BILL NUMBER: AB 2747	AMENDED
	BILL TEXT

	AMENDED IN SENATE  JULY 2, 2008
	AMENDED IN ASSEMBLY  MAY 15, 2008
	AMENDED IN ASSEMBLY  APRIL 24, 2008
	AMENDED IN ASSEMBLY  APRIL 7, 2008
	AMENDED IN ASSEMBLY  MARCH 25, 2008

INTRODUCED BY   Assembly Members Berg and Levine
   (Coauthors: Assembly Members Bass, Jones, Mullin, Salas, Torrico,
and Wolk)

                        FEBRUARY 22, 2008

   An act to add Part 1.8 (commencing with Section 442) to Division 1
of the Health and Safety Code, relating to end-of-life care.


	LEGISLATIVE COUNSEL'S DIGEST


   AB 2747, as amended, Berg. End-of-life care.
   Existing law provides for the licensure and regulation of health
facilities and hospices by the State Department of Public Health.
Existing law provides for the regulation and licensing of physicians
and surgeons by the Medical Board of California.
   This bill would provide that when a health care provider, as
defined, makes a diagnosis that a patient has a terminal illness
 or makes a prognosis that a patient has less than one year
to live  , the health care provider shall, upon the patient'
s request, provide the patient with information and counseling
regarding legal end-of-life options, as specified, and provide for
the referral or transfer of a patient if the patient's health care
provider does not wish to comply with the patient's  choice
of   request for information on  end-of-life
options.
   Vote: majority. Appropriation: no. Fiscal committee: no.
State-mandated local program: no.


THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:

  SECTION 1.  The Legislature finds and declares all of the
following:
   (a) Palliative and hospice care are invaluable resources for
terminally ill Californians in need of comfort and support at the end
of life.
   (b) Palliative care and conventional medical treatment  for
terminally ill patients  should be thoroughly integrated rather
than viewed as separate entities.
   (c) Even though Californians with a prognosis of six months or
less to live are eligible for hospice care, nearly two-thirds of them
receive hospice services for less than one month.
   (d) Many  terminally ill  patients benefit from being
referred to hospice care earlier, where they receive better pain and
symptom management and have an improved quality of life.
   (e) Significant information gaps may exist between health care
providers and their patients on end-of-life care options potentially
leading to delays in, or lack  of, referrals to 
 of referrals to,  hospice care for terminally ill patients.
The sharing of important information regarding specific treatment
options in a timely manner by health care providers  with
terminally ill patients  is a key component of quality
end-of-life care. Information that is helpful to patients and their
families includes, but is not limited to, the availability of hospice
care, the efficacy and potential side effects of continued curative
treatment, and withholding or withdrawal of life-sustaining
treatments.
   (f) Terminally ill and dying patients rely on their health care
providers to give them timely and informative data. Research shows a
lack of communication between health care providers and their
terminally ill patients can cause problems, including poor
availability of, and lack of clarity regarding, advance health care
directives and patients' end-of-life care preferences. This lack of
information and poor adherence to patient choices can result in "bad
deaths" that cause needless physical and psychological suffering to
patients and their families.
   (g) Those problems are complicated by social issues, such as
cultural and religious pressures  for   on 
the providers, patients, and their family members. A recent survey
found that providers that object to certain practices are less likely
than others to believe they have an obligation to present all of the
options to patients and refer patients to other providers, if
necessary.
   (h) Every medical school in California is required to include
end-of-life care issues in its curriculum and every physician in
California is required to complete continuing education courses in
end-of-life care.
   (i) Palliative care is not a one-size-fits-all approach. Patients
have a range of diseases and respond differently to treatment
options. A key benefit of palliative care is that it customizes
treatment to meet the needs of each individual person.
   (j) Informed patient choices will help terminally ill patients and
their families cope with one of life's most challenging situations.
  SEC. 2.  Part 1.8 (commencing with Section 442) is added to
Division 1 of the Health and Safety Code, to read:

