BILL ANALYSIS                                                                                                                                                                                                    



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          Date of Hearing:  September 1, 2015 


           ASSEMBLY COMMITTEE ON PUBLIC HEALTH AND DEVELOPMENTAL SERVICES


                                  Rob Bonta, Chair


          ABX2 15  
          (Eggman, et.al.) - As Introduced August 17, 2015


          SUBJECT:  End of life.


          SUMMARY:  Enacts the End of Life Option Act allowing an adult  
          diagnosed with a terminal disease, and with the capacity to make  
          medical decisions, to receive a prescription for an aid-in-dying  
          drug to end his or her life in a humane and dignified manner.    
          Specifically, this bill:  


          1)Defines a qualified individual as an adult who has the  
            capacity to make medical decisions, is a resident of  
            California, and has satisfied all of the requirements of these  
            provisions in order to obtain a prescription for a drug to end  
            his or her life.


          2)Defines various other terms for purposes of these provisions,  
            including defining an adult as an individual 18 years of age  
            or older, an aid-in-dying drug as a drug determined and  
            prescribed by a physician for a qualified individual, and an  
            attending physician as the physician who has primary  
            responsibility for the health care of an individual and  
            treatment of the individual's terminal disease.  Defines  
            terminal disease as an incurable and irreversible disease that  
            has been medically confirmed and will, within reasonable  








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            medical judgment, result in death within six months.


          3)Requires an individual requesting an aid-in-dying drug to have  
            done so voluntarily.


          4)Specifies that the individual must be a resident of California  
            with the ability to establish residency through possession of  
            a California driver's license or other identification issued  
            by the State of California; registration to vote in  
            California; or, filing of a California tax return for the most  
            recent tax year.


          5)Allows a request for a prescription for an aid-in-dying drug  
            to be made only by the individual diagnosed with the terminal  
            disease, not by others on behalf of the individual, including  
            prohibiting requests through a power of attorney, an advance  
            health care directive, a conservator, health care agent,  
            surrogate, or any other legally recognized health care  
            decision maker.


          6)Specifies that a person will not be qualified to obtain an  
            aid-in-dying drug solely because of age or disability.


          7)Requires an individual requesting a prescription for an  
            aid-in-dying drug to submit two oral requests, a minimum of 15  
            days apart, and a written request, and for the attending  
            physician to personally receive all three requests.  Requires  
            written requests to be signed and dated by the individual in  
            the presence of two witnesses who must attest to the best of  
            their knowledge and belief that the individual is personally  
            known to them or has provided proof of identity, is of sound  
            mind, and not under duress, fraud, or undue influence.










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          8)Prohibits the attending physician, consulting physician, or  
            the mental health specialist of the requesting individual from  
            being a witness on the written request.


          9)Allows only one of the witnesses to be related to the  
            individual by blood, marriage, registered domestic  
            partnership, or adoption or be entitled to a portion of the  
            individual's estate upon death, and only one of the witnesses  
            to own, operate, or be employed at a health care facility  
            where the individual is receiving medical treatment or  
            resides.


          10)Specifies that at any time an individual may withdraw or  
            rescind his or her request for an aid-in-dying drug, or decide  
            not to ingest an aid-in-dying drug, without regard to their  
            mental state.


          11)Prohibits an attending physician from writing a prescription  
            for an aid-in-dying drug without first personally offering the  
            individual an opportunity to withdraw or rescind the request,  
            and, requires the attending physician before prescribing to do  
            all of the following:


             a)   Make an initial determination whether the requesting  
               adult has the capacity to make medical decisions, and if  
               there are indications of a mental disorder, to refer the  
               individual for a mental health specialist assessment.  If a  
               mental health assessment referral is made, no aid-in-dying  
               drugs will be prescribed until the mental health specialist  
               determines that the individual has the capacity to make  
               medical decisions and is not suffering from impaired  
               judgment due to a mental disorder;
             b)   Determine whether the requesting adult has a terminal  
               disease;









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             c)   Determine whether the requesting adult has voluntarily  
               made the request for an aid-in-dying drug and is a  
               qualified individual;


             d)   Confirm that the individual is making an informed  
               decision by discussing all of the following with them:


               i)     Their medical diagnosis and prognosis;
               ii)The potential risks associated with ingesting the  
                 requested aid-in-dying drug;


               iii)The possibility that they may choose to obtain the  
                 aid-in-dying drug but not take it; and,


               iv)Feasible alternatives or additional treatment options  
                 including, but not limited to, comfort care, hospice  
                 care, palliative care, and pain control.


             e)   Refer the individual to a consulting physician for  
               medical confirmation of the diagnosis and prognosis, and  
               for a determination that the individual has the capacity to  
               make medical decisions;
             f)   Confirm that the individual's request does not arise  
               from coercion or undue influence by another person by  
               privately discussing, unless an interpreter is needed,  
               whether or not the individual is feeling coerced or unduly  
               influenced by another person;


             g)   Counsel the individual about the importance of all of  
               the following:










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               i)     Having another person present when they ingest the  
                 aid-in-dying drug;
               ii)Not ingesting the aid-in-dying drug in a public place;


               iii)Notifying the next of kin of their request for an  
                 aid-in-dying drug.  An individual's inability or refusal  
                 to notify their next of kin does not constitute a reason  
                 to deny their request for an aid-in-dying drug;


               iv)Participating in a hospice program; and,


               v)     Maintaining the aid-in-dying drug in a safe and  
                 secure location until they will ingest it.


             h)   Inform the individual that they may withdraw or rescind  
               the request for an aid-in-dying drug at any time and in any  
               manner, and offer the individual an opportunity to withdraw  
               or rescind the request for an aid-in dying drug before  
               prescribing the aid-in-dying drug;
             i)   Verify, immediately prior to writing the prescription  
               for the aid-in-dying drug, that the individual is making an  
               informed decision;


             j)   Confirm that all the requirements for requesting an  
               aid-in-dying drug have been met; and,


             aa)Fulfill all medical record documentation requirements,  
               including completing the End of Life Option Act Checklist  
               and Compliance Form and placing it in the individual's  
               medical record.  


