BILL ANALYSIS                                                                                                                                                                                                    

          |SENATE RULES COMMITTEE            |                         SB 19|
          |Office of Senate Floor Analyses   |                              |
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          |327-4478                          |                              |

                                   THIRD READING 

          Bill No:  SB 19
          Author:   Wolk (D), et al.
          Amended:  6/2/15  
          Vote:     21  

           SENATE HEALTH COMMITTEE:  9-0, 4/8/15
           AYES:  Hernandez, Nguyen, Hall, Mitchell, Monning, Nielsen,  
            Pan, Roth, Wolk

           SENATE JUDICIARY COMMITTEE:  6-0, 4/28/15
           AYES:  Jackson, Anderson, Hertzberg, Leno, Monning, Wieckowski
           NO VOTE RECORDED:  Moorlach

           AYES:  Lara, Bates, Beall, Hill, Leyva, Mendoza, Nielsen

           SUBJECT:   Physician Orders for Life Sustaining Treatment form:  
                     statewide registry

          SOURCE:    Coalition for Compassionate Care of California
          DIGEST:   This bill 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:


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          1)Requires the Secretary of State (SOS) to establish a registry  
            system through which a person who has executed a written  
            advance health care directive may register 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.  
            Defines advance health care directive or directive to mean  
            either an individual health care instruction or a power of  
            attorney for health care.  

          2)Establishes the POLST form and medical intervention and  
            procedures, and requires that POLST is explained by a health  
            care provider, as defined. 

          3)Requires POLST 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)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, who is a person  
            authorized by CHHS.  Permits the Registry to be operated and  
            maintained by a contractor of CHHS.

          2)Requires CHHS to implement this bill only after determining  
            that sufficient non-state funds have been received to allow  
            for the development of the POLST Registry and any related  
            start-up costs.

          3)Requires CHHS to adopt all rules necessary for the operation  
            of the Registry, and establishes minimum rules that include  
            the means to submit an initial or subsequent POLST form, or  
            withdraw a form, from the Registry, including a method for  
            electronic delivery and the use of legally sufficient  


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            electronic signatures.

          4)Requires the operation of the Registry to comply with state  
            and federal privacy and security laws and regulations  
            including the federal Health Insurance Portability and  
            Accountability Act of 1996.

          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  

          6)Protects a health care provider who honors a patient's request  
            regarding resuscitative measures obtained from the Registry  
            from criminal prosecution, civil liability, discipline for  
            unprofessional conduct, administrative sanction, or any other  
            sanction, as specified.
          1)Author's statement.  According to the author, 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?  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  


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            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  

          3)POLST in California.  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)Advance health care directive registry.  The SOS maintains the  
            advance health care directive registry.  An advance health  
            care directive can be made a part of the SOS' registry by  
            attaching a copy of the advance health care directive to the  
            Registration of Written Advance Health Care Directive filed  
            with the SOS or the location of an advance health care  
            directive 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.  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 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. 

          5)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  


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            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% of patients  
            who specified comfort measures only on their POLST forms died  
            in a hospital and 34.2% 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  

          6)California pilot project.  In October of 2014, the California  
            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  


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            until September.

          FISCAL EFFECT:   Appropriation:    No          Fiscal  
          Com.:YesLocal:   No

          According to the Senate Appropriations Committee:

              Start-up costs of about $2.5 million over the first three  
              years to develop the system (private funds). CHCF has  
              commissioned a feasibility report to examine the concept of  
              a POLST registry. According to a draft of the report, it  
              will cost about $2.5 million to develop the information  
              technology system for an online-accessible registry and set  
              up the program.

              Ongoing costs of about $1.3 million per year to maintain  
              the system, assist health care providers trying to access a  
              POLST form for a patient, and market the system (General  
              Fund or other unknown fund source).

              Unknown potential cost savings due to avoided unwanted  
              medical care (various fund sources). The primary purpose of  
              a POLST and the POLST registry proposed in this bill is to  
              ensure that individuals do not receive medical care they do  
              not wish to receive. By creating a registry of POLST forms,  
              this bill will improve access to POLST forms by emergency  
              medical services and hospitals. In turn, this will lead to  
              fewer emergency health care services for individuals who do  
              not want those services. The size of this impact is unknown.
          SUPPORT:   (Verified5/28/15)

          Coalition for Compassionate Care of California (source)
          Alliance of Catholic Health Care
          Arc and United Cerebral Palsy California Collaboration
          Blue Shield of California
          California Accountable Physician Groups
          California American College of Emergency Physicians
          California Assisted Living Association
          California Association of Physician Groups
          California Chapter American College of Emergency Physicians
          California Commission on Aging
          California Hospital Association


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          Care Like A Daughter, LLC
          Long Term Care Ombudsman Services of San Luis Obispo County
          Mission Hospital, Laguna Beach
          Mission Hospital, Mission Viejo
          Petaluma Valley Hospital
          Providence Health & Services Southern California
          Queen of the Valley Medical Center, Napa
          Redwood Memorial Hospital, Fortuna
          Riverside Family Physicians
          Santa Rosa Memorial Hospital 
          St. Mary Medical Center, Apple Valley
          St. Joseph Hospital, Orange
          St. Jude Medical Center, Fullerton

          OPPOSITION:   (Verified5/28/15)

          California Advocates for Nursing Home Reform 
          California Right to Life Committee

          ARGUMENTS IN SUPPORT:      According to this bill's sponsor,  
          Coalition for Compassionate Care of California (CCCC), POLST has  
          been widely adopted in California, almost 95% of California  
          hospitals have admitted a patient with a POLST and 87% have  
          blank forms available; 69% of nursing homes had reported  
          admitting a resident with a POLST form and 81% 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  


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          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.

          ARGUMENTS IN 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 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.   

          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.
          Prepared by:Teri Boughton / HEALTH / 
          6/2/15 10:38:34

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