose to the appropriate individual (inmate, next of kin, or legally acceptable agent) the following: the inmate's medical history; diagnosis (to the extent allowed by law); the treatment attempted and the medical futility of such treatment; other medical treatment available and their medical futility; and the physician's decision and basis for such decision.

1. Legally Acceptable Agent: A personal agent designated by the inmate and recognized by state law to make health care decisions for the inmate. Texas law recognizes properly appointed guardians or an individual legally recognized in a directive or a Durable Power of Attorney for Health Care.

J. Life-Sustaining (Supporting) Procedures: Any medical procedure or intervention that uses mechanical or other artificial means to sustain, restore, or supplant a vital function, and only artificially postpones the moment of death of a patient in a terminal condition, whose death is imminent, or will result within a relatively short time without the application of the procedure. The term does not include the administration of medication or the performance of a medical procedure considered to be necessary to provide comfort care or to alleviate pain.

k. Medical Futilitv: A decision a medical doctor makes when there is a high degree of probability that a medical treatment cannot accomplish its goal.

I. Principal: The individual who has elected a Durable Power of Attorney for Health Care.

m. Oualified Patient: An inmate with a terminal condition who has been diagnosed and certified in writing by the attending physician and one other physician who have personally examined the inmate.

n. Terminal Condition: An incurable or irreversible condition caused by injury, disease or illness that would produce death without the application of life-sustaining procedures, according to reasonable medical judgment, and in which the application oflife-sustaining procedures serves only to postpone the moment of the inmate's death.

7. PROCEDURES:

a. FCC Beaumont remains committed to the principle of preserving and extending life.

A seriously ill or dying inmate should be provided care consistent with this goal.

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When an inmate is detennined to be seriously or critically ill, contract Health Services staff will notify the Health Systems Specialist (HSS) and Operations Lieutenant. The Operations Lieutenant will notify the Institution Duty Officer (IDO) who will in turn notify the Associate Warden with oversight of Medical, Unit Manager, and Chaplain describing the nature of the illness and the inmate's prognosis.

b. Serious illness of an inmate is of immediate concern to the inmate's family and FCC Beaumont will promptly notify the next of kin. The Chaplain will attempt to notify the inmate's family by telephone and convey the inmate's medical condition, the inmate's location, and the limitation placed on visitation. If telephone contact cannot be accomplished, a telegram will be sent prepaid to the person designated to receive such notification (BP-408, Section 3, Central File).

While the Bureau will continue to control conditions under which a family member may visit, consideration will be given providing the maximum opportunity for visitation. The family member(s) will visit the inmate in accordance with the outside hospital's visitation policy.

c. When an inmate is in an outside hospital, FCC Beaumont retains authority regarding administrative decisions (visitors and movement of inmates). The hospital retains authority to make medical decisions consistent with the inmate and his family's wishes. The hospital will be pennitted to follow its established by-laws concerning seriously ill or dying patients. Contract Health Services staff will keep the HSS aware of all treatment received by the inmate on an ongoing basis (in a timely manner as dictated by the inmate's condition).

d. In the event an inmate is a suitable candidate for release and appropriate arrangements can be made in conjunction with the family for early release or furlough, the Unit Team will expedite the processing of the release action.

e. Death of an Inmate:

I ) Pronouncement of death according to Texas state law shall be perfonned under the guidelines of the Health & Safety Code, Title 8. Death and Disposition of the Body, Subtitle A. Death, Chapter 671 . Detennination of Death and Autopsy Reports, Subchapter A. Detennination of Death. (671 .001 - Standard Used in Detennining Death). The authority to pronounce death at the FCC is the responsibility of the contract Clinical Director, but may not be delegated below the level of staff physician. Medical staff at the local hospital will be pennitted to follow their established by-laws when determining inmate deaths.

2) Contract Health Services staff will notify the Operations Lieutenant and HSS.

The Operations Lieutenant will notify the IDO, after hours, who will then notify the Administrative Duty Officer, Warden, Associate Wardens, Camp

Administrator (if applicable), Captain, Special Investigative Agent/Special Investigative Supervisor, Complex Case Management Coordinator, Supervisory Inmate Systems Specialist, and the Chaplain.

3) If death occurs at the Complex, contract Health Services staff will immediately contact the Justice of the Peace serving as Coroner, by telephone, explaining the circumstances and request permission to move the body. Additionally, contract Health Services staff will contact the HSS and Operations Lieutenant.

4) If death occurs at an area hospital, contract Health Services staff will contact the hospital to insure the appropriate Justice of the Peace has been contacted for Autopsy Authorization.

