BILL ANALYSIS                                                                                                                                                                                                    



          SENATE COMMITTEE ON HEALTH
                          Senator Ed Hernandez, O.D., Chair

          BILL NO:                    SB 19     
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          |AUTHOR:        |Wolk                                           |
          |---------------+-----------------------------------------------|
          |VERSION:       |March 25, 2015                                 |
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          |HEARING DATE:  |April 8, 2015  |               |               |
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          |CONSULTANT:    |Teri Boughton                                  |
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           SUBJECT  :  Physician Orders for Life Sustaining Treatment form:   
          statewide registry

           SUMMARY  :  Establishes a Physician Orders for Life Sustaining Treatment  
          (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.

          Existing law:
          1.Defines advance health care directive or directive to mean  
            either an individual health care instruction or a power of  
            attorney for health care.  Requires the Secretary of State to  
            establish a registry system through which a person who has  
            executed a written advance health care directive may register  
            in a central information center, information regarding the  
            advance directive, making that information available upon  
            request to any health care provider, the public guardian, or  
            the legal representative of the registrant. 

          2.Requires the Secretary of State to establish procedures to  
            verify the identities of health care providers, the public  
            guardian, and other authorized persons requesting information  
            from the registry system. Prohibits a fee from being charged  
            to any health care provider, the public guardian, or other  
            authorized person requesting information from the registry  
            system.


          3.Establishes the POLST form and medical intervention and  
            procedures offered by the form, and requires that it be  
            explained by a health care provider, defined as an individual  







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            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. 

          4.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.

          5.Requires a request regarding resuscitative orders to be made  
            by an Emergency Medical Services Authority (EMSA) developed  
            prehospital "Do Not Resuscitate" or other substantially  
            similar form or, an EMSA approved POLST form.

          6.Establishes the Confidentiality of Medical Information Act  
            (CMIA) which prohibits any health care provider, health  
            insurer, or medical service contractor from disclosing a  
            patient's medical information without the patient's consent,  
            subject to certain mandatory and voluntary exceptions.  

          7.Requires under the federal Health Insurance Portability and  
            Accountability Act of 1996 (HIPAA) procedures for health care  
            providers, health plans, health care clearinghouses and their  
            business associates for protecting and confidentially handling  
            protected health information.
          
          This bill:
          1.Establishes the California POLST Registry Act, and requires  
            CHHS to establish and operate a statewide registry system for  
            the purpose of collecting a POLST form received from a  
            physician or physician designee and disseminating the  
            information in the form to an authorized user.  

          2.Permits the registry to be operated and maintained by a  
            contractor of CHHS.

          3.Requires CHHS to adopt all rules necessary for the operation  
            of the registry, and requires but does not limit the rules to  
            include the following:

                  a.        The means to submit an initial or subsequent  
                    POLST form, or withdraw a form, from the registry,  








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                    including a method for electronic delivery and the use  
                    of legally sufficient electronic signatures;
                  b.        Appropriate and timely methods by which the  
                    information may be disseminated to an authorized user;
                  c.        Procedures for verifying the identity of an  
                    authorized user;
                  d.        Procedures to ensure the accuracy of, and to  
                    appropriately protect the confidentiality of, POLST  
                    forms submitted to the registry;
                  e.        That a patient, or when appropriate, his or  
                    her legally recognized health care decision maker,  
                    receive a confirmation or a receipt that the patient's  
                    POLST form has been received by the registry;
                  f.        The ability of the physician who signed the  
                    POLST form, his or her designee, the patient, or when  
                    appropriate, his or her legally recognized health care  
                    decision maker, to review the information in the  
                    patient's POLST form after it has been entered into  
                    the registry, and to confirm it is accurate, prior to  
                    it being available to an authorized user; and,
                  g.        The ability of a patient, or when appropriate,  
                    his or her legally recognized health care decision  
                    maker, to withdraw a POLST form from the registry.

          4.Requires the operation of the registry to comply with state  
            and federal privacy and security laws and regulations,  
            including, but not limited to, compliance with the CMIA and  
            the regulations promulgated pursuant to HIPAA.