      PART 1.8.  End-Of-Life Care


   442.  For the purposes of this part, the following definitions
shall apply: 
   (a) "Actively dying" means the phase of terminal illness when
death is imminent. 
   (a) 
    (b)  "Curative treatment" means treatment intended to
cure or alleviate symptoms of a given disease or condition. 
   (b) 
    (c)  "Health care provider" means an attending physician
and  surgeon, nurse practitioner,   surgeon. It
also means a nurse practitioner  or physician assistant in
accordance with standardized procedures or protocols developed and
approved by the supervising physician and surgeon and the nurse
practitioner or physician assistant. 
   (c) 
    (d)  "Hospice" means a specialized form of
interdisciplinary health care that is designed to provide palliative
care, alleviate the physical, emotional, social, and spiritual
discomforts of an individual who is experiencing the last phases of
life due to the existence of a terminal disease, and provide
supportive care to the primary caregiver and the family of the
hospice patient, and that meets all of the criteria specified in
subdivision (b) of Section 1746. 
   (d) 
    (e)  "Palliative care" means medical treatment,
interdisciplinary care, or consultation provided to a patient or
family members, or both, that has as its primary purpose the
prevention of, or relief from, suffering and the enhancement of the
quality of life, rather than treatment aimed at investigation and
intervention for the purpose of cure or prolongation of life as
described in subdivision (b) of Section 1339.31. 
   (e) "Palliative sedation" means the administration of sedative
medication to the point of unconsciousness in a terminally ill
patient. It is an intervention of last resort to reduce severe,
refractory pain or other distressing clinical symptoms that do not
respond to aggressive, symptom specific palliation. Palliative
sedation is not intended to cause death or shorten life. 
   (f) "Refusal or withdrawal of life-sustaining treatment" means
forgoing treatment or medical procedures that replace or support an
essential bodily function, including, but not limited to,
cardiopulmonary resuscitation, mechanical ventilation, artificial
nutrition and hydration, dialysis, and any other treatment or
discontinuing any or all of those treatments after they have been
used for a reasonable time. 
   (g) "Voluntary stopping of eating and drinking" or "VSED" means
the patient's choice to voluntarily refuse to eat and drink in order
to alleviate his or her suffering, and includes the withholding or
withdrawal of life-sustaining treatment at the request of the
patient. 
   442.5.  When a health care provider makes a diagnosis that a
patient has a terminal illness  or makes a prognosis that a
patient has less than one year to live  , the health care
provider shall provide the patient with comprehensive information and
counseling regarding legal end-of-life care options, upon the
patient's request and pursuant to this section. When a 
terminally ill  patient is in a health facility, as defined in
Section 1250, the health care provider  ,  or medical
director  of the health facility, if the patient's health care
provider is not available,  may refer the patient to a hospice
provider or private or public agencies and community-based
organizations that specialize in end-of-life care case management and
consultation to receive information and counseling regarding legal
end-of-life care options.
   (a) If the patient indicates a desire to receive the information
and counseling, the  comprehensive  information shall
include, but not be limited to, the following:
   (1) Hospice care at home or in a health care setting.
   (2) A prognosis with and without the continuation of curative
treatment.
   (3) The patient's right to refusal of or withdrawal from
life-sustaining treatment.
   (4) The patient's right to continue to pursue curative 
treatment while receiving palliative care.   treatment.

   (5) The patient's right to comprehensive pain and symptom
management at the end of life, including, but not limited to,
adequate pain medication, treatment of nausea, palliative
chemotherapy, relief of shortness of breath and fatigue, 
VSED, and palliative sedation   and other clinical
treatments useful when a patient is actively   dying. 
    (6)     The patient's right to give
individual health care instruction pursuant to Section 4670 of the
Probate Code, which provides the means by which a patient may provide
written health care instruction, such as an advance health care
directive, and the patient's right to appoint a legally recognized
health care decisionmaker  .
   (b) The information described in subdivision (a) may, but is not
required to be, in writing. Health care providers may utilize
information from organizations specializing in end-of-life care that
provide information on factsheets and Internet Web sites to convey
the information described in subdivision (a).
   (c) Counseling may include, but not be limited to, discussions
about the outcomes for the patient and his or her family, based on
the interest of the patient. Information and counseling as described
in subdivision (a) may occur over a series of meetings with the
health care provider or others who may be providing the information
and counseling based on the patient's needs.  The health care
provider may encourage the patient to include his or her family in
the counseling described in this subdivision.  
   (d) The information and counseling sessions may include a
discussion of benefits and burdens of treatment options in a manner
that the patient and his or her family can easily understand. If the
patient requests information on the costs of treatment options, the
patient shall be referred to the appropriate entity for that
information. 
   442.7.  If a health care provider does not wish to comply with his
or her patient's  choice of   request for
information on  end-of-life options, the health care provider
shall do both of the following:
   (a) Refer or transfer a patient to another health care provider.
   (b) Provide the patient with information on procedures to transfer
to another health care provider.