          12)Once all of the requirements have been met, allows the  








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            attending physician to deliver the aid-in-dying drug in any of  
            the following ways:
             a)   Dispensing the aid-in-dying drug directly, including  
               ancillary medication intended to minimize the qualified  
               individual's discomfort, if the attending physician is  
               authorized to dispense medicine under California law, has a  
               current United States Drug Enforcement Administration  
               certificate, and complies with any applicable  
               administrative rule or regulation;
             b)   With the individual's written consent, contacting a  
               pharmacist to inform them of the prescriptions, and  
               delivering the written prescriptions personally, by mail,  
               or electronically to the pharmacist, who may dispense the  
               drug to the individual, the attending physician, or a  
               person expressly designated by the individual and with the  
               designation delivered to the pharmacist in writing or  
               verbally; and,


             c)   Delivery of the dispensed drug to the qualified  
               individual, the attending physician, or a person expressly  
               designated by the individual may be made by personal  
               delivery, or, with a signature required on delivery, by the  
               United Parcel Service, United States Postal Service,  
               Federal Express, or by messenger service.


          13)Prior to the individual obtaining an aid-in-dying  
            prescription from the attending physician, requires the  
            consulting physician to:  
             a)   Examine the individual and their medical records;
             b)   Confirm in writing the attending physician's diagnosis  
               and prognosis;


             c)   Determine that the individual has the capacity to make  
               medical decisions, is acting voluntarily, and has made an  
               informed decision;









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             d)   Refer the individual for a mental health specialist  
               assessment, if there are indications of a mental disorder;  
               and,


             e)   Document all of the above in the individual's medical  
               record.


          14)If the attending or consulting physician refers the  
            individual to a mental health specialist, requires the mental  
            health specialist to:
             a)   Examine the qualified individual and their medical  
               records;
             b)   Determine that the individual has the mental capacity to  
               make medical decisions, act voluntarily, and make an  
               informed decision;


             c)   Determine that the individual is not suffering from  
               impaired judgment due to a mental disorder; and,


             d)   Document all of the above in the individual's medical  
               record.


          15)Requires all of the following to be documented in the  
            individual's medical record:
             a)   All oral requests for aid-in-dying drugs;
             b)   All written requests for aid-in-dying drugs;


             c)   Both the attending physician's and consulting  
               physician's diagnosis and prognosis, and the determination  
               that a qualified individual has the capacity to make  
               medical decisions, is acting voluntarily, and has made an  
               informed decision, or that the attending or consulting  








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               physician has determined that the individual is not a  
               qualified individual;


             d)   A report on the outcome and determinations made during a  
               mental health specialist's assessment, if performed;


             e)   The attending physician's offer to the qualified  
               individual to withdraw or rescind his or her request at the  
               time of the individual's second oral request; and,


             f)   A note by the attending physician indicating that all  
               requirements have been met and indicating the steps taken  
               to carry out the request, including a notation of the  
               aid-in-dying drug prescribed.


          16)Requires the attending physician, within 30 calendar days of  
            writing a prescription for an aid-in-dying drug, to submit a  
            copy of the patient's written request, the attending physician  
            compliance form, and the consulting physician compliance form  
            to the State Department of Public Health (DPH).  
          17)Requires the attending physician, within 30 calendar days  
            following the qualified individual's death from ingesting the  
            aid-in-dying drug, or any other cause, to submit the attending  
            physician follow-up form to DPH.


          18)Outlines the requirements of the witnessed form an individual  
            must submit to request an aid-in-dying drug.  Requires the  
            language of the request to be written in the same translated  
            language as any conversations, consultations, or interpreted  
            conversations between a patient and his or her attending or  
            consulting physicians.  Prohibits an interpreter from being  
            related to the individual requesting the aid-in-dying drug and  
            requires interpreters to meet certain professional association  
            standards.








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          19)Makes a provision in a contract, will, or other agreement  
            executed on or after January 1, 2016, whether written or oral,  
            to the extent the provision would affect whether a person may  
            make, withdraw, or rescind a request for an aid-in-dying drug,  
            invalid.


          20)Prohibits the sale, procurement, or issuance of a life,  
            health, or accident insurance or annuity policy; health care  
            service plan contract; or, health benefit plan, or the rate  
            charged for a policy or plan contract from being conditioned  
            upon or affected by a person making, withdrawing, or  
            rescinding a request for an aid-in-dying drug.  Also provides  
            that an obligation owing under any contract executed on or  
            after January 1, 2016 may not be conditioned or affected by a  
            qualified individual making, withdrawing, or rescinding a  
            request for an aid-in-dying drug.


          21)Provides that death resulting from the self-administration of  
            an aid-in-dying drug is not suicide, and therefore health and  
            insurance coverage shall not be exempted on that basis.


          22)Provides that a qualified individual's act of  
            self-administering an aid-in-dying drug has no effect upon a  
            life, health, or accident insurance or annuity policy other  
            than that of a natural death from the underlying disease.


          23)Prohibits an insurance carrier from providing any information  
            in communications to an individual about the availability of  
            an aid-in-dying drug unless requested by the individual or  
            their attending physician at the behest of the individual.   
            Clarifies that any communication must not include both a  
            denial of treatment and information about the availability of  
            aid-in-dying drug coverage.








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          24)Protects a person from civil, criminal, administrative,  
            employment, or contractual liability or professional  
            disciplinary action for participating in the provisions of  
            this bill, including an individual who is present when a  
            qualified individual self-administers the prescribed  
            aid-in-dying drug.  


          25)Prohibits a health care provider or professional organization  
            or association from subjecting an individual to censure,  
            discipline, suspension, loss of license, loss of privileges,  
            loss of membership, or other penalty for participating in good  
            faith compliance with these provisions, or for refusing to  
            participate.


          26)Prohibits a health care provider from being be subject to  
            civil, criminal, administrative, disciplinary, employment,  
            credentialing, professional discipline, contractual liability,  
            or medical staff action, sanction, or penalty or other  
            liability for participating in these provisions.


