BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: AB 637
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|AUTHOR: |Campos |
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|VERSION: |February 24, 2015 |
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|HEARING DATE: |June 10, 2015 | | |
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|CONSULTANT: |Teri Boughton |
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SUBJECT : Physician Orders for Life Sustaining Treatment forms.
SUMMARY : Allows a nurse practitioner or a physician assistant acting
under the supervision of a physician to sign a completed
Physician Orders for Life Sustaining Treatment form.
Existing law:
1)Establishes the Physicians Orders for Life Sustaining
Treatment (POLST) form and medical intervention and
procedures, and requires that POLST be explained by a health
care provider, defined as an individual licensed, certified,
or otherwise authorized or permitted by the law of this state
to provide health care in the ordinary course of business or
practice of a profession.
2)Requires the form to be completed by a health care provider
based on patient preferences and medical indications, and
signed by a physician and the patient or his or her legally
recognized health care decision maker. Requires the health
care provider, during the process of completing form, to
inform the patient about the difference between an advance
health care directive and the POLST form.
This bill:
1)Adds a nurse practitioner (NP) or a physician assistant (PA)
acting under the supervision of the physician and within the
scope of practice authorized by law to sign a completed POLST
form.
FISCAL
EFFECT : This bill is keyed non-fiscal.
AB 637 (Campos) Page 2 of ?
PRIOR
VOTES :
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|Assembly Floor: |75 - 0 |
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|Assembly Judiciary Committee: |10 - 0 |
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COMMENTS :
1)Author's statement. According to the author, POLST is viewed
by health care professionals as useful, helpful, reliable and
most importantly, very effective at ensuring preferences for
end-of-life care are honored. Physicians recognize and
appreciate the value of the multiple member health care team
and support efforts to increase productivity while ensuring
quality of care. NPs and PAs are currently having
conversations with patients about their end-of-life care
options and preferences, and in some instances are able to
sign off on other immediately actionable documents under
supervision, such as drug orders and medical certificates. By
allowing NPs and PAs under physician supervision to sign POLST
forms, this bill will improve end-of-life care by increasing
the availability of actionable medical orders for medically
indicated care consistent with patient preferences.
2)What is POLST? According to the POLST Legislative Guide,
approved February 28, 2014 by the National POLST Paradigm Task
Force, the POLST paradigm is a clinical process designed to
facilitate communication between health care professionals and
patients with serious illness or frailty (or their authorized
surrogate) where the health care professional would not be
surprised if the patient died within the next year. The
process encourages shared, informed medical decision-making
leading to a set of portable medical orders that respects the
patient's goals for care in regard to the use of
cardiopulmonary resuscitation and other medical interventions,
is applicable across health care settings, and can be reviewed
and revised as needed. The POLST paradigm promotes the use of
a highly visible, portable medical form that transfers from
one setting to another with the patient. It functions as a Do
Not Resuscitate order and provides treatment direction for
multiple situations. The POLST form itself is outcome
neutral, meaning treatment options range from full treatment
AB 637 (Campos) Page 3 of ?
to comfort care only. As of December 2013, the POLST Paradigm
Task Force had endorsed the POLST programs of 16 states, and
another 12 states were developing POLST implementation plans.
The 16 endorsed states are: California, Colorado, Georgia,
Hawaii, Idaho, Louisiana, Montana, New York, North Carolina,
Oregon, Pennsylvania, Tennessee, Utah, Washington, West
Virginia, and Wisconsin (Wisconsin has been endorsed only
regionally).
POLST is neither an advance directive nor a replacement for
advance directives. However, both documents are helpful for
communicating patient wishes when appropriately used. An
advance directive is a form in which an individual appoints a
person or persons to make health care decisions for the
individual if and when the individual loses capacity to make
health care decisions (health care power of attorney) and/or
provides guidance or instructions for making health care
decisions (living will). An advance directive is from the
patient, not a medical order. POLST consists of a set of
medical orders that applies to a limited population of
patients and addresses a limited number of critical medical
decisions. POLST is a complement to advance directives in
that it serves as a translation tool and a continuity of care
assurance.
3)POLST in California. As published in an August 10, 2012,
article in the Journal of General Internal Medicine,
Implementation of Physician Orders for Life Sustaining
Treatment in Nursing Homes in California: Evaluation of a
Novel Statewide Dissemination Mechanism, 546 California
nursing homes were surveyed and in 82 percent of responding
nursing homes, staff received POLST education and 59 percent
reported having a formal policy on POLST. Two-thirds had
admitted a resident with a POLST and 15 percent of newly
admitted residents over the past month had a POLST. Few
nursing homes reported difficulty following POLST orders, but
38 percent noted difficulty involving physicians in POLST
completion. A 2013 article in the Journal of American
Geriatrics Society, Implementing Physician Orders for
Life-Sustaining Treatment in California Hospitals: Factors
Associated with Adoption, indicates of 349 hospitals surveyed,
81.9 percent responded. Sixty-five percent of hospitals had a
policy on POLST, 87 percent had available POLST forms, 84
percent had educated staff, and 94 percent reported handling
AB 637 (Campos) Page 4 of ?