          5.Requires a physician or physician designee who completes a  
            POLST form with a patient or his or her legally recognized  
            health care decision maker to include the POLST form in the  
            patient's official medical record, and submit a copy to the  
            registry unless the patient or the legally recognized health  
            care decision maker chooses not to participate in the  
            registry.

          6.Protects an authorized user acting upon information obtained  
            from the registry from criminal prosecution, civil liability,  
            discipline for unprofessional conduct, administrative  
            sanction, or any other sanction, if the person acted in good  
            faith and had no knowledge that the action or decision would  
            be inconsistent with a health care decision that the  
            individual signing the POLST form would have made on his or  
            her own behalf, or on behalf of the patient, under the  








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            circumstances.

          7.Defines authorized user as a person authorized by CHHS to  
            submit information to, or receive information from, the POLST  
            registry, including health care providers and their designees.
             
           FISCAL  
          EFFECT  :  This bill has not been analyzed by a fiscal committee.
           
          COMMENTS  :
          
          1.Author's statement.  According to the author, the "Physician  
            Orders for Life-Sustaining Treatment" (POLST) is a form that  
            contains a doctor's orders to ensure that a patient's wishes  
            are honored regarding medical treatment towards the end of  
            life. Currently, the POLST form is a paper document, and as  
            such, is oftentimes a key barrier to its effectiveness given  
            that it can be misplaced. Furthermore, there isn't a central  
            database or registry that first responders can access in an  
            emergency situation.  

            A statewide electronic POLST registry in California would help  
            ensure immediate access to vital medical orders by emergency  
            medical personnel.  In an era of ever-increasing technology  
            and federal funding available to specifically support  
            electronic health records. Several states are developing and a  
            few states have already completed a statewide registry to  
            access POLST forms more effectively. 

          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  








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            multiple situations.  The form itself is outcome neutral.  Its  
            options range from full treatment 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  








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            percent had educated staff, and 94 percent reported handling  
            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 Dr. Neil Wenger of UCLA Health  
            Ethics Center 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.  Dr. Wenger suggests a registry is  
            one solution to these challenges.



          4.Other California Registries.  


                a.     Advance Health Care Directive Registry  .  The  
                 Secretary of State maintains the advance health care  
                 directive registry, as required by law, which allows a  
                 person who has executed an advance health care directive  
                 to register information regarding the directive with the  
                 Secretary of State.  An advance health care directive can  
                 be made a part of the Secretary of State's registry by  
                 attaching a copy of the advance health care directive to  
                 the Registration of Written Advance Health Care Directive  
                 filed with the Secretary of State. As an alternative to  
                 providing a copy of the written directive to the  
                 Secretary of State, its location can be indicated on the  
                 registration form.  As of April 3, 2015, there are 4,907  
                 advance health care directives on file.  In the past five  
                 fiscal years, a total of 2,152 written advance health  
                 care directives have been filed for an average of 430  
                 filings per year.  For this fiscal year, 279 written  
                 advance health care directives have been filed through  
                 the month of February.  This information is made  
                 available upon request to the registrant's health care  
                 provider, public guardian, or legal representative. A  
                 request for information must state the need for the  
                 information.  Over the last two years, there has been a  
                 spike in the number of inquiries due to the fact that  
                 Ventura and Los Angeles counties have been permitted to  
                 send email inquiries with supporting documentation.  In  








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                 the past two years, there has been an average of 526  
                 inquiries each year with a vast majority of the inquiries  
                 being email inquiries.  Prior to fiscal year 2013-14, an  
                 average of two inquiries were received a year. The annual  
                 cost to maintain the registry is approximately $45,000,  
                 excluding overhead costs.  Staff support for the filings  
                 and inquiries equates to a .5 personnel year.  Although  
                 there is a $10 registration fee, maintaining the registry  
                 is absorbed as part of other programs and services  
                 provided by the Business Programs Division through the  
                 Business Fees Fund, which consists of a cumulative pool  
                 of money paid by all businesses and individuals that are  
                 required or are permitted to file documents with the  
                 Secretary of State's office.  