          27)Specifies that a request by a qualified individual to an  
            attending physician to provide an aid-in-dying drug in good  
            faith compliance with these provisions does not constitute the  
            sole basis for the appointment of a guardian or conservator,  
            and actions taken in compliance with these provisions do not  
            provide the basis for a claim of neglect or elder abuse. 


          28)Provides that participation in activities authorized by this  
            bill must be voluntary, and further clarifies that an  
            individual is not subject to any type of sanction for refusing  
            to inform a patient regarding his or her rights under these  
            provisions and not referring an individual to a physician who  
            does participate in activities authorized by this bill.








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          29)Allows a health care provider, with advance notice, to  
            prohibit its employees, independent contractors, or other  
            persons or entities, including other health care providers,  
            from participating in these provisions while on premises owned  
            or under the management or control of the prohibiting health  
            care provider.


          30)Allows, if a health care provider has given notice, and an  
            individual or entity violates the prohibition to participate  
            in these provisions, the prohibiting provider to take action  
            against an individual or entity, including, but not limited  
            to, loss of privileges or membership, suspension, loss of  
            employment, or termination of any lease or other contract  
            between the prohibiting health care provider and the  
            individual or entity that violates the policy.


          31)Clarifies that nothing in these provisions prevent a health  
            care provider from providing an individual with services that  
            do not constitute participation in these provisions, that a  
            health care provider may not be sanctioned for making a  
            determination that an individual has a terminal disease and  
            informing them of their medical prognosis, or for providing  
            information about the End of Life Option Act to a patient upon  
            the request of the individual.


          32)Makes knowingly altering or forging a request for an  
            aid-in-dying drug to end an individual's life without their  
            authorization, or concealing or destroying a withdrawal or  
            rescission of a request, punishable as a felony.  


          33)Makes coercing or exerting undue influence on an individual  
            to request an aid-in-dying drug punishable as a felony.









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          34)Specifies that nothing in these provisions may be construed  
            to authorize a physician or any other person to end an  
            individual's life by lethal injection, mercy killing, or  
            active euthanasia.


          35)Specifies that nothing in these provisions may be construed  
            to limit civil liability.


          36)Requires DPH to collect and review the information submitted  
            by the attending physician on the patient's written request,  
            the attending physician's compliance form, and the consulting  
            physician's compliance form; requires the information to be  
            confidential and collected in a manner that protects the  
            privacy of the patient, the patient's family, and any medical  
            provider or pharmacist involved with the patient under these  
            provisions.


          37)Requires DPH, on or before July 1, 2017, and each year  
            thereafter, based on the information collected on the  
            attending physician follow-up form in the previous year, and  
            DPH's access to vital statistics, to compile a report which  
            includes, but is not limited to all of the following:


             a)   The number of people for whom an aid-in-dying  
               prescription was written;
             b)   The number of known individuals who died each year for  
               whom aid-in-dying prescriptions were written, and the cause  
               of death of those individuals;


             c)   For the period commencing January 1, 2016, to and  
               including the previous year, cumulatively, the total number  
               of aid-in-dying prescriptions written, the number of people  
               who died due to use of aid-in-dying drugs, and the number  








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               of those people who died who were enrolled in hospice or  
               other palliative care programs at the time of death;


             d)   The number of known deaths in California from using  
               aid-in-dying drugs per 10,000 deaths in California;


             e)   The number of physicians who wrote prescriptions for  
               aid-in-dying drugs;


             f)   Of the people who died due to using an aid-in-dying  
               drug, demographic percentages organized by the following  
               characteristics:


               i)     Age at death;
               ii)Education level;


               iii)Race;


               iv)Sex;


               v)     Type of insurance, including whether or not they had  
                 insurance; and,


               vi)Underlying illness.


          38)Requires DPH to make the following forms available on its  
            Internet Website:  the attending physician checklist and  
            compliance form, the consulting physician compliance form, and  
            the attending physician follow-up form.  The forms identify  
            each and every requirement that must be fulfilled by a health  








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            care provider to be in compliance with the End of Life Option  
            Act.
          39)Requires a person with any unused aid-in-dying drugs after  
            the death of a patient, to personally deliver the unused drugs  
            to the nearest qualified disposal facility, or if none is  
            available, to dispose of the drugs in accordance with  
            guidelines developed by the California State Board of Pharmacy  
            (BOP) or a federal Drug Enforcement Administration approved  
            take back program.


          40)Provides that any governmental entity that incurs costs  
            resulting from an individual terminating his or her life under  
            these provisions in a public place will have a claim against  
            the estate of the individual to recover those costs and  
            reasonable attorney fees related to enforcing the claim.


          41)Requires the Medical Board of California (MBC), on or before  
            January 1, 2019, to develop, revise, and update an attending  
                                                                                        physician checklist and compliance form, a consulting  
            physician compliance form, and an attending physician  
            follow-up form, based on those already provided by DPH.   
            Requires DPH, upon completion of the new forms, to publish  
            them on its Internet Website.


          42)Makes various findings and declarations, including that any  
            limitation to public access to personally identifiable patient  
            data collected pursuant to these provisions is necessary to  
            protect the privacy rights of the patient and his or her  
            family, and that the statistical report to be made available  
            to the public is sufficient to satisfy the public's right to  
            access.


          43)Makes the provisions of this bill severable if any provision  
            is held invalid.









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          EXISTING LAW:





          1)Requires a health care provider, who makes a diagnosis that a  
            patient has a terminal illness, to notify the patient of his  
            or her right to comprehensive information and counseling  
            regarding legal end-of-life options, and requires the  
            comprehensive information to include, but not be limited to:


             a)   Hospice care at home or in a health care setting;


             b)   A prognosis with and without the continuation of  
               disease-targeted treatment;


             c)   The patient's right to refusal of or withdrawal from  
               life-sustaining treatment;


             d)   The patient's right to continue to pursue  
               disease-targeted treatment, with or without concurrent  
               palliative care;


             e)   The patient's right to comprehensive pain and symptom  
               management at the end of life; and, 


             f)   The patient's right to give individual health care  
               instruction, 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 decision maker.