POLST properly in the emergency department on admission.
Although POLST is widely used in California, a significant
minority of hospitals remain unprepared three years after
implementation. According to information presented at a
December 3, 2014, briefing on POLST in California, based on an
evaluation by UCLA, POLST is widely used in California but
there are challenges with completing the form and making sure
it travels with the patient. Additional problems include
incomplete or inaccurate information and for emergency medical
responders the documents are not always available.
4)NPs and PAs. A PA may perform those medical services as set
forth in regulations when the services are rendered under the
supervision of a licensed physician and surgeon. A PA may
only provide those medical services which he or she is
competent to perform and which are consistent with his or her
education, training, and experience, and which are delegated
in writing by a supervising physician who is responsible for
the patients cared for by that PA. According to the California
Association of Nurse Practitioners, NPs are advanced practice
registered nurses who are licensed by the Board of Registered
Nursing and have pursued higher education, either a master's
or doctoral degree, and certification as a NP. NPs provide
care in a variety of settings, including hospitals, community
clinics, and private practice settings under physician
supervision.
5)Related legislation. SB 19 (Wolk), would establish a POLST
Registry operated by the California Health and Human Services
Agency (CHHS) for the purpose of collecting a POLST form
received from a physician, or his or her designee, and
disseminating the information in the form to persons
authorized by CHHS. SB 19 (Wolk) is pending in the Assembly.
SB 128 (Wolk and Monning), would permit a qualified adult with
capacity to make medical decisions, who has been diagnosed
with a terminal disease to receive a prescription for an aid
in dying drug if certain conditions are met, such as two oral
requests, a minimum of 15 days apart and a signed written
request witnessed by two individuals is provided to his or her
attending physician, the attending physician refers the
patient to an independent, consulting physician to confirm
diagnosis and capacity of the patient to make medical
AB 637 (Campos) Page 5 of ?
decisions, and the attending physician refers the patient for
a mental health specialist assessment if there are indications
of a mental disorder. SB 128 is pending in the Assembly.
SB 323 (Hernandez) would authorize a NP who holds a national
certification to practice without physician supervision in
specified settings. SB 323 is pending in the Assembly
Business and Professions Committee.
6)Prior legislation. SB 1357 (Wolk, 2014), would have
established a POLST registry at CHHS and is substantially
similar to SB 19. The bill was held on the Senate
Appropriations suspense file.
AB 3000 (Wolk, Chapter 266, Statutes of 2008), created 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.
7)Support. The California Medical Association writes that a
POLST becomes actionable when signed by a physician and the
patient. NPs and PAs are having conversations with patients
about their end-of-life care options and preferences and, in
some instances, are able to sign off on other immediately
actionable documents under supervision, such as drug orders,
and medical certificates. The Coalition for Compassionate
Care of California writes that the two signature requirement
can create a roadblock to timely completion, particularly in
rural areas and skilled nursing facilities where timely access
to a physician can be difficult to obtain. The situation can
create an unnecessarily stressful delay. NPs and PAs receive
advanced training that enables them to talk with patients
about the medical treatment choices in POLST and they are
often able to spend more one-on-one time with patients than
physicians. Sixteen states, including Oregon, already allow
NPs and PAs to sign POLST forms, and no problems have
occurred. The California Chapter of the American College of
Emergency Physicians writes that end-of-life decisions a
patient sets out in their POLST are often put into practice in
the emergency department, and unfortunately, many patients
arrive with an invalid POLST not signed by a physician.
Allowing a NP or PA, under physician supervision, to sign and
validate a POLST form will increase the number of valid POLST
AB 637 (Campos) Page 6 of ?
forms that emergency physicians can act on, and ensure
patient's end-of-life wishes are honored. AARP writes POLST
is an effective but underutilized advance-care planning tool
and utilization may be improved by authorizing other health
care team members such as NPs and PAs who are already
discussing health care decisions with patients and/or their
decision makers regarding the levels of medical intervention
identified on the POLST form.
8)Opposition. The California Right to Life Committee, Inc.
writes that this bill raises the status of nurse practitioners
and nursing assistants to a level of medical competences that
is not warranted by their level of education and knowledge of
illness or treatments.
SUPPORT AND OPPOSITION :
Support: California Medical Association (co-sponsor)
Coalition for Compassionate Care of California
(co-sponsor)
AARP
Association of Northern California Oncologists
Blue Shield of California
California Assisted Living Association
California Association for Health Services at Home
California Association for Nurse Practitioners
California Chapter of the American College of
Emergency Physicians
California Long-Term Care Ombudsman Association
Contra Costa County Advisory Council on Aging
Contra Costa County Board of Supervisors
LeadingAge California
Medical Board of California
Medical Oncology Association of Southern California,
Inc.
Physician Assistant Board
Oppose: California Right to Life Committee, Inc.
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