                b.     California Cancer Registry  .  According to the  
                 California Department of Public Health, California Cancer  
                 Registry (CCR) is California's statewide population-based  
                 cancer surveillance system. The CCR collects information  
                 about all cancers diagnosed in California (except basal  
                 and squamous cell carcinoma of the skin and carcinoma in  
                 situ of the cervix).  In 1985, statewide,  
                 population-based cancer reporting was required by law.  
                 The CCR is now recognized as one of the leading cancer  
                 registries in the world. Due to the size and diversity of  
                 the California population, more is now known about the  
                 occurrence of cancer in diverse populations than ever  
                 before. The CCR has proven to be the cornerstone of a  
                 substantial amount of cancer research in the California  
                 population.  


                c.     California Immunization Information Registry (CAIR)  .  
                  CAIR is a collaborative effort involving local health  
                 departments, the California Department of Public Health  
                 (DPH), Immunization Branch, and a spectrum of key  
                 stakeholders across the state.  There are seven regional  
                 registries managed by department staff.  CAIR is working  
                 to develop an integrated, statewide computerized registry  
                 to network each child's full immunization history. 









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                 Health care providers and other authorized users log in  
                 to the registry using a user ID and password.  In  
                 addition to accessing patient immunization information,  
                 users can utilize the integrated vaccine algorithm to  
                 determine vaccinations due, enter new patients or vaccine  
                 doses administered, manage vaccine inventory, run patient  
                 or inventory reports, or run reminder/recalls on their  
                 patients.  New patients or vaccine doses can either be  
                 entered directly into CAIR using the web interface or can  
                 be submitted electronically as aggregated data files  
                 (e.g. exported from their EHR systems) for upload to  
                 CAIR.  Many prominent private and public health care  
                 entities already share data electronically with CAIR.


                 Statewide there are 14.9 million patients with 160  
                 million vaccines registered.  In 2010, state General Fund  
                 support for the registries (approximately $3.5 million)  
                 was withdrawn and efforts to integrate the registries  
                 were put on hold.  Support to users and system  
                 enhancements were diminished.

          5.Lessons Learned.  Pathways to POLST Registry Development:   
            Lessons Learned by Zive and Schmidt, October 2012, examined  
            POLST Paradigm registry systems in seven different states  
            (California, which has no current registry, Idaho, New York,  
            Oregon, Utah, Washington State, and West Virginia).  Five of  
            the states studied had either an active registry or an  
            Electronic Form Completion System.  Several key findings  
            emerged from the study:  1) Defining the registry's purpose is  
            essential.  2) A mature, widespread POLST program supports  
            more rapid population of the registry.  3) Strong leadership  
            is essential.  4) Integrating into existing health care  
            systems and Electronic Medical Records increases use and  
            economizes resources.  5) Volume of submissions is impacted by  
            the process for submission and who can submit.  6) Launching a  
            registry prematurely can divert resources from other aspects  
            of establishing a successful POLST program.  7) Sustaining  
            funding for registry operations is vital to long-term success.  
             According to the 2012 study, California's POLST is relatively  
            new.  Since California is such a large and diverse state,  
            statewide coordination including interaction and communication  
            with local health care leaders has been extremely important.   
            Much of the focus is on quality implementation.  Because  








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            emergency responders are overseen by 32 local emergency  
            medical authorities rather than a single statewide entity  
            there is no logical centralized home for a registry.   
            Additionally, the desire to share information electronically  
            expands to health care information beyond POLST, and the state  
            of health information technology is in flux.  The registry  
            needs to interface with future health information technology.

          6.West Virginia.  West Virginia has established the West  
            Virginia e-Directive Registry. With the permission of patients  
            or their legal agents, the electronic registry houses and  
            makes available to treating health care providers advance  
            directive forms, do not resuscitate (DNR) cards, and Physician  
            Orders for Scope of Treatment (POST) forms. The registry is  
            password-protected and HIPAA compliant. As of January 31,  
            2015, the registry had received 36,526 total forms, which  
            includes POST forms, medical power of attorney and living  
            wills as individual documents and many combined DNR cards and  
            other documents which are helpful in a time of medical crisis.