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          2)Requires a health care provider who does not wish to provide  
            the information in 1) above to refer or transfer a patient to  
            another health care provider who will.


          3)Licenses and regulates physicians and surgeons under the  
            Medical Practice Act by MBC, within the Department of Consumer  
            Affairs (DCA) and provides for the licensure and regulation of  
            pharmacies, pharmacists and wholesalers of dangerous drugs or  
            devices by the BOP, also within the DCA.


          4)Mandates health care practitioners to report any suspected  
            elder abuse.


          5)Provides, for purposes of a judicial determination, a person  
            has the capacity to give informed consent to a proposed  
            medical treatment if the person is able to do all of the  
            following:


             a)   Respond knowingly and intelligently to queries about  
               that medical treatment;


             b)   Participate in that treatment decision by means of a  
               rational thought process; and,


             c)   Understand all of the following items of minimum basic  
               medical treatment information with respect to that  
               treatment:


               i)     The nature and seriousness of the illness, disorder,  
                 or defect that the person has;








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               ii)    The nature of the medical treatment that is being  
                 recommended by the person's health care providers;


               iii)   The probable degree and duration of any benefits and  
                 risks of any medical intervention that is being  
                 recommended by the person's health care providers, and  
                 the consequences of lack of treatment; and, 


               iv)    The nature, risks, and benefits of any reasonable  
                 alternatives.


          6)Provides that a person who has the capacity to give informed  
            consent to a proposed medical treatment also has the capacity  
            to refuse consent to that treatment.


          7)Provides that a resident of a long-term care facility lacks  
            the capacity to make a decision regarding his or her health  
            care if the resident is unable to understand the nature and  
            consequences of the proposed medical intervention, including  
            its risks and benefits, or is unable to express a preference  
            regarding the intervention.  Requires the physician, in making  
            the determination regarding capacity, to interview the  
            patient, review the patient's medical records, and consult  
            with facility staff, family members and friends of the  
            resident, if any have been identified.


          8)Requires the physician and surgeon last in attendance, or in  
            the case of a patient in a long-term care facility at the time  
            of death, the physician last in attendance or a licensed  
            physician assistant under the supervision of the physician  
            last in attendance, on a deceased person, to state on the  
            certificate of death the disease or condition directly leading  








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            to death, antecedent causes, other significant conditions  
            contributing to death and any other medical and health section  
            data as may be required on the certificate.  Requires the  
            physician or physician assistant to specifically indicate the  
            existence of any cancer, as defined, of which the physician or  
            physician assistant has actual knowledge.


          FISCAL EFFECT:  This bill has not been analyzed by a fiscal  
          committee.


          COMMENTS: 


          1)PURPOSE OF THIS BILL.  According to the author this bill would  
            allow an adult in California with a terminal disease that has  
            the capacity to make medical decisions and who has been given  
            a prognosis of less than six months to live, to make end of  
            life decisions.  The author states by giving these patients  
            the legal right to ask for and receive an aid-in-dying  
            prescription from his/her physician, this bill would provide  
            one more option to the number of options one has when faced  
            with the end of their life.  The author notes this bill  
            includes strong provisions to safeguard patients from coercion  
            and to allow voluntary participation by physicians,  
            pharmacists, and health care facilities, and that this medical  
            practice is already recognized in five other states.  The  
            author contends there is substantial evidence from those  
            states that prove this law can be used safely and effectively.  
             The author concludes, Californians that are faced with a  
            terminal disease should not have to leave the state in order  
            to have a peaceful death.  In the end, how each of us spends  
            the end of our lives is a deeply personal decision.  That  
            decision should remain with the individual, as a matter of  
            personal freedom and liberty, without criminalizing those who  
            help to honor our wishes and ease our suffering.










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          2)BACKGROUND.  Five states have authorized what is referred to  
            as Death with Dignity or Aid-in-Dying.  Oregon and Washington  
            enacted their legislation through voter initiatives that took  
            effect in 1997 and 2009, respectively.  Vermont enacted  
            legislation in 2013.  In Montana and New Mexico, the courts  
            have effectively authorized doctors to engage in the practice.  
             Belgium, the Netherlands, Luxembourg, and Switzerland all  
            allow for physician aid-in-dying, and next year Canada will  
            implement the practice as well.


             a)   Dying in America.  A 2014 report published by the  
               Institute of Medicine, "Dying in America:  Improving  
               Quality and Honoring Individual Preferences Near the End of  
               Life," identified persistent major gaps in care near the  
               end of life that require urgent attention.  Understanding  
               and perceptions of death and dying vary considerably across  
               the population and are influenced by culture, socioeconomic  
               status, and education, as well as by misinformation and  
               fear.  Engaging people in defining their own values, goals,  
               and preferences concerning care at the end of life, and  
               ensuring that their care team understands their wishes, has  
               proven remarkably elusive and challenging.  While the  
               clinical fields of hospice and palliative care have become  
               more established, the number of specialists in these fields  
               is too small.  Too few clinicians in the primary and  
               specialty fields that entail caring for individuals with  
               advanced serious illnesses are proficient in basic  
               palliative care.  Often, clinicians are reluctant to have  
               honest and direct conversations with patients and families  
               about end of life issues.  Patients and families face  
               additional difficulties presented by the health care system  
               itself, which does not provide adequate financial or  
               organizational support for the kinds of health care and  
               social services that might truly make a difference to them.  
                The report notes that a patient-centered, family-oriented  
               approach to care near the end of life should be a high  
               national priority and that compassionate, affordable, and  
               effective care for these patients is an achievable goal.