If death is due to natural causes or the result of a diagnosed illness, an autopsy will be requested. In cases where the cause of death is under investigation, an autopsy will be ordered as provided for in Program Statement 6080. 0 1 , Autopsies, dated May 27, 1 994.

5) Under no circumstances will the body be removed without prior consent of the affected Warden.

6) The Supervisory Inmate Systems Specialist, or hislher designee, will make official identification of the body by fingerprinting the right thumb on a FD-249 to compare with the fingerprints on file in the Judgment and Commitment file prior to removal of the body from the institution or hospital.

Inmate Systems Management staff must contact appropriate hospital staff to ensure the body is properly identified prior to removal.

7) The HSS will notify Procurement staff of the inmate's death. Procurement staff will then initiate body preparation arrangements, transportation arrangements, and request for the Death Certificate. Procurement staff will coordinate such activities with appropriate representatives of the local hospitals.

8) The following information will be assembled:

Name, register number, date of birth.

Offense and sentence.

Date and time of death.

Place (or Location) at time of death.

Apparent cause of death.

Investigative steps being taken, if necessary.

Name and address of survivor or designee, whether notified; and if notified, whether permission to conduct an autopsy was received.

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If decedent was an alien, whether consulate and immigration officials were notified.

If decedent was a state prisoner, whether the administrator (Director, Commissioner, etc.) of the state correctional agency was notified.

If the death occurs during regular duty hours, the above information will be telephonically reported to the Regional Correctional Services Administrator by the Captain and confirmed via electronic mail message with a copy to the Correctional Services Administrator, Central Office. Reports during non-duty hours will be made by the Institution Duty Officer immediately by telephone to the Regional Duty Officer and confirmed by electronic mail message to the Regional Office by the next regular work day by the Captain. In conjunction with Health Services staff, the HSS will prepare and submit a cursory 24 hour report for the Office of Quality Management, Medical Director (BOP HSD/Medical Director), and the Office of Health Programs (BOP-HSDlHealth Programs Branch) Central Office, within 24 hours (or the next working day) of the demise of the inmate.

9) If the decedent is a Federally-sentenced or unsentenced inmate, the Unit Team will prepare a letter for the Warden's signature to the appropriate United States District Judge(s), with copies to the United States Attorney, and the Chief United States Probation Officer. If the inmate is not a citizen of the United States or is a state prisoner, the Warden will immediately notifY, by telephone, the appropriate consulate official or the administrator of the state correctional agency, whichever is appropriate. The Unit Team will prepare a follow-up letter for the Warden's signature, confirming the notification, and explaining the circumstances of the death. A copy of this letter will also be forwarded to the Regional Director.

EXCEPTION: When an inmate assigned to the Witness Security Program dies or is seriously ill, the Inmate Monitoring Branch, Central Office, is to be notified immediately. Staff should refer to the Central Inmate Monitoring (CIM) Manual for notification procedures and call the institution CIM Coordinator or hislher alternate immediately. Victim or witness notification will be conducted in accordance with Program Statement 1490.06, Victim and Witness Notification Program, dated May 23, 2002. Additionally if a WITSEC inmate dies and an autopsy is not performed, Wardens are directed to document why it was determined to not be warranted. A copy of this with justification is to be forwarded to the Assistant Administrator, Inmate Monitoring

1 0) The Chaplain should call the next of kin to advise them of the death. The following items should be conveyed:

Apparent cause of death.

Time of death.

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Secure permission for a complete autopsy. Inform next of kin they may fax or telegraph the institution collect with their response.

Encourage the family to have the remains returned to the home community.

Explain that expenses are borne by the Government (this covers all expenses incurred until the remains reach the nearest airport in the home community, including embalming, clothing, coffin, and transportation to airport nearest to the home of the decedent).

The family must bear expenses incurred after the remains arrive at the home airport.

Obtain name and address of community funeral home which the family designates to receive the remains and the place of burial.

II) If the family cannot be contacted by telephone, a telegram will be sent to the designated next of kin making notification. The designated next of kin will be found in Section 3 of the inmate's Central File on the BP-408 Form, Acknowledgments of Inmate.

12) The Unit Team will prepare a letter of condolence to the next of kin for the Warden's signature, as soon as possible, advising them of the circumstances of the death. In cases of death by natural causes, a summary of the cause of death will be given. In cases of accidental death, other than by foul play, a reference to the nature of the accident and the cause of death is appropriate. In cases of death under suspicious circumstances or by foul play, the cause of death may be given, but with a statement the matter is under investigation and details of the case may not be provided for that reason.

