BILL ANALYSIS Ó ----------------------------------------------------------------- |SENATE RULES COMMITTEE | AB 2139| |Office of Senate Floor Analyses | | |1020 N Street, Suite 524 | | |(916) 651-1520 Fax: (916) | | |327-4478 | | ----------------------------------------------------------------- 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: CONTINUED AB 2139 Page 2 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 CONTINUED AB 2139 Page 3 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 CONTINUED AB 2139 Page 4 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 CONTINUED AB 2139 Page 5 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 CONTINUED AB 2139 Page 6 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 CONTINUED AB 2139 Page 7 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 **** END **** CONTINUED