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             b)   Hospice and palliative care.  At the center of hospice  
               and palliative care is the belief that each of us has the  
               right to die pain-free and with dignity, and that our  
               families will receive the necessary support to allow us to  
               do so.  Hospice care is available to patients who no longer  
               wish treatment directed at curing their disease.  Patients  
               are usually referred to hospice by their personal  
               physician, although they can be referred by their families  
               or even by themselves.  Initially, a physician certifies  
               that the patient has a life expectancy of six months or  
               less if the disease follows its normal course.  Hospice  
               usually begins within 48 hours after a referral, and can  
               begin sooner based on the circumstances.  A hospice nurse  
               evaluates what the person and family needs and develops a  
               plan of care.  The plan addresses the entire family's  
               needs:  medical; emotional; psychological; spiritual; and,  
               support services.  The nurse then coordinates the care with  
               a physician and the full team of health professionals.  

          Palliative care is patient and family-centered care that  
          optimizes quality of life by anticipating, preventing, and  
          treating suffering.  Palliative care involves addressing  
          physical, intellectual, emotional, social, and spiritual needs  
          and, to facilitate patient autonomy, access to information and  
          choice.  Palliative care is provided and services are  
          coordinated by an interdisciplinary team - patients, families,  
          palliative and non-palliative health care providers collaborate  
          and communicate about care needs.  Palliative care services are  
          available concurrently with or independent of curative or  
          life-prolonging care.  A Center to Advance Palliative Care and  
          National Palliative Care Research Center analysis conducted in  
          July of 2012, found that larger hospitals are more likely to  
          have a palliative care team.  More than 81% of hospitals in the  
          U.S. with more than 300 beds have a palliative care team, while  
          less than one-quarter of hospitals with fewer than 50 beds  
          reported having a palliative care team. 










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             c)   How we want to die.  In February of 2012 the California  
               HealthCare Foundation published a survey, "Final Chapter:  
               Californians' Attitudes and Experiences with Death and  
               Dying".  The survey found that most Californians would  
               prefer a natural death if they became severely ill, rather  
               than have all possible care provided.  We want to die at  
               home rather than in a hospital or nursing home, and want to  
               talk with our doctor about our wishes for end-of-life care.  
                However, what we want isn't what we always get, as the  
               survey numbers illustrate:


               i)     Seventy percent of Californians would prefer to die  
                 at home; however of deaths in 2009, 32% occurred at home,  
                 42% in a hospital, and 18% in a nursing home;


               ii)    Almost 80% say they definitely or probably would  
                 like to talk with a doctor about end of life wishes, but  
                 only 7% have had a doctor speak with them about it; and,


               iii)   The survey also found that what matters most at the  
                 end of life varies by race and ethnicity, for example,  
                 Latinos rate living as long as possible more highly than  
                 do other groups.  African Americans and Latinos are much  
                 more likely to place importance on being at peace  
                 spiritually.  Asians and white/non-Latinos place the  
                 least importance on living as long as possible.  Sixty  
                 percent of all respondents say it is extremely important  
                 that their family not be burdened by decisions regarding  
                 their care.  


             d)   Current options at the end of life.  While palliative  
               care is generally agreed to be the standard of care for the  
               dying, in some cases some patients who are very ill do not  
               respond to pain medications or may be suffering in other  
               ways that make comfort impossible.  In these circumstances  








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               patients' last resort options include aggressive pain  
               management, forgoing life-sustaining treatments,  
               voluntarily stopping eating and drinking, and sedation to  
               unconsciousness to relieve suffering.

             With terminal sedation (TS), a patient will be given  
               medications that induce sleep or unconsciousness until  
               death occurs, often as a result of starvation or  
               dehydration as in these instances artificial life support  
               (such as tube feeding) is withheld, or as a result of the  
               underlying illness or disease.  Although death is certain  
               in this instance, it may not happen for days or weeks.   
               Because the patient is sedated, they are believed to be  
               free of suffering.  Some patients reject TS because they  
               believe their dignity would be violated if they have to be  
               unconscious for a prolonged period before they die, or that  
               their families suffer unnecessarily while waiting for them  
               to die.

             Some patients who are physically capable of taking  
               nourishment may choose to voluntarily stop eating and  
               drinking (VSED), and then are gradually allowed to die,  
               primarily of dehydration or some other complication.   
               Legally, the right of competent, informed patients to  
               refuse life-prolonging interventions is clear and voluntary  
               cessation of eating and drinking could be considered an  
               extension of that right.  However, VSED may initially  
               increase suffering because the patient may experience  
               thirst and hunger and patients can lose mental clarity at  
               the end of the process, which may undermine their sense of  
               personal integrity, or raise questions about whether the  
               action remains voluntary.



             e)   Ethics.  The American Medical Association (AMA) code of  
               medical ethics (opinion 2.201) states the duty to relieve  
               pain and suffering is central to the physician's role as  
               healer and is an obligation physicians have to their  








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               patients.  Palliative sedation to unconsciousness is 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 an accepted and appropriate  
               component of end-of-life care under specific, relatively  
               rare circumstances. Indeed, the AMA code states, when  
               symptoms cannot be diminished through all other means of  
               palliation, including symptom-specific treatments, it is  
               the ethical obligation of a physician to offer palliative  
               sedation to unconsciousness as an option for the relief of  
               intractable symptoms.



             f)   Oregon.  Oregon's Death with Dignity Act (DWDA), enacted  
               in late 1997, allows terminally-ill adult Oregonians to  
               obtain and use prescriptions from their physicians for  
               self-administered, lethal doses of medications.  In 2011  
               the Oregon Public Health Division published a summary of  
               DWDA activity up to 2010 which also examined the larger  
               trends seen over 13 years of DWDA.  The first prescriptions  
               and deaths under DWDA occurred in 1998, with 24  
               prescriptions written and 16 self-administered deaths.  At  
               the end of 2010, a total of 821 prescriptions had been  
               written and 525 patients had died from ingesting medication  
               prescribed under DWDA.  The report noted that demographic  
               characteristics remained relatively unchanged over 13  
               years.  Of the 65 patients who died under DWDA in 2010,  
               most (70.8%) were over age 65; the median age was 72.  One  
               hundred percent of decedents were white, well-educated  
               (42.2% had at least a baccalaureate degree), had cancer  
               (78.5%), or amyotrophic lateral sclerosis (11%).  As in  
               previous years, the most commonly mentioned end of life  
               concerns among those who died in 2010 were loss of autonomy  
               (93.8%), decreasing ability to participate in activities  
               that made life enjoyable (93.8%), and loss of dignity  