1 3) Authority to Conduct Autopsies:

(a) The Warden may order an autopsy and related scientific or medical tests to be performed on the body of a deceased inmate in the event of homicide, suicide, fatal illness or accident, or unexplained death. An autopsy or tests may be ordered in these situations when the Warden determines the autopsy or test is necessary to detect a crime, maintain discipline, protect the health or safety of other inmates, remedy official misconduct, or defend the United States or its employees from civil liability arising from the administration of the facility. The authority of the Warden under this section may not be delegated below the level of Acting Warden (see Attachment A).

(b) In any situation other than those described in paragraph (a) of this section, the Warden may request an autopsy be performed on the body of a deceased inmate. In these situations, State of Texas law requires either written consent from the deceased inmate's next of kin or an order from the Coroner to conduct an autopsy prior to such an autopsy being conducted. The Warden may order a post-mortem operation for the purposes of removal of tissue for transplantation only if the decedent had authorized such removal of tissue prior to death or if written consent is obtained from the deceased inmate's next of kin.

1. The authority of the Warden under this section may not be delegated below the level of Acting Warden.

II. If consent to conduct an autopsy from the deceased inmate's next of kin is necessary, the request for consent is to be included in the telegram notifYing the next of kin of the inmate's death. The next of kin should be advised to provide consent by sending a return telegram. Where permission is not received from the Coroner or next of kin, an autopsy may not be performed.

(c) Time is a critical factor in arranging for an autopsy, as this ordinarily must be performed within 48 hours. While a decision on an autopsy is pending, no action should be taken that will affect the validity of the autopsy results. Therefore, while the body may be released to a funeral home, this should be done only with the written understanding from the funeral home that no preparation for burial, including embalming, should be performed until a final decision is made on the need for an autopsy.

Once approval is obtained, contract Health Services staff will make arrangements for the autopsy. The autopsy will ordinarily be performed by a contract pathologist.

14) Religious Requirements:

(a) The Chaplain will identifY and approve all religious requirements and make arrangements with the funeral home to ensure religious requirements are met.

(b) In any instance where there is question that performance of an autopsy is in conflict with an inmate's religious belief, the Chaplain will be consulted prior to the autopsy.

1 5) The Supervisory Contract Specialist, upon notification of the family's wishes concerning the funeral, will arrange through the contract mortuary for the body to be embalmed, dressed and fitted with a suitable casket. The Supervisory Contract Specialist will prepare the necessary forms for transportation of the body, as the family directs, through the contract mortuary. At any time, when above written procedures are handled by telephone rather than written communication, the individual accomplishing such will prepare a memorandum explaining the action taken and arrangements agreed upon and ensure a copy is placed in the decedent's file.

1 6) If the family does not desire the body, the institution will bear the cost of a local burial.

1 7) The Mortality Review Committee (MRC) will consist of at least the contract

Clinical Director (CD), contract Health Services Administrator, contract Mid Level Practitioner, Bureau of Prisons (BOP) Health Services Specialist, and the BOP Associate Warden with oversight of Medical. Other staff may participate as appointed by the Warden. The contract Clinical Director will serve as Chairman of the MRC. Where possible, members of the review committee will not be composed of individuals who were involved in the treatment of the inmate.

The contract Clinical Director is responsible for the preparation of a complete report of the death and for scheduling an institution review. The Mortality Review Report, with all related documents, will be sent to Central Office within 30 days. When the MRC conducts a death review, a Mortality Review report will be assembled which, at a minimum, will contain:

(a) A comprehensive narrative clinical summary of the case to include, but not limited to the following: history, diagnosis, current treatment plan, sequence of events leading to the death, and cause of death.

(b) A summary of activities by institution staff related to the death, including who responded, how quickly they responded, and what they did. This summary should also report any significant events or activities of other staff from the institution and the community.

(c) Designator and Community Corrections Manager's reports.

(d) Autopsy report, if available.

(e) If the inmate was admitted to a community hospital, the attending physician's report and other pertinent information. If the discharge/death summary is not available in a timely manner, the narrative summary will relate any information which has been obtained verbally from the attending community physicians and health care staff.

(f) Unless strongly indicated by circumstances, staff names will not be used in the report, instead titles will be substituted.

(g) The reports, documentation, and summaries will be designated confidential material and be treated as such. Only staff with a need to know will be privy to its contents.

1 8) In conducting the review, the MRC will:

(a) Review the report packet, review the Medical Record, and interview staff as needed to obtain all the facts of the case.

(b) Analyze the complete report, identifying for both individuals and systems, the respective strengths and weaknesses. This analysis will be done for two discrete time frames: the events immediately surrounding the death and the clinical and case management history which preceded the final event.

