BILL ANALYSIS                                                                                                                                                                                                    Ó



                                                                            



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                                    THIRD READING


          Bill No:  AB 2139
          Author:   Eggman (D)
          Amended:  5/13/14 in Assembly
          Vote:     21

           
           SENATE HEALTH COMMITTEE  :  6-2, 6/18/14
          AYES:  Hernandez, Beall, DeSaulnier, Evans, Monning, Wolk
          NOES:  Morrell, Nielsen
          NO VOTE RECORDED:  De León

           SENATE JUDICIARY COMMITTEE  :  5-2, 6/24/14
          AYES:  Jackson, Corbett, Lara, Leno, Monning
          NOES:  Anderson, Vidak
           
          ASSEMBLY FLOOR  :  46-28, 5/29/14 - See last page for vote


           SUBJECT  :    End-of-life care:  patient notification

           SOURCE  :     Author


           DIGEST  :    This bill requires a health care provider to notify a  
          patient diagnosed with a terminal illness, or when applicable,  
          the other person authorized to make health care decisions for  
          the patient, of his/her right to comprehensive information and  
          counseling regarding legal end-of-life options.  

           ANALYSIS  :    

          Existing law:

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           1. Establishes the Right to Know End of Life Act of 2008, which  
             requires, when a health care provider makes a diagnosis that  
             a patient has a terminal illness, the health care provider  
             to, upon the patient's request, provide the patient with  
             comprehensive information and counseling regarding legal  
             end-of-life care options. 

           2. Authorizes, when a terminally ill patient is in a health  
             facility, the health care provider, or medical director of  
             the health facility if the patient's health care provider is  
             not available, to 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 comprehensive information and  
             counseling regarding legal end-of-life care options.

           3. Requires, if the patient indicates a desire to receive  
             end-of-life care information and counseling, to include  
             specified comprehensive information.

           4. Authorizes the information described in #3 above to be in  
             writing and health care providers to utilize information from  
             organizations specializing in end-of-life care that provide  
             information on factsheets and Internet Web sites to convey  
             the information.

           5. Authorizes counseling to include, but not be limited to,  
             discussions about the outcomes for the patient and his/her  
             family, based on the interest of the patient, and to 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.

           6. Authorizes the information and counseling sessions to  
             include a discussion of treatment options in a manner that  
             the patient and his/her family can easily understand.   
             Requires, 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 to  
             be referred to the appropriate entity for that information.

           7. Requires, if a health care provider does not wish to comply  
             with his/her patient's request for information on end-of-life  
             options, the health care provider to refer or transfer a  

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             patient to another health care provider that shall provide  
             the requested information, and provide the patient with  
             information on procedures to transfer to another health care  
             provider that shall provide the requested information.

           8. Authorizes an adult having capacity to give an individual  
             oral or written health care instruction, which may be limited  
             to take effect only if a specified condition arises.

           9. Defines advanced health care directive or advance directive  
             to mean either an individual health care instruction or a  
             power of attorney for health care.  Establishes a process and  
             form for an individual to give instructions about health care  
             decision making and designating an agent to make decisions on  
             his/her behalf.

           10.Defines health care decisions as a decision made by a  
             patient or patient's agent, conservator, or surrogate,  
             regarding a patient's health care, including the selection  
             and discharge of health care providers and institutions,  
             approval or disapproval of diagnostic tests, surgical  
             procedures, programs of medication, and directions to  
             provide, withhold, or withdraw artificial nutrition and  
             hydration and all other forms of health care, including  
             cardiopulmonary resuscitation.

          This bill:

           1. Requires a health care provider to notify a patient  
             diagnosed with a terminal illness of his/her right to, or  
             when applicable, the right of another person authorized to  
             make health care decisions for the patient, to comprehensive  
             information and counseling regarding legal end-of-life  
             options.  Authorizes this notification to be provided at the  
             time of diagnosis or at a subsequent visit.