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               (78.5%).  Since the law was passed in 1997, a total of  
               1,327 people have had DWDA prescriptions written and 859  
               patients have died from ingesting medications prescribed  
               under DWDA.  Over 90% of patients who used DWDA were  
               enrolled in hospice.

             g)   Improved end of life care.  A 2001 report published in  
               the Journal of American Medicine, "Oregon Physicians'  
               Attitudes About and Experiences with End-of-Life Care Since  
               Passage of the Oregon Death with Dignity Act," found that a  
               high proportion of physicians reported they had made  
               efforts to improve their knowledge of palliative care since  
               DWDA passed in 1994.  Among the 2094 physicians who cared  
               for at least one terminally ill patient in the previous  
               year, 76% reported that they had made efforts to improve  
               their knowledge of the use of pain medications in the  
               terminally ill "somewhat" or "a great deal," 69% reported  
               that they sought to improve their recognition of  
               psychiatric disorders, such as depression, and 79% reported  
               that their confidence in the prescribing of pain  
               medications had improved.



             h)   Taking the end of life drug.  The following narrative  
               describes how end of life drugs are prepared and ingested.   
               It was received from a retired Oregon family physician who  
               wrote approximately 15 prescriptions for aid-in-dying drugs  
               over the course of his career:


                 "The most common drug prescribed is 10 grams of  
                 secobarbital (Seconal).  A standard size Seconal  
                 capsule is 100 mg.  This drug was very commonly used  
                 as a sleeping pill before the invention of the  
                 benzodiazepines (e.g. Dalmane, or Valium) and then  
                 later zolpidem (Ambien).  The 100 Seconal capsules  
                 are delivered in a bottle with a label stating they  
                 are for use in the Oregon Death with Dignity Law.   








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                 In all of the cases I've been involved with, family  
                 members, volunteers, and hospice workers have all  
                 been very aware that the patient has been in  
                 possession of the medication, and I am not aware of  
                 a dose that is unaccounted for.  In Oregon it is  
                 important to understand that it would be very  
                 unusual for a patient to actually obtain the drug  
                 and then not use it.  It is much more common for the  
                 patient to request that the prescription be held on  
                 file at the pharmacy until they decide to use it.   
                 Pharmacies have been very willing to do this.  When  
                 the patient decides to take the drug the capsules  
                 are opened and emptied by the pharmacist, a  
                 volunteer or family member, and the powder is mixed  
                 with about three ounces of liquid for use."


               Seconal is not the only drug used in DWDA.  According  
               to the Oregon Public Health Division, DWDA 2013 annual  
               report, since 2010, the trend has shifted to  
               predominant use of pentobarbital (90% of all  
               prescriptions in 2013).  Patients are usually also  
               prescribed an anti-nausea medication to take before  
               ingesting an aid-in-dying drug.  




             i)   Cost and coverage.  This bill does not mandate  
               coverage of the aid-in-dying medication.  Individual  
               insurers will determine whether or not to participate.  
                However, federal funding cannot be used for services  
               rendered under the End of Life Options Act.  The  
               Oregon Medicaid program, which is paid for in part  
               with federal funds, ensures that charges for services  
               rendered under their DWDA are paid only with state  
               funds.  According to Compassion & Choices (C&C), the  
               current approximate cost of the medication in Oregon  
               is $1,500.








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             j)   Rough estimate of potential aid-in-dying  
                                                                                 participation in California.  On average, over the  
               last 17 years, 50 people a year have used DWDA in  
               Oregon.  Oregon has about 33,000 residents die each  
               year.  California is approximately seven times more  
               populous than Oregon and has approximately 230,000  
               deaths each year.  If the same percentage of people in  
               California chooses to use the End of Life Options Act  
               as in Oregon, we may have approximately 350  
               participants a year.



             aa)  Shifting views on Death with Dignity.  While Death  
               with Dignity remains a very controversial issue,  
               opinions have shifted significantly over the last  
               several years.  A Medscape survey of 17,000 U.S.  
               doctors released in December 2014 found that 54% of  
               doctors surveyed in 2014 think physician-assisted  
               suicide should be allowed. That is up from 46% in  
               2010.  A 2014 Gallup poll found that 69% of Americans  
               support laws allowing doctors to "end the patient's  
               life by some painless means" if the patient has an  
               incurable disease.  In the same poll, 58% of Americans  
               said they support laws allowing doctors to "assist the  
               patient to commit suicide" if the patient has an  
               incurable disease and is in severe pain.  A June 2015  
               phone survey of 601 likely November 2016 election  
               voters, conducted by Goodwin Simon Strategic Research  
               for C&C, shows nearly 69% of likely voters in  
               California would favor a Death with Dignity measure,  
               and support is significant among every voter subgroup,  
               including:


               i)     Men (70%) and women (67%);









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               ii)    Younger voters (69% ages 18-54) and older  
                 voters (68% ages 55+);


               iii)   Catholics (60%), non-evangelical Protestants  
                 (65%), and evangelical Christians (57%); and, 


          iv)Democrats (73%), Independents (80%), and Republicans  
            (55%).


               Only 24% of Californians would oppose the measure.


          1)SUPPORT.  C&C supports this bill stating it will improve the  
            quality of end of life care for terminally ill Californians  
            and their families, while protecting physicians who care for  
            them.  C&C writes they want people to be free to choose how  
            they live - and when the time comes, how they die.  They  
            contend that all Californians should have the option, in  
            consultation with their families and doctors, to make the end  
            of life decisions that are right for them in the final stages  
            of a terminal illness.  



          AIDS Project, Los Angeles supports this bill stating that this  
            issue is particularly important because of its impact on the  
            LGBT community, and noting that the roots of the death with  
            dignity movement owes much to mothers of men dying painfully  
            during the early days of the AIDS epidemic.