          7.Oregon.  Oregon's POLST registry is housed in the Oregon  
            Health Authority and operated on contract with the Oregon  
            Health and Science University Department of Emergency  
            Medicine, which already had a 24-hour Emergency Communication  
            Center.  Legislation adopted in Oregon mandated that all  
            completed POLST forms be submitted to the registry by the  
            signer unless the patient opts out.  At a December 3, 2014  
            briefing in Sacramento, Dr. Susan Tolle, an official with the  
            Oregon POLST Registry, indicated that by September 2014,  
            Oregon had received over 225,000 POLST forms.  Based on a  
            study using 2010-2011 death records matched with POLST orders  
            of 58,000 decedents, Dr. Tolle indicates that 6.4 percent of  
            patients who specified comfort measures only on their POLST  
            forms died in a hospital and 34.2 percent of people with no  
            POLST form died in a hospital.  The study concludes that  
            end-of-life preferences of people who wish to avoid  
            hospitalization as documented in POLST orders are honored.   
            Dr. Tolle identifies as key elements of Oregon's success that  
            the POLST registry contains POLST forms only; that completion  
            of POLST by a patient or caregiver is voluntary; providers  
            must submit POLST forms to the registry but patients can opt  
            out; the registry operates statewide and within the emergency  
            medical response/health system.
          
          8.California Pilot Project.  In October of 2014, the California  








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            HealthCare Foundation (CHCF) issued a request for information  
            to learn about the technical, infrastructure, and cost  
            requirements for developing a POLST Registry in a single  
                                                  California community.  CHCF was looking for information from  
            vendors around the technology, operational, and support  
            services necessary to establish a POLST registry and estimates  
            of corresponding costs. The ideal technical solution(s) should  
            receive the POLST information for patients from varied  
            sources, communicate POLST records to emergency responders and  
            other medical professionals, and maintain data accuracy by  
            interfacing with medical and public health information systems  
            (such as the California death registry).  CHCF also requested  
            letters of interest from California communities with the  
            ability to convene acute care hospitals, medical groups,  
            nursing homes, hospices, and emergency medical services to  
            test a registry platform that would make POLST records  
            available to authorized providers telephonically,  
            electronically, or both. The ideal provider community would be  
            able to modify clinical workflows to use the pilot POLST  
            registry, integrate the POLST form into electronic health  
            record systems, and explore a sustainable financing model.  A  
            decision by CHCF to move forward with a pilot is not expected  
            until September.

          9.Double referral. This bill is double referred. Should it pass  
            out of this committee it will be referred to the Senate  
            Judiciary Committee.
          
          10.Related legislation.

               a.     SB 128 (Wolk and Monning), would permit a competent,  
                 qualified individual who is a terminally ill adult to  
                 receive a prescription for aid in dying medication if  
                 certain conditions are met, such as two oral requests, a  
                 minimum of 15 days apart, and a written request signed by  
                 two witnesses, is provided to his or her attending  
                 physician, the attending physician refers the patient to  
                 a consulting physician to confirm diagnosis and  
                 competency of the patient, and the attending physician  
                 refers the patient for counseling, if appropriate.  This  
                 bill is scheduled for hearing in the Senate Judiciary  
                 Committee on April 7, 2015.

               b.     AB 972 (Jones), requires DPH to inform a patient  
                 diagnosed with cancer by, or receiving cancer therapy  








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                 treatment from, a specified health care practitioner, or  
                 a hospital or other facility within an area designated as  
                 a cancer reporting area of the reporting requirement, and  
                 requires DPH to also notify a patient of specified  
                 information, including, among other things, that DPH is  
                 authorized to release confidential patient information to  
                 health researchers. This bill is pending in the Assembly  
                 Health Committee.

               c.     AB 637 (Campos) allows nurse practitioners and  
                 physician assistants acting under the supervision of the  
                 physician and within the scope of practice authorized by  
                 law to sign a POLST form.  AB 637 is scheduled for a  
                 hearing in the Assembly Judiciary Committee on April 7,  
                 2015.
          
               d.     AB 791 (Cooley) requires the State Medicaid Health  
                 Information Technology Plan to specify the process by  
                 which patient advance health care directive information  
                 would be managed, including the secure preparation,  
                 storage, printing, and display of the patient's advance  
                 health direction information, as prescribed.  AB 791 is  
                 scheduled for a hearing in the Assembly Health Committee  
                 on April 21, 2015.

