BILL ANALYSIS Ó SENATE COMMITTEE ON HEALTH Senator Ed Hernandez, O.D., Chair BILL NO: AB 637 --------------------------------------------------------------- |AUTHOR: |Campos | |---------------+-----------------------------------------------| |VERSION: |February 24, 2015 | --------------------------------------------------------------- --------------------------------------------------------------- |HEARING DATE: |June 10, 2015 | | | --------------------------------------------------------------- --------------------------------------------------------------- |CONSULTANT: |Teri Boughton | --------------------------------------------------------------- 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 : ----------------------------------------------------------------- |Assembly Floor: |75 - 0 | |------------------------------------+----------------------------| |Assembly Judiciary Committee: |10 - 0 | | | | ----------------------------------------------------------------- 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. -- END -- AB 637 (Campos) Page 7 of ?