          The AIDS Healthcare Foundation (AHF) notes they have invested  
            more than a quarter of a century to the palliative care  
            necessary to minimize end of life pain and suffering.  AHF  
            states their medical staff has been witness to end stages for  
            countless citizens that rob the patient of his or her dignity  








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            and impose unnecessary misery and they have employed every  
            medical device available to them to reduce the misery, often  
            with little or no success.  AHF concludes, when a person with  
            HIV reaches the end of life with treatment options no longer  
            available, it is inhumane that we fail to provide them with  
            the choice that would bring them peace.
            Numerous other organizations support this bill including the  
            California Council of Churches IMPACT, the California  
            Association for Nurse Practitioners, and the California  
            Commission on Aging because they value autonomy in making  
            fundamental life decisions.  These organizations also applaud  
            the many patient protections in the bill, including provisions  
            which make it a felony to coerce someone to request an  
            aid-in-dying prescription.


          2)OPPOSITION.  A broad coalition of opposition to this bill,  
            including, Disability Rights Education & Defense Fund (DREDF),  
            Silicon Valley Independent Living Center, and The ARC  
            California all state physician assisted suicide is bad for  
            Californians, particularly those with low incomes who may lack  
            adequate access to health care, including mental health  
            services.  These organizations contend this bill will have a  
            devastating impact on the treatment of terminally ill and  
            disabled patients, stating that if assisted suicide is made  
            legal it quickly becomes just another treatment option, always  
            being the cheapest, and therefore, eventually the treatment of  
            choice.


            The California Catholic Conference notes that the mere fact  
            that this bill has been introduced as part of the second  
            extraordinary session, which was created to specifically  
            address the state's future financing of our Medi-Cal and  
            publicly financed healthcare systems, should invite concern  
            and offer reason enough to not support the bill.


            The Association of Northern California Oncologists states they  








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            oppose this bill for several specific reasons the first, being  
            it is contrary to a physician's oath and primary  
            responsibility to do no harm.  Secondly, legalizing physician  
            assisted suicide undermines the valuable and overwhelmingly  
            successful work of their hospice and pain and palliative care  
            colleagues.  Finally, they state the legislation is based on a  
            common misunderstanding that it is easy to determine when a  
            patient is terminal, noting that despite a physician's  
            prognosis, many patients outlive a terminal diagnosis.


          3)RELATED LEGISLATION.  


             a)   SB 128 (Wolk and Monning) is substantially similar to  
               this bill.  SB 128 is pending a hearing in the Assembly  
               Health Committee.

             b)   SB 19 (Wolk) establishes the Physician Orders for Life  
               Sustaining Treatment (POLST) eRegistry Pilot.  SB 19 is  
               pending a vote on the Assembly Floor.


               


             c)   SB 149 (Stone), SB 715 (Anderson), and AB 159 (Calderon)  
               permit a manufacturer of an investigational drug,  
               biological product, or device to make the product available  
               to eligible patients with terminal illnesses, and  
               authorizes a health plan to provide coverage for any  
               investigational drug, biological product, or device made  
               available pursuant to these provisions. The bills also  
               prohibit the MBC and the Osteopathic Medical Board of  
               California from taking any disciplinary action against the  
               license of a physician based solely on the physician's  
               recommendation to an eligible patient regarding, or  
               prescription for or treatment with, an investigational  
               drug, biological product, or device, provided that the  








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               recommendation or prescription is consistent with medical  
               standards of care.  SB 149 was held in the Assembly  
               Appropriations Committee and SB 715 is pending in the  
               Senate Health Committee.  AB 159 is pending a vote on the  
               Senate Floor.
               


             d)   AB 637 (Campos) Chapter 217, Statutes of 2015, allows  
               nurse practitioners and physician assistants acting under  
               the supervision of the physician and within the scope of  
               practice authorized by law to sign a POLST form.  

          4)PREVIOUS LEGISLATION. 


             a)   AB 2139 (Eggman), Chapter 568, Statutes of 2014,  
               requires a health care provider, when making a diagnosis  
               that a patient has a terminal illness, to notify the  
               patient of his or her right to comprehensive information  
               and counseling regarding legal end of life options.   
               Extends the right to request information to a person  
               authorized to make health care decisions for the patient  
               and specifies that the information may be provided at the  
               time of diagnosis or at a subsequent visit with the health  
               care provider.


             b)   SB 1357 (Wolk), of 2014 would have established a POLST  
               registry at the California Health and Human Services  
               Agency.  SB 1357 was held on the Senate Appropriations  
               suspense file. 


             c)   SB 1004 (Ed Hernandez), Chapter 574, Statutes of 2014,  
               requires the Department of Health Care Services (DHCS) to  
               assist Medi-Cal managed care plans in delivering palliative  
               care services, and requires DHCS to consult with  
               stakeholders and directs DHCS to ensure the delivery of  








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               palliative care services in a manner that is cost-neutral  
               to the General Fund, to the extent practicable.


             d)   AB 2747 (Berg), Chapter 683, Statutes of  2008,  
               facilitates 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. 


             e)   AB 3000 (Wolk), Chapter 266, Statutes of 2008, creates  
               POLST in California, which is a standardized form to  
               reflect a broader vision of resuscitative or  
               life-sustaining requests and to encourage the use of POLST  
               orders to better handle resuscitative or life sustaining  
               treatment consistent with a patient's wishes.


             f)   AB 374 (Berg), of 2007, would have enacted the  
               California Compassionate Choices Act, which would authorize  
               competent adults who have been determined by two physicians  
               to be suffering from a terminal disease to make a request  
               for medication to hasten the end of their lives in a humane  
               manner.  AB 374 was moved to the inactive file on the  
               Assembly Floor without a vote recorded.


             g)   AB 651 (Berg), of 2006, would have established a  
               procedure for a competent adult person who is terminally  
               ill and expected to die within six months to obtain from  
               his or her physician a prescription for medication that he  
               or she may self-administer in order to end his or her life.  
                AB 651 failed passage in the Senate Judiciary Committee.


             h)   AB 654 (Berg), of 2005, would have enacted the  
               California Compassionate Choices Act, which would authorize  








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               competent adults who have been determined by two physicians  
               to be suffering from a terminal disease to make a request  
               for medication to hasten the end of their lives in a humane  
               and dignified manner.  AB 654 was moved to the inactive  
               file on the Assembly Floor without a vote recorded.