          11.Prior legislation. SB 1357 (Wolk), of 2014, would have  
            established a POLST registry at CHHS.  The bill was held on  
            the Senate Appropriations suspense file.  

            AB 2452 (Pan), of 2014, would have required the Secretary of  
            State to transfer the contents of its advance health care  
            directive's registry to the DPH on January 1, 2016, and would  
            have required DPH to maintain a health care decision registry,  
            to be referred to as the California Health Care Decisions  
            Online Registry.  The bill was never scheduled for a hearing  
            in the Senate Judiciary Committee.

            AB 1683 (Jones), of 2014, would have required DPH to inform  
            all patients diagnosed with, or being treated for cancer that  
            their case has been reported to the Ken Maddy CCR within six  
            months of their case being reported. This bill was held on the  
            Assembly Appropriations suspense file. 
          
            AB 3000 (Wolk), Chapter 266, Statutes of 2008, created POLST  
            in California, which is a standardized form to reflect a  








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            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.
          
            AB 1676 (Richman and Nation), Chapter 434, Statutes of 2005,  
            created the Advance Directives and Terminal Illness Decisions  
            Program, which requires the Secretary of State to work with  
            the Department of Health Services (now DHCS) and the Attorney  
            General (AG) to develop information about end-of-life care,  
            advance health care directives, and registration of the  
            advance health care directives at the advance health care  
            directive registry. This act also requires links to be  
            provided for this information on the websites of the Secretary  
            of State, DHCS, the AG, Department of Managed Health Care,  
            Department of Insurance, Board of Registered Nursing, and the  
            Medical Board of California.
          
            AB 2442 (Canciamilla), Chapter 882, Statutes of 2004, requires  
            the Secretary of State, as part of the duties associated with  
            the advance health care directive registry, to receive and  
            release a person's advance health care directive and transmit  
            the information to the registry of another jurisdiction upon  
            request. It requires the Secretary of State to respond by the  
            close of business on the next business day to a request for  
            information received from the emergency department of a  
            general acute care hospital.
          
            AB 891 (Alquist), Chapter 658, Statutes of 2000, established  
            the Health Care Decisions Law which also governs advance  
            health care directives.
            
            SB 1857 (Watson), Chapter 1280, Statutes of 1994, requires the  
            Secretary of State to establish a central registry for power  
            of attorney for health care or a Natural Death Act  
            declaration.  This legislation was repealed and replaced by  
            the Health Care Decisions Law.
          
            AB 48 (Cedillo), Chapter 368, Statutes of 2000, renamed the  
          CCR the Ken Maddy CCR.
          
            AB 136 (Connelly), Chapter 841, Statutes of 1985, established  
          CCR.
            
          12.Support.  According to the Coalition for Compassionate Care  








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            of California (CCCC), POLST has been widely adopted in  
            California, almost 95 percent of California hospitals have  
            admitted a patient with a POLST and 87 percent have blank  
            forms available; 69 percent of nursing homes had reported  
            admitting a resident with a POLST form and 81 percent report a  
            staff member had completed a POLST with a resident; and after  
            hearing a description of POLST almost two thirds of  
            Californians say they would definitely or probably want to  
            complete a POLST form if they were seriously ill.  CCCC states  
            that gaining access to a patient's POLST during a medical  
            crisis is a critical factor in honoring patients' wishes and a  
            statewide registry will eliminate delays in care and  
            confusion.  Hospitals have written that POLST is an important  
            care planning tool, but it does little good if the information  
            is not easily available in a time of crisis.  POLST forms  
            sometimes get lost when patients transition from care settings  
            and a statewide registry would eliminate this problem.  Others  
            write that POLST facilitates free and informed consent  
            required for medical treatments and procedures for persons who  
            are frail and elderly or who have a compromised medical  
            condition.  There are common roadblocks to effective use of  
            POLST but the registry can be a solution.  The Long Term Care  
            Ombusdsman Services of San Luis Obispo indicates many people  
            who have a POLST do not have the document available when they  
            are in an emergency room or receiving assistance from  
            paramedics/EMTs.  The creation of a registry will greatly  
            improve access to these forms when they are needed most.  The  
            California Assisted Living Association writes that this bill's  
            effort to make POLST forms available online in a secure format  
            reinforces the important issue of honoring end of life wishes.
          
