BILL ANALYSIS                                                                                                                                                                                                    



                                                                   AB 15 X2


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          ASSEMBLY THIRD READING


          AB 15  
          X2 (Eggman, et al.)


          As Amended  September 3, 2015


          Majority vote


           ------------------------------------------------------------------ 
          |Committee       |Votes|Ayes                  |Noes                |
          |                |     |                      |                    |
          |                |     |                      |                    |
          |                |     |                      |                    |
          |----------------+-----+----------------------+--------------------|
          |Public Health   |10-3 |Bonta, Maienschein,   |Mayes, Santiago,    |
          |                |     |Baker, Bonilla,       |Steinorth           |
          |                |     |Campos,               |                    |
          |                |     |                      |                    |
          |                |     |                      |                    |
          |                |     |Eduardo Garcia,       |                    |
          |                |     |Levine,               |                    |
          |                |     |                      |                    |
          |                |     |                      |                    |
          |                |     |Mark Stone, Thurmond, |                    |
          |                |     |Wood                  |                    |
          |                |     |                      |                    |
          |----------------+-----+----------------------+--------------------|
          |Finance         |5-3  |Weber, Bloom,         |Melendez, Bigelow,  |
          |                |     |Jones-Sawyer,         |Obernolte           |
          |                |     |McCarty, Ting         |                    |
          |                |     |                      |                    |
          |                |     |                      |                    |
           ------------------------------------------------------------------ 









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          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  
            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  








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            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.


          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  








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            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;


             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,








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               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:


               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.









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             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.  


             bb)Provide the individual with a final attestation form and  
               instruct them to fill it out and sign it 48 hours prior to  
               ingesting the aid-in-dying drug.  The form attests, among  
               other things, that the individual has been fully informed  
               of their diagnosis and prognosis, counseled regarding  
               feasible alternatives, including hospice and palliative  
               care, and that the individual understands they may choose  
               not to ingest the drug and is under no obligation to ingest  
               the drug.  Requires the form to be delivered by the  
               individual's health care provider, family member, or other  
               representative to the attending physician to be included in  
               the patient's medical record.


          12)Once all of the requirements have been met, allows the  
            attending physician to deliver the aid-in-dying drug in any of  
            the following ways:
             a)   Dispensing the aid-in-dying drug directly, including  








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               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;


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








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









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             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.


          19)Makes a provision in a contract, will, or other agreement  








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            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.


          24)Provides that a person will not be subject to civil or  








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            criminal liability solely because the person was present when  
            the qualified individual self-administered the prescribed  
            aid-in-dying drug, and that a person may, without civil or  
            criminal liability assist the qualified individual by  
            preparing the aid-in-dying drug, but not assist the individual  
            in ingesting the 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 the immunities and prohibitions on sanction of  
            a health care provider are solely reserved for actions of a  
            health care provider taken pursuant to these provisions, and  
            clarifies a health care provider may be sanctioned by their  
            licensing board or agency for conduct and actions constituting  
            unprofessional conduct, including failure to comply in good  
            faith with these provisions.


          28)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. 









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          29)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.


          30)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.


          31)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.


          32)Specifies 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.


          33)Makes knowingly altering or forging a request for an  
            aid-in-dying drug to end an individual's life without their  








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            authorization, or concealing or destroying a withdrawal or  
            rescission of a request, or administering an aid-in-dying drug  
            to an individual without his or her knowledge or consent,  
            punishable as a felony.  


          34)Prohibits the attending physician, consulting physician, or  
            mental health specialist from being related to the qualified  
            individual by blood, marriage, registered domestic  
            partnership, or adoption, or be entitled to a portion of the  
            individual's estate upon death.


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


          36)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.


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


          38)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.


          39)Requires DPH, on or before July 1, 2017, and each year  








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            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  
               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;








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               iv)Sex;


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


               vi)Underlying illness.


          40)Requires DPH to post the report on its Internet Web site.
          41)Requires DPH to make the following forms available on its  
            Internet Web site:  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  
            care provider to be in compliance with the End of Life Option  
            Act.


          42)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  
            (BOF) or a federal Drug Enforcement Administration approved  
            take back program.


          43)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.


          44)Allows the Medical Board of California to develop, revise,  








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            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 Web site.


          45)Specify that these provisions remain in effect only until  
            January 1, 2026, and as of that date are repealed, unless a  
            later enacted statute, that is enacted before January 1, 2026,  
            deletes or extends that date.


          46)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.


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


          EXISTING LAW:  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:


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


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









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


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


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


          6)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.


          FISCAL EFFECT:  According to the Assembly Finance Committee: 


          Department of Health Care Services


          Potential minor costs and savings in Medi-Cal based on the  
          Medi-Cal program choosing to cover this end-of-life option  
          (General Fund (GF)).


          DPH


          DPH would incur one-time GF costs of $90,000 for information  
          technology services, and ongoing GF costs in the range of  
          $250,000. 