           2. Authorizes the information and counseling sessions to  
             include a discussion of treatment options in a culturally  
             sensitive manner that the patient and his/her family, or  
             another person authorized to make health care decisions for  
             the patient, can easily understand.

           3. Clarifies that the notification in #1 above is not required  
             if the patient or other person authorized to make health care  

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             decisions for the patient has already received the  
             notification.

           4. Updates existing law to include another person authorized to  
             make health care decisions for the patient, as specified, as  
             a proxy for the patient with regard to end-of-life care  
             information and counseling.

           

          Comments
           
          According to the author's office, this bill simply seeks to  
          ensure that patients who have been diagnosed with a terminal  
          illness are notified of their right under existing law to  
          request comprehensive information and counseling about  
          end-of-life treatment options.  Increasing the awareness of this  
          right will help terminally ill patients, their families, and  
          their physicians make informed treatment decisions and better  
          ensure the wishes of the patients are fulfilled.  Research -  
          including surveys conducted by the California HealthCare  
          Foundation (CHCF), indicate that a wide discrepancy exists  
          between the end-of-life care that individuals say they want and  
          what - in practice - the terminally ill actually receive.  While  
          an overwhelming number of Californian's (70 % in one CHCF  
          survey) indicate a desire to die at home and only 7% say they  
          would like all possible care to prolong life, the reality is  
          quite different.  Individuals frequently receive aggressive  
          treatment or life-sustaining care in the last few weeks of life  
          and are nearly as likely to spend their last month in a hospital  
          as they are at home.  This discrepancy is attributable to a  
          variety of factors, including individuals not making their  
          wishes clear in advance and a lack of familiarity with what  
          options exist outside of aggressive treatment.  Existing law  
          requires a health care provider, when he/she makes a diagnosis  
          that a patient has a terminal illness, to provide the patient  
          comprehensive information and counseling about legal end-of-life  
          options, upon the request of the patient.  This bill represents  
          a modest - but essential - step to ensure patients are notified  
          of this right.

           End-of-life cancer care in California  .  According to an August  
          2013 report by the CHCF, compared to the country as a whole, in  
          2010 California's patients with advanced cancer were more likely  

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          to die in the hospital, spend time in an intensive care unit  
          (ICU), receive life-support procedures in the last month of  
          life, and receive chemotherapy in the last two weeks of life.   
          Some regions saw a steep increase in the percentage of patients  
          receiving life-sustaining procedures in the last month of life,  
          while others saw no change or a decrease.  In 2010, nearly  
          one-third of Californians with poor-prognosis cancer spent their  
          last days in hospitals and ICUs, a decline of 7% compared with  
          2003-07 but still 20% higher than the national average.  More  
          than 10% of Californians with poor-prognosis cancer who were in  
          the last month of life received advanced life-support procedures  
          in 2010.  About 6% of cancer patients were given chemotherapy in  
          the last two weeks of life in 2010; in some regions of the state  
          and in some hospitals, the rate exceeded 10%.  The percentage of  
          dying cancer patients in California who received hospice care  
          increased slightly between 2003-07 and 2010, but remained below  
          the national average.  In some California hospitals, referral to  
          hospice care occurred so close to the day of death that it was  
          unlikely to have provided much assistance or comfort to  
          patients. 

           Prior Legislation
           
          AB 2747 (Berg, Chapter 683, Statutes of 2008) seeks to  
          facilitate meaningful end-of-life care communication between  
          doctors and their patients by enacting the California Right to  
          Know End-of-Life Act of 2008 to ensure that health care  
          providers provide critically-needed information in  
          carefully-circumscribed instances. 

          AB 891 (Alquist, Chapter 658, Statutes of 1999) streamlined and  
          updated the provisions governing health care decisions for  
          adults without decisionmaking capacity.  Specifically, the bill  
          repealed the provisions governing durable powers of attorney for  
          health care and the Natural Death Act, and revised and recast  
          these provisions as part of a new Health Care Decisions Law.  