(c) Evaluate both individual and system performance immediately approximate to the death. The MRC will specifically address:

Alert and response times.

Communications.

Transportation.

Clinical skills (especially the utilization of Cardiopulmonary Resuscitation (CPR), Advanced Cardiac Life Support (ACLS), or other appropriate protocols).

Equipment/supplies/pharmaceutical.

Documentation, especially in the medical record. In discussing this factor, the committee will clearly distinguish, if possible, between lack of documentation or failure to actually provide the care.

(d) Evaluate individual system performance in the days or months preceding the death. The MRC will specifically address:

Documentation.

Working diagnosis versus final diagnosis.

Appropriateness and timeliness of diagnostics and treatment regimens.

Complicating factors, either human or system, in the overall care of the patient which may have affected the outcome.

1 9) The Committee will document by summary report the discussion of the above listed factors, as well as any aspects deemed appropriate. Highlighting the positive aspects of the case is as important as constructively detailing any deficiencies. The report will conclude with recommendations for commendations and/or corrective actions.

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The Warden will review the report and all attachments and approve or disapprove the MRC's findings and recommendations. Copies of the report, all attachments, the medical record, and a transntittal memorandum signed by the Warden will be forwarded to the Regional Director with a copy to the Office of Quality Management, Health Services Division, Central Office.

8. ADVANCED DIRECTIVESILIVING WILLS:

a. All inmates will be advised of their right to execute an Advanced Directive in Admission and Orientation by the Health Services Representative.

b. An inmate requesting an "Advanced Directive" will be advised of the following:

1 . Advise the UTMB Administrative Associates (AA) to provide a copy of "Declaration of Adult Health Care Decisions Form" (Attachment B).

2. The UTMB AA will advise the inmate he has the option of retaining private legal counsel at his own expense for assistance in completion of the form.

3. Advise the inmate of the need to obtain the necessary witness signatures.

4. Advise the inmate that a copy of the completed form will need to be forwarded to the UTMB AA for filing in the "Advance Directive" section of the medical record or section 5 .

5 . Advise the inmate the Advanced Directive should include "types of health care instructions" such as:

Quality of life considerations.

Preferences for particular types of treatment.

Management of the dying process, place of death.

Instructions for organ donation.

Lintitations on authority of agent.

Preference for primary physician.

Nomination of conservator.

It is the responsibility of the contract CD to:

1 . Upon notification from the inmate of an Advanced Directive, the CD should request a copy of the directive to be placed in the medical record.

2. Document the existence or revocation of a written or oral directive.

3 . Document the loss and the recovery of decision-making capacity.

4. Comply with the instructions of the patient or surrogate (with limited exceptions).

5 . Inform the patient of decisions made by the surrogate before implementing those decisions.

In the event that FCC Beaumont declines to follow a request:

I. The CD should promptly inform the patient or agent.

2. Assist with all reasonable efforts to immediately transfer the patient to a MRC or a local community hospital willing to comply with the request.

3. Provide continuing care unti I transfer.

c. Competent inmates may produce an Advanced Directive for future eventualities, in accordance with Texas law and BOP procedures. The directive will be maintained in Section 5 of the inmate's medical record under the Advanced Directives divider. The Advanced Directive is only to be implemented once the inmate falls into a terminal condition and is deemed incompetent or lacking the capacity to make health care decisions.

d. The inmate must submit an Advanced Directive to medical personnel for placement in the medical record for the directive to be valid.

e. Valid written directives of an inmate's decision regarding medical procedures will be honored if it is legally valid in the state of Texas. Durable Powers of Attorney from other states are effective if valid in that state. Several options exist in completing an Advanced Directive. An attorney can be contacted by the inmate to execute a Directive to Physician and/or Durable Power of Attorney for health care, the inmate can complete the forms provided in the attached state legislation (Attachment C), or the inmate can complete the forms provided with these guidelines (Attachments B, C, & D). Directives must be signed by the declarant in the presence of two witnesses.

f. Normally, the witnesses will be through the Legal Assistance Program if available.

However, a Chaplain, Social Worker, Counselor, or Case Manager would also be appropriate.

g. If the inmate is comatose, incompetent, or mentally or physically incapable of communication, and:

-- The inmate has designated another person to make a treatment decision, the attending physician and the designated person may make a treatment decision to withhold or withdraw life-sustaining procedures from the inmate, regardless of the existence of a written directive prepared by the inmate.

The inmate has not designated a person to make a treatment decision, the attending physician will comply with the written directive unless the physician believes the directive does not reflect the patient's present desire.

h. If the inmate is comatose, incompetent, or mentally or physically incapable of communication, and has not executed an Advanced Directive, the attending physician may make a treatment decision, including a decision to withhold or withdraw life sustaining procedures, pursuant to Tex. Health & Safety Code Ann. § 1 66.039.

