BILL ANALYSIS Ó
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|SENATE RULES COMMITTEE | SB 19|
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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
SENATE APPROPRIATIONS COMMITTEE: 7-0, 5/28/15
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.
ANALYSIS:
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
Registry.
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.
Comments
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
assurance.
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
system.
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)
AARP
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
Vynca
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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