BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 19
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|AUTHOR: |Wolk |
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|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
SB 19 (Wolk) Page 14 of ?
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
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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
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