          5)SUGGESTED AMENDMENTS.


             a)   As currently drafted the bill provides immunity to  
               persons participating in good faith with these provisions  
               who are present when a qualified individual  
               self-administers the prescribed aid-in-dying drug.  In  
               order to clarify that this provision applies to individuals  
               who are not health care providers, the Committee may wish  
               to amend the bill as follows:


               443.14. (a) Notwithstanding any other law, a person  , other  
               than a health care provider,  shall not be subject to civil  
                or criminal liability solely because the person was present  
               when the qualified individual self-administers the  
               prescribed aid-in-dying drug.  A person who is present may,  
               without civil or criminal liability, assist the qualified  
               individual by preparing the aid-in-dying drug so long as  
               the person does not assist the qualified person in  
               ingesting the aid-in-dying drug.   criminal, administrative,  
               employment, or contractual liability or professional  
               disciplinary action for participating in good faith  
               compliance with this part, including an individual who is  
               present when a qualified individual self-administers the  
               prescribed aid-in-dying drug .


             b)   As currently drafted the bill provides blanket immunity  
               for health care providers participating in these  
               provisions, even in instances where their actions are  
               grossly negligent.  The Committee may wish to amend the  








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               bill as follows: 


                  443.14  (d) The immunities from liability specified in  
               this section do not apply to any acts or omissions  
               constituting gross negligence or willful or wanton  
               misconduct.


              c)   As currently drafted the bill requires DPH to report  
               information based on information collected from the  
               attending physician, and for the report to be available to  
               the public, however it does not specifically require DPH to  
               post the report on its Internet Web site.  The Committee  
               may wish to amend the bill as follows:


                  (b) On or before July 1, 2017, and each year thereafter,  
               based on the information collected in the previous year,  
               the department shall  report   create a report with  the  
               information collected from the attending physician  
                follow-up form   follow-up form, and post that report to its  
               Internet Web site  .


             d)   As currently drafted the bill requires the Medical Board  
               to revise several of the forms required by this bill.  The  
               Committee may wish to amend the bill to instead authorize  
               the Board to update the forms when and if that becomes  
               necessary.


             e)   Additional minor, technical amendments to correct  
               drafting errors and add Speaker Atkins, Assemblymember  
               Perea, and Senator Glazer as co-authors.


          REGISTERED SUPPORT / OPPOSITION:









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          Support



          Insurance Commissioner Dave Jones
          AIDS Healthcare Foundation
          AIDS Project Los Angeles
          Area Agency on Aging, Central Coast Commission for Senior  
          Citizens
          Bloom in the Desert Ministries
          California Association of Marriage and Family Therapists
          California Association for Nurse Practitioners
          California Church IMPACT
          California Commission on Aging
          California Democratic Party
          California Primary Care Association
          Cardinal Point at Mariner Square Residents' Association
          Coastside Democrats
          Compassion & Choices, California
          County of Santa Cruz
          Democratic Women of Santa Barbara County
          Desert Stonewall Democrats
          Full Circle Living & Dying Collective
          Gay and Lesbian Medical Association
          Gray Panthers of Long Beach
          Laguna Woods Democratic Club
          Mar Vista Community Council
          National Association of Social Workers, California Chapter
          Older Women's League, San Francisco
          Potrero Hill Democratic Club
          Progressive Christians Uniting
          Sacramento Central Labor Council AFL-CIO
          San Francisco AIDS Foundation
          Santa Barbara County Board of Supervisors
          San Mateo County Medical Association
          Unitarian Universalist Church of the Desert








                                                                    ABX2 15


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          Ventura County Board of Supervisors
          West Hollywood United Church of Christ
          Numerous individuals
          Opposition


          
          Agudath Israel of California


          Alliance of Catholic Health Care
          Arroyo Grande Community Hospital
          Association of Northern California Oncologists
          Autistic Self Advocacy Network


          California Catholic Conference
          California Disability Alliance
          California Foundation for Independent Living Centers
          California Hospital Medical Center
          California Nurses for Ethical Standards
          Choice is an Illusion
          Coalition of Concerned Medical Professionals
          Communities Actively Living Independent and Free
          Community Hospital of San Bernardino
          Communities United in Defense of Olmstead
          Crusade for Life
          Dignity Health
          Disability Action Center
          Disability Rights Education & Defense Fund
          Dominican Hospital
          FREED Center for Independent Living
          Glendale Memorial Hospital and Health Center
          Independent Living Center of Southern California
          Independent Living Resource Center, San Francisco
          Life Priority Network
          League of United Latin American Citizens, Evergreen Council
          League of United Latin American Citizens, Mayfair Council
          League of United Latin American Citizens, Santa Clara Council








                                                                    ABX2 15


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          Marian Regional Medical Center
          Medical Oncology Association of Southern California, Inc.
          Mercy General Hospital
          Mercy Hospital Folsom
          Mercy Medical Center
          Mercy Medical Center Mt. Shasta
          Patients' Rights Action Fund
          Placer Independent Resource Services
          Providence Health & Services, Southern California
          The Salvador E. Alvarez Institute for Non-Violence
          Santa Rosa Memorial Hospital
          Scholl Institute of Bioethics


          Sequoia Hospital
          Silicon Valley Independent Living Center
          St. Agnes Medical Center
          St. Bernardine Medical Center
          St. John's Regional Medical Center & Pleasant Valley Hospital
          St. Joseph's Behavioral Health Center
          St. Joseph Health
          St. Joseph Health, Mission Hospital Viejo & Laguna Beach
          St. Joseph Hospital, Orange
          St. Joseph's Medical Center
          St. Joseph Health, Queen of the Valley
          St. Jude Medical Center
          St. Mary Medical Center, Long Beach
          St. Mary Medical Center, Apple Valley
          The Arc, California
          Numerous individuals


          Analysis Prepared by:Lara Flynn / HEALTH / (916) 319-2097














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