I. Once the attending physician is aware that an inmate has a terminal condition, the physician must determine if an Advanced Directive exists. If so, the procedures for patient certification must be followed, as outlined in Tex. Health & Safety Code Ann.

§ 1 66.00 1 (or Tex. Health & Safety Code Ann. § 1 66. 1 5 1 , Durable Power of Attorney for Health Care).

J. If the attending physician refuses to comply with the treatment decision, the physician will make reasonable efforts to transfer the patient to another physician, or inform the agent.

k. If an inmate requires resuscitative services while in a general population institution or while in transit to a community hospital or Medical Referral Center (MRC) from a general population institution, all necessary resuscitative services will be provided despite the presence of a living will.

9. DNR ORDERS:

a. DNR orders do not apply and may not be written at general population institutions. If an inmate requires resuscitative services while at FCC Beaumont, or while in transit to the contract hospital, or to and from a MRC, all necessary resuscitative services will be provided despite the presence of a living will.

b. If an inmate is admitted for care at a MRC, DNR orders may be executed in accordance with the policies and regulations of the MRC.

c. A DNR order is not to be confused with other Advanced Directives, as DNR orders are only for resuscitation purposes in the event of cardiac or pulmonary arrest.

10. DOCUMENTATION:

a. A divider will be established in the medical record in accordance with Program

Statement 6090.02, Health Information Management, dated October 1 3, 2008. All Advanced Directives must be made part of the medical file and contained under the Advanced Directives section. A copy of these forms will be delivered to the Clinical Director's office following completion.

b. Documentation of the Advanced Directive status will be clearly identified on the outside of the inmate's medical record, as required in Program Statement 6090.02, Health Information Management, Section 7, Page II.

c. It is essential this information is accurate and the Medical Records Department should periodically ensure the markings on and the contents in the medical file are consistent.

1 1 . IMPLEMENTATION AND NOTIFICATION: If an inmate is in a community based hospital, the hospital's by-laws, local and state laws, and family'S wishes determine whenlhow/if at all a living will, will be implemented.

12. PROXY DECISION MAKER: According to Texas state law and Bureau of Prison policy, an inmate may designate an individual to make a treatment decision for the declarant "inmate" in the event the inmate becomes comatose, incompetent, or otherwise mentally or physically incapable of communication. If the inmate chooses to designate a proxy decision maker, the inmate must comply with the following:

a. The inmate must include the proxy decision maker information in the directives directions;

b. The decision maker cannot be a BOP staff member or another inmate; and

c. If the inmate is admitted in the local hospital, the local hospital has a policy covering proxy decision makers.

13. REVOCATION: An Advanced Directive is valid until revoked as prescribed in Vernon's Texas Statutes and Codes Annotated Currentness, Health & Safety Code Ann. § 1 66.04 1 if a Directive to Physician, or Health & Safety Code Ann. § 1 66. 1 55 if a Durable Power of Attorney. A declarant may revoke a Directive at any time without regard to the declarant's mental state or competency. The on-call physician will be notified of this event immediately.

14. APPLICABLE LEGISLATION: A copy of the applicable Texas legislation is attached.

15. ACTION: A copy of this supplement will be forwarded to the South Central Regional Director for approval prior to issuance.

ATTACHMENTS:

Attachment A Autopsy Authorization

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Attachment B Declaration of Adult Health Care Decisions Notice Attachment C Declaration Attachment D Statement of Witnesses Attachment E State of Texas Advance Directives Act

W\.<J>- Complex Warden Warden

OFFICE OF PRIMARY RESPONSIBILITY: Health Services

M. Martin Warden

AUTOPSY AUTHORIZATION

Name of Deceased inmate: _____________ _

Register Number: __________ _

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Attachment A

As Warden, I have reviewed the above inmate's death with the attending physician, and find, pursuant to my authority under Title 1 8, U.S.c. , Section 4505, that an autopsy should be performed. I find that the death is within the categories of deaths listed in 28 C.F.R. Section

549.80 (a) and that the autopsy is required, as it is necessary to determine the cause of death to:

1. Detect a crime.

2 . Maintain discipline.

3. Protect the health or safety of other inmates.

4. Remedy official misconduct.

5 . Defend the United States or its employees from civil liability arising from the administration of the facility.

Warden's Signature Date

Attachment B

DECLARATION OF ADULT HEALTH CARE DECISIONS NOTICE

This is an important legal document. This declaration gives you the opportunity to make your wishes clear regarding the withholding or withdrawal of life-sustaining procedures should you ever suffer a terminal and irreversible condition.

