BILL ANALYSIS Ó
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|SENATE RULES COMMITTEE | AB 637|
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THIRD READING
Bill No: AB 637
Author: Campos (D)
Introduced:2/24/15
Vote: 21
SENATE HEALTH COMMITTEE: 8-0, 6/10/15
AYES: Hernandez, Nguyen, Hall, Mitchell, Monning, Pan, Roth,
Wolk
NO VOTE RECORDED: Nielsen
ASSEMBLY FLOOR: 75-0, 4/16/15 - See last page for vote
SUBJECT: Physician Orders for Life Sustaining Treatment forms
SOURCE: California Medical Association
Coalition for Compassionate Care of California
DIGEST: This bill 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.
ANALYSIS:
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,
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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 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 the POLST law
to sign a completed POLST form.
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? POLST includes 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,
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is applicable across health care settings, and can be reviewed
and revised as needed. The POLST form is 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
to comfort care only.
3)POLST and advance directive. POLST is neither an advance
directive nor a replacement for an advance directive. 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.
4)POLST in California. 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.
5)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
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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.
Related Legislation
SB 19 (Wolk) establishes 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 is pending in the
Assembly.
SB 128 (Wolk) permits 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 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 set for
hearing in the Assembly Health Committee on June 23, 2015.
SB 323 (Hernandez) authorizes a NP who holds a national
certification to practice without physician supervision in
specified settings. SB 323 is set for hearing in the Assembly
Business and Professions Committee on June 30, 2015.
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 Committee 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.
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FISCAL EFFECT: Appropriation: No Fiscal
Com.:NoLocal: No
SUPPORT: (Verified6/15/15)
California Medical Association (co-source)
Coalition for Compassionate Care of California (co-source)
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
OPPOSITION: (Verified6/15/15)
California Right to Life Committee, Inc.
ARGUMENTS IN SUPPORT: The California Medical Association,
this bill's co-sponsor, 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, the other co-sponsor of
this bill, 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
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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 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.
ARGUMENTS IN OPPOSITION: The California Right to Life
Committee, Inc. writes that this bill raises the status of NPs
and PAs to a level of medical competence that is not warranted
by their level of education and knowledge of illness or
treatments.
ASSEMBLY FLOOR: 75-0, 4/16/15
AYES: Achadjian, Alejo, Travis Allen, Baker, Bigelow, Bloom,
Bonilla, Bonta, Brough, Brown, Burke, Calderon, Campos, Chang,
Chau, Chávez, Chiu, Chu, Cooley, Cooper, Dababneh, Dahle,
Daly, Frazier, Beth Gaines, Gallagher, Cristina Garcia,
Eduardo Garcia, Gatto, Gomez, Gonzalez, Gordon, Gray, Grove,
Hadley, Roger Hernández, Holden, Irwin, Jones, Jones-Sawyer,
Kim, Lackey, Levine, Linder, Lopez, Low, Maienschein, Mathis,
Mayes, McCarty, Medina, Melendez, Mullin, Nazarian, Obernolte,
O'Donnell, Olsen, Patterson, Perea, Rendon, Ridley-Thomas,
Rodriguez, Salas, Santiago, Steinorth, Mark Stone, Thurmond,
Ting, Wagner, Waldron, Weber, Wilk, Williams, Wood, Atkins
NO VOTE RECORDED: Dodd, Eggman, Gipson, Harper, Quirk
Prepared by:Teri Boughton / HEALTH /
6/16/15 13:51:05
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