INTRODUCED BY   Assembly Members Berg and Levine
   (Coauthors: Assembly Members Bass,  Brownley,  
Huffman,  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.


   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, the
health care provider shall, upon the patient's request, provide the
patient with  comprehensive  information and counseling
regarding legal end-of-life options, as specified, and provide for
the referral or transfer of a patient  , as provided,  if
the patient's health care provider does not wish to comply with the
patient's request for information on end-of-life options.
   Vote: majority. Appropriation: no. Fiscal committee: no.
State-mandated local program: no.


  SECTION 1.  The Legislature finds and declares all of the
   (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, 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   disease-targeted  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 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. 
   (b) "Curative treatment" means treatment intended to cure or
alleviate symptoms of a given disease or condition.  
   (b) "Disease-targeted treatment" means treatment directed at the
underlying disease or condition that is intended to alter its natural
history or progression, irrespective of whether or not a cure is a
   (c) "Health care provider" means an attending physician and
surgeon. It also means a nurse practitioner or physician assistant
 practicing  in accordance with standardized procedures or
protocols developed and approved by the supervising physician and
surgeon and the nurse practitioner or physician assistant.
   (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
   (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.  In some cases, disease-targeted
treatment may be used in palliative care. 
   (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.
   442.5.  When a health care provider makes a diagnosis that a
patient has a terminal illness, the health care provider shall  ,
upon the patient's request,  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  com   prehensive 
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   disease-targeted  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   disease-targeted treatment, with or without
concurrent palliative care  .
   (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, 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,  including the availability of insurance and
eligibility of the patient for coverage,  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 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
 that shall provide the requested information  .
   (b) Provide the patient with information on procedures to transfer
to another health care provider  that shall provide the
requested information  .