PLEASE DO NOT SIGN THIS DOCUMENT WITHOUT CAREFULLY READING IT.

YOU SHOULD KNOW THE FOLLOWING FACTS:

a. This document gives your health care providers the power and guidance to make health care decisions when you are in a terminal and irreversible condition and cannot do so yourself.

b. This document may include what kind of treatment you want or do not want and under what circumstances you want these decisions to be made. You may state whether you want or you do not want to recei ve treatment.

c. Your health care providers will attempt to act consistently with your instructions, subject to legitimate Goverrunent interests, including the law of the State in which you receive treatment.

d. The decisions you make in this declaration regarding your medical treatment are personal.

Your health care providers have the duty to follow your instructions, within sound medical judgement, and regardless of the wishes or beliefs of your family members, friends, or significant others.

e. This document will remain valid and in effect until and unless you amend it. You may advise your health care providers or another appropriate correctional official, such as your case manager, of such changes. It is preferable that you state your instructions in writing if you are able to do so.

f. You have the right to receive a copy of this document. Review this document periodically to make sure it continues to reflect your preferences.

g. A copy of this declaration will be made part of your medical record at the institution to which you are assigned.

h. As used in these instructions and in the foregoing declaration, the following words are defined below, unless the context clearly states otherwise. These definitions are for descriptive purposes only and may be different than or superseded by applicable State law.

Attachment B

I. "Declaration" means a writing, a witnessed document, statement, or expression voluntarily made by the declarant, authorizing the withholding or withdrawal of life sustaining procedures, in accordance with the requirements of this part.

2. "Declarant" means a person who has signed a declaration as defined herein.

3 . "Life-sustaining procedure" means any medical procedure or intervention which, within reasonable medical judgment, would only serve to prolong the dying process for a person diagnosed as having a terminal and irreversible condition. This includes the artificial administration of nutrition and hydration when defined as such by applicable State law.

A "life-sustaining procedure" will not include any measure deemed necessary to provide comfort care.

4. "Comfort care" means any medical procedure or intervention deemed necessary to alleviate pain.

5 . "Health care provider" means a person, health care facility, organization, or corporation licensed, certified, or otherwise authorized or permitted by the laws of the State where the declarant is located to administer health care directly or through an arrangement with other health care providers, who is selected by or assigned to the declarant, and has primary responsibility for the treatment and care of the declarant. The term "health care provider" includes the Federal Bureau of Prisons.

6. "Qualified patient" is defined as one certified in writing as having a terminal and irreversible condition. Certification will be made by two persons who qualifY as health care providers.

7. "Terminal and irreversible condition" is defined as including a condition of persistent vegetative state. This term also includes a condition caused by injury, disease, or illness which, within reasonable medical judgment, would cause death and for which the application of life-sustaining procedures would serve only to postpone the moment of death.

8. "Persistent vegetative state" means a condition caused by injury, disease, or illness in which, within reasonable medical judgment, the qualified patient will have no cognitive (conscious) or reflexive ability to swallow food or water to maintain daily needs and in which the brain has degenerated in an irreversible, permanent, progressive, and ongoing manner.

9. "Witness" means a competent adult, not an inmate, who is not related to the declarant by blood or marriage and who would not be entitled to any portion ofthe estate of the person from whom life-sustaining procedures are to be withheld or withdrawn upon hislher death. This term includes institution staff.

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October 5, 2009

Attachment B Page 3 of3

If there is anything in this document that you don't understand, you should ask for professional help to have it explained to you. You may need to re-execute this document if you are transferred to a Bureau of Prisons institution in another State.

I, ______________ , hereby certify that I have read the preceding notice (please print) carefully and that I, to the best of my knowledge, understand the aforementioned definitions.

Signed, Declarant's signature

Date

Witness

Address

DECLARATION

October 5, 2009

Attachment C

TO MY FAMILY, DOCTORS, AND ALL THOSE CONCERNED WITH MY CARE:

I, , being of sound mind, willfully and voluntarily make known my directives to be followed if I am in a terminal and irreversible condition and become unable to participate in decisions regarding my health care. I understand that my health care providers are legally bound to act consistently with my wishes, within the limits of reasonable medical practice and other applicable law.

[ understand that I am able to revoke this declaration at any time, in the manner prescribed by Tex. Health & Safety Code Ann. § 166.042.

