BILL ANALYSIS Ó ----------------------------------------------------------------- |SENATE RULES COMMITTEE | SB 19| |Office of Senate Floor Analyses | | |(916) 651-1520 Fax: (916) | | |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 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: SB 19 Page 2 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 SB 19 Page 3 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 SB 19 Page 4 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 SB 19 Page 5 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 SB 19 Page 6 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 SB 19 Page 7 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 SB 19 