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.









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           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  








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            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  








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            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  








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            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  








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            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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