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          DPH anticipates that a secure drive with password protection  
          would be needed to store the confidential data collected  
          pursuant to this bill, and would require a Structured Query  
          Language (SQL) database to perform data collection and storage.   
          DPH states that a database could be developed with one-time  
          development costs of approximately $88,000, and ongoing yearly  
          maintenance by Information Technology Services Division of  
          approximately $10,000 per year, as shown in the chart below.  


           


                  ---------------------------------------------------- 
                 |Database Development Task          |Hours  |Cost    |
                 |-----------------------------------+-------+--------|
                 |Application Development            |       |        |
                 |-----------------------------------+-------+--------|
                 |            Requirements          |267    | $16,000|
                 |       Specifications              |       |        |
                 |-----------------------------------+-------+--------|
                 |            Design / Test Plan    |133    |  $8,000|
                 |-----------------------------------+-------+--------|
                 |            System Development /  |800    | $48,000|
                 |       Code & Test                 |       |        |
                 |-----------------------------------+-------+--------|
                 |            Acceptance Testing /  |133    |  $8,000|
                 |       User Training               |       |        |
                 |-----------------------------------+-------+--------|
                 |            Initial Internet / SQL |133    |  $8,000|
                 |       DBA setup                   |       |        |
                 |-----------------------------------+-------+--------|
                 |                                   |       |        |
                 |-----------------------------------+-------+--------|
                 |Total One-Time Cost                |1466   | $88,000|
                 |-----------------------------------+-------+--------|
                 |Ongoing yearly maintenance ($845 x |14/mo  |$10,140 |
                 |12)                                |       |        |
                 |                                   |       |        |








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                 |                                   |       |        |
                 |                                   |       |        |
                 |                                   |       |        |
                  ---------------------------------------------------- 


                 Additionally, once the database is established, DPH estimates  
          that two full-time positions would be required to perform  
          confidential program and reporting duties outlined in this bill,  
          with duties including:  


          1)Collect data, enter reports received, collect forms, track  
            program utilization and associated deaths;
          2)Follow-up with providers that submit incomplete reports;


          3)Perform data analysis, cross-check decedent deaths with list  
            of prescribed participants, and draft annual reports;


          4)Prepare the annual report mandated by the bill;


          5)Maintain program information on the public website, and  
            respond to inquiries regarding program policy; and


          6)Update website as needed, and make reporting forms available  
            for download online.


               Summary of Total Cost to DPH





                  ----------------------------------------------- 








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                 | Total Budget Year Cost  |  Total Cost Budget  |
                 |                         |      Year + 1       |
                 |-------------------------+---------------------|
                 |        $323,087         |$245,227             |
                 |                         |                     |
                 |                         |                     |
                 |                         |                     |
                  ----------------------------------------------- 


                 Department of Managed Health Care (DMHC)


          Due to the sensitive and controversial nature of aid-in-dying,  
          DMHC anticipates a high level of public interest, which will  
          result in Public Records Act (PRA) or Information Practices Act  
          (IPA) requests during the first three years.  The Office of  
          Legal Services (OLS) anticipates PRA/IPA requests regarding  
          which health plans that cover aid-in-dying medications and under  
          what terms the medications are covered, as well as information  
          on relevant policy decisions, enforcement policies, and consumer  
          grievances.  OLS estimates that these tasks will have no cost in  
          the current fiscal year, $276,000 (Managed Care Fund (MCF)) and  
          2.0 positions in the 2015-16 fiscal year, and $244,000 MCF and  
          2.0 positions each in the 2016-17 and 2017-18 fiscal years.  OLS  
          does not anticipate ongoing costs after the 2017-18 fiscal year.


          The Help Center, Office of Administrative Services, Office of  
          Technology and Innovation, Office of Enforcement, Office of Plan  
          Licensing, Division of Plan Surveys, and Office of Financial  
          Review anticipate absorbable workload that will have no  
          significant fiscal impact on those programs.


          Medical Board of California


          Minor costs to the Medical Board to update several of the forms  








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          required by this bill as deemed necessary (Contingent Fund of  
          the Medical Board of California).


          Board of Pharmacy (BOP)


          Minor costs to the BOP.  The BOP would not need to amend or  
          adopt any regulations. The BOP estimates that any additional  
          enforcement actions due to this bill would result in minor costs  
          (Pharmacy Fund).


          COMMENTS: 


          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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          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.


          1)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.  








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          2)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:
             a)   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;


             b)   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,


             c)   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.  


          3)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 patients' last  
            resort options include aggressive pain management, forgoing  








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            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.


          4)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  








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            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 (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.


          5)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.


          6)Taking the end of life drug.  The following narrative  
            describes how end of life drugs are prepared and ingested.  It  








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            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 [milligram].  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.  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.  
            










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          1)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.




          2)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.


          3)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 United States 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  








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            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:


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


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


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


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


            Only 24% of Californians would oppose the measure.


          12)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  








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            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 acquired immune deficiency  
            syndrome (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  
            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  
            human immunodeficiency virus (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.


          13)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  








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            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 this bill.




            The Association of Northern California Oncologists states they  
            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.




          Analysis Prepared by:                                             
                          Lara Flynn / HEALTH / (916) 319-2097  FN:  
          0002237















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