It is my wish that my dying will not be artificially prolonged under the circumstances set forth below and do hereby declare:

If at any time I should have an incurable injury, disease, or illness certified to be a terminal and irreversible condition by two physicians, and my attending physicians have determined that my death will occur within a relatively short time without the application of life-sustaining procedures, and where the application of such life-sustaining procedures would serve only to artificially prolong the dying process, or that I have entered a persistent vegetative state, I direct that such life-sustaining procedures be withheld or withdrawn. It is further my wish that I be permitted to die naturally with only the administering of medication or the performance of any medical procedure deemed necessary to provide me with comfort care.

[n the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intention that this declaration will be honored by my family and health care providers as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences from such refusal. However, if I choose to designate anotber person to make treatment decisions for me in the event I should become incompetent, as set forth below, the treatment decisions of the person whom I designate will be complied with regardless of this directive.

I recognize that my health care providers will attempt to act consistently with my instructions, within sound medical judgment and subject to legitimate governmental interests. [ hereby authorize them to enter and participate in any judicial or administrative proceedings necessary to review or to uphold this declaration. I agree that this proceeding should be a private and speedy one, so that my wishes can be complied with as soon as practicable.

I understand that such proceedings would be performed on my behalf and, when applicable, the Federal Bureau of Prisons has my permission to file pleadings in my name and to request that judicial or administrative costs or other kind of payment not be assessed against the Bureau of

Prisons.

BMX 6031 .01.240

October 5, 2009

Attacbment C

I understand that Texas law allows me to designate another person to make a treatment decision for me if ! should become comatose, incompetent, or otherwise mentally or physically incapable of communication. I hereby designate , who resides at , to make such a treatment decision for me if !

should become incapable of communicating with my physician.

I have discussed my wishes with _________ and trust hislher judgment.

I understand that if I become incapable of communication, my physician will comply with this directive unless I have designated another person to make a treatment decision for me, or unless my physician believes this directive no longer reflects my wishes. I also understand that my expressed desires will supersede the effect of this directive.

I hereby request that the following person(s) be notified of my condition and my wishes as expressed in this declaration as soon as it is practicable and after my health care providers have certified that I have suffered a terminal and irreversible condition:

Name(s), Address and Telephone Number Relationship

Further instructions:

Should any portion of this declaration be declared invalid, such invalidity will not affect other parts of the declaration, which can be given effect independent of the invalid portion.

I understand the full import of this declaration, and I am mentally competent to make this declaration and do so without duress of any kind.

Signed:

Reg. No.:

SUBSCRIBED by __________ in the presence of the undersigned witnesses, each of whom is 1 8 years of age or older, this __ day of ______ , 20 __ .

STATEMENT OF WITNESSES

October 5, 2009

Attachment D

I, the undersigned witness, am not related to declarant by blood or marriage. I would not be entitled to any portion of the declarant's estate on the declarant's death, nor do I have any claim against any portion of the declarant's estate on the declarant's death. I am not the attending physician of the declarant or any employee supervised by the attending physician. I am not an inmate in any correctional facility. Furthermore, if ! am an employee of a health facility in which the declarant is a patient, I am not involved in providing direct patient care to the patient and am not directly involved in the financial affairs of the health facility. I am not named in any legal action filed by the declarant.

WITNESSES: PLACES OF RESIDENCE:

THE STATE OF TEXAS

COUNTY OF ________ __

This instrument was sworn to and acknowledged before me on the

__ day of _____ , 20_, by _____ , Declarant, and by ______ and

____ , Witnesses.

My commission expires:

Notary Public in and for the State of Texas

______ , 20 _.

BMX 6031.01.240

Attachment 0 Page 2 of2

U.S. Department of Justice

Federal Bureau of Prisons

Federal Correctional Complex

P.D. Box 26035 Beaumont, Texas 77720-6035

Date

MEMORANDUM FOR [ [ , REGIONAL COUNSEL

FROM:

SUBJECT:

SOUTH CENTRAL REGION

), Clinical Director Via Facsimile Federal Correctional Complex, Beaumont, Texas

Review of Advanced Directive Submission

In accordance with Program Statement 603 1 .0 1 , Patient Care, Section 24, I am requesting a review of the attached Advanced Directive for the following patient:

NAME:

REGISTER NO:

DIAGNOSIS:

PROGNOSIS:

TREATMENT

PLAN:

SIGNIFICANT

FACTS:

Upon your review, please route to the Regional Director and then to the Medical Director for approval. Please notify as soon as possible of such approval via EMS "[EMS CODE) MED REC" or via facsimile at [FAX #1.