          13.Support in Concept.  The Medical Board of California supports  
            the concept of making the POLST form available electronically  
            and establishing a statewide POLST Registry.  The Board can  
            only support the concept at this point, as many of the details  
            of the implementation of the Registry are not included in this  
            bill.  Currently, this bill does not address funding, who will  
            have access to the POLST forms as authorized users, or how the  
            electronic registry will operate.
          
          14.Opposition.  The California Right to Life Committee, Inc.,  
            opposes this bill because the organization believes the goals  
            of this bill are directly tied to SB 128.  The California  
            Right to Life Committee, Inc., believes this bill is another  
            interjection of the state into the medical field and will  








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            result in an authorization of the death industry to heavily  
            pressure ill, elderly or disabled, especially low-income  
            citizens to succumb to their sales pitch and seek to end their  
            own lives.   
          
          15.Oppose unless amended.  The California Advocates for Nursing  
            Home Reform (CANHR) believes using state resources to create a  
            POLST registry without including advance health care  
            directives represents a significant missed opportunity and  
            threatens to further relegate advance health care directives  
            to second class status compared to POLST.   CANHR believes the  
            POLST promotion has exacerbated some of the form's problems,  
            namely the form does not need to be signed by patients and can  
            sometimes be used to override their actual wishes.  CANHR  
            writes that the advance health care directives are generally  
            superior to POLSTs for advance care planning, but under this  
            bill, advance health care directives will continue to languish  
            in a registry system that is ancient, unused, and virtually  
            useless.
          
          16.Is California ready for a statewide registry?  There are many  
            issues with regard to the registry yet to be worked out.  Is  
            CHHS the appropriate entity to house the registry?  Would CHHS  
            delegate to one of the departments under its jurisdiction?   
            Should the POLST registry be housed together with the advance  
            health care directive registry?  The low uptake of the advance  
            health care directive registry suggests that the Secretary of  
            State may not be the appropriate place to house a POLST  
            registry.  Will a POLST registry have better uptake?  DPH has  
            some experience with other registries.  Since advance  
            directives and POLST forms complement one another perhaps the  
            registries should be housed together.  According to the  
            October 2012 lessons learned report there were a number of  
            issues raised that suggested California wasn't quite ready for  
            a POLST registry.  What has changed since that report was  
            published?  Has California's POLST program matured enough?  Is  
            there leadership at the state level?  Does California have the  
            resources now to support this activity?  Should the state  
            support development of a registry through a pilot project  
            prior to the creation of a statewide registry?

          17.Technical amendments.  
               a.     On page 3 (b)(1) and (b)(7) appear to be duplicative  
                 and should be revised.
               b.     On page 2, line 31 a technical amendment is  








          SB 19 (Wolk)                                        Page 15 of ?
          
          
                 suggested in (b)(6) ?.. prior to the information being  
                 available to  an   other  authorized user  s.  

           SUPPORT AND OPPOSITION  :
          
          Support:  
          The Coalition for Compassionate Care of California (sponsor)
          AARP
          Alliance of Catholic Health Care
          Blue Shield of California
          California Assisted Living Association 
          California Association of Physician Groups
          California Chapter American College of Emergency Physicians 
          California Commission on Aging
          California Hospital Association
          California Long Term-Care Ombudsman Association
          Long Term Ombudsman Services of San Luis Obispo County
          Petaluma Valley Hospital
          Providence Health and Services Southern California
          Queen of the Valley Medical Center
          Riverside Family Physicians
          Santa Rosa Memorial Hospital
          St. Joseph Hospital, Orange
          St. Jude Medical Center, Fullerton
          Numerous individuals
          
          Oppose:   
          California Advocates for Nursing Home Reform (unless amended)
          California Right to Life Committee
          Numerous individuals
                                      -- END --