           FISCAL EFFECT  :    Appropriation:  No   Fiscal Com.:  No   Local:  
           No

           SUPPORT  :   (per Senate Health Committee analysis of 6/18/14 -  
          unable to reverify at time of writing)

          American Cancer Society Cancer Action Network

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          California Commission on Aging
          Compassion & Choices
          National Association of Social Workers, California Chapter

           OPPOSITION  :    (per Senate Health Committee analysis of 6/18/14  
          - unable to reverify at time of writing)

          Association of Northern California Oncologists
          California Medical Association 
          Medical Oncology Association of Southern California

           ARGUMENTS IN SUPPORT  :    Compassion & Choices believes this bill  
          improves the existing California Right to Know End of Life  
          Options Act in a few reasonable, simple ways.  Having the  
          physician notify a patient improves the law because a provider  
          might otherwise be reluctant to provide such notice.  According  
          to the American Cancer Society Cancer Action Network, learning  
          that a cancer is advanced and that treatment is not helping is  
          more than any person should be forced to endure but it is at  
          this time that information about end of life options becomes  
          most important.  This bill ensures that all California patients  
          with a terminal diagnosis or their caretakers are aware of their  
          right to comprehensive information or counseling about their  
          end-of-life options as the standard of care.  The California  
          Commission on Aging writes that by offering to provide the  
          information, the physician opens the door for an important  
          conversation that can strengthen the patient's ability to make  
          wise decisions at such a crucial time.

           ARGUMENTS IN OPPOSITION  :    The Association of Northern  
          California Oncologists and the Medical Oncology Association of  
          Southern California oppose mandates and similar efforts to  
          legislate the specifics of the physician-patient relationship  
          because state law cannot address the complexity and nuance of  
          that relationship, especially during the end-of-life period.   
          This bill undoes a carefully negotiated agreement codified in AB  
          2747 (Berg, 2008).  There is no evidence that this current  
          system is not working, or would need to be changed.  

          The California Medical Association (CMA) writes that physicians  
          support informing and educating patients regarding end-of-life  
          issues, but generally are opposed to legislation mandating the  
          specifics of how this occurs within the physician-patient  
          relationship given the varying complexities particular to each  

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          individual patient and each individual diagnosis.  CMA requests  
          that this bill be amended to clarify that the notification would  
          not be required at these times if deemed inappropriate by a  
          physician.  This amendment would ensure there is flexibility  
          within the statute to allow a physician to use their  
          professional assessment of that patient's physical, emotional,  
          and psychosocial needs to make sure these conversations occur  
          without causing undue emotional distress to the patient.  
           

           ASSEMBLY FLOOR  :  46-28, 5/29/14
          AYES:  Achadjian, Alejo, Ammiano, Bloom, Bocanegra, Bonilla,  
            Bonta, Bradford, Brown, Ian Calderon, Campos, Chau, Chesbro,  
            Cooley, Dahle, Daly, Dickinson, Eggman, Fong, Fox, Frazier,  
            Garcia, Gomez, Gordon, Hall, Roger Hernández, Jones-Sawyer,  
            Levine, Lowenthal, Mullin, Muratsuchi, Nazarian, Olsen, Pan,  
            Perea, John A. Pérez, Quirk, Quirk-Silva, Rendon,  
            Ridley-Thomas, Salas, Skinner, Stone, Wieckowski, Yamada,  
            Atkins
          NOES:  Allen, Bigelow, Chávez, Conway, Dababneh, Donnelly, Beth  
            Gaines, Gatto, Gorell, Gray, Grove, Hagman, Harkey, Holden,  
            Jones, Linder, Logue, Maienschein, Mansoor, Medina, Melendez,  
            Nestande, Patterson, V. Manuel 



            Pérez, Ting, Wagner, Waldron, Wilk
          NO VOTE RECORDED:  Buchanan, Gonzalez, Rodriguez, Weber,  
            Williams, Vacancy


          JL:k  6/27/14   Senate Floor Analyses 

                           SUPPORT/OPPOSITION:  SEE ABOVE

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