Attachment

STATE OF TEXAS

ADVANCE DIRECTIVES ACT

CHAPTER 166. Advance Directives

SUBCHAPTER A. GENERAL PROVISIONS

§ 166.001. Short Title

BMX 6031.01.24D

October 5, 2009

Attachment E

This chapter may be cited as the Advance Directives Act. Added by Acts 1 999, 76th Leg., ch. 450, § 1 .02, eff. Sept. 1 , 1 999. For text of section as added by Acts 1 999, 76th Leg., ch. 642, § I , see § 1 66.00 I , post.

§ 166.002. Definitions

In this chapter:

(I) "Advance Directive" means:

(a) A directive, as that term is defined by Section 1 66.03 1 ;

(b) an out-of-hospital DNR order, as that term is defined by Section 1 66.08 1 ; or

(c) a medical power of attorney under Subchapter D.

(2) "Artificial nutrition and hydration" means the provision of nutrients or fluids by a tube inserted in a vein, under the skin in the subcutaneous tissues, or in the stomach (gastrointestinal tract).

(3) "Attending physician" means a physician selected by or assigned to a patient who has primary responsibility for a patient's treatment and care.

(4) "Competent" means possessing the ability, based on reasonable medical judgment, to understand and appreciate the nature and consequences of a treatment decision, including the significant benefits and harms of and reasonable alternatives to a proposed treatment decision.

(5) "Declarant" means a person who has executed or issued a directive under this chapter.

(6) "Ethics or medical committee" means a committee established under Sections 1 6 1 .03 1-161 .033.

(7) "Health care or treatment decision" means consent, refusal to consent, or withdrawal of consent to health care, treatment, service, or a procedure to maintain, diagnose, or treat an individual's physical or mental condition.

October 5, 2009

Attachment E

(8) "Incompetent" means lacking the ability, based on reasonable medical judgment, to understand and appreciate the nature and consequences of a treatment decision, including the significant benefits and harms of and reasonable alternatives to a proposed treatment decision.

(9) "Irreversible condition" means a condition, injury, or illness:

(a) That may be treated but is never cured or eliminated;

(b) that leaves a person unable to care for or make decisions for the person's own self;

and

(c) that, without life-sustaining treatment provided in accordance with the prevailing standard of medical care, is fatal.

( 10) "Life-sustaining treatment" means treatment that, based on reasonable medical judgment, sustains the life of a patient and without which the patient will die. The term includes both life-sustaining medications and artificial life support, such as mechanical breathing machines, kidney dialysis treatment, and artificial nutrition and hydration. The term does not include the administration of pain management medication or the performance ofa medical procedure considered to be necessary to provide comfort care, or any other medical care provided to alleviate a patient's pain.

( I I ) "Medical power of attorney" means a document delegating to an agent authority to make health care decisions executed or issued under Subchapter D.

( 1 2) "Physician" means:

(a) A physician licensed by the Texas State Board of Medical Examiners; or

(b) a properly credentialed physician who holds a commission in the uniformed services of the United States and who is serving on active duty in this state.

( 1 3) "Terminal condition" means an incurable condition caused by injury, disease, or illness that according to reasonable medical judgment will produce death within six months, even with available life-sustaining treatment provided in accordance with the prevailing standard of medical care. A patient who has been admitted to a program under which the person receives hospice services provided by a home and community support services agency licensed under Chapter 142 is presumed to have a terminal condition for purposes of this chapter.

( 14) "Witness" means a person who may serve as a witness under Section 1 66.003.

Added by Acts 1999, 76th Leg., ch. 450, § 1 .02, eff. Sept. I , 1 999.

§ 166.003. Witnesses

BMX 6031.01.240

October S, 2009

Attachment E

In any circumstance in which this chapter requires the execution of an advance directive or the issuance of a non-written advance directive to be witnessed:

( l ) Each witness must be a competent adult; and

(2) at least one of the witnesses must be a person who is not:

(a) A person designated by the declarant to make a treatment decision;

(b) a person related to the declarant by blood or marriage;

(c) a person entitled to any part of the declarant's estate after the declarant's death under a will or codicil executed by the declarant or by operation of law;

(d) the attending physician;

(e) an employee of the attending physician;

(f) an employee ofa health care facility in which the declarant is a patient if the employee is providing direct patient care to the declarant or is an officer, director, partner, or business office employee of the health care facility or of any parent organization of the health care facility; or

(g) a person who, at the time the written advance directive is executed or, ifthe directive is a non-written directive issued under this chapter, at the time the non-written directive is issued, has a claim against any part of the declarant's estate after the declarant's death.

Added by Acts 1 999, 76th Leg., ch. 450, § 1 .02, eff. Sept. 1 , 1 999.

§ 166.004. Statement Relating to Advance Directive

(I) In this section, "health care provider" means:

(a) A hospital;

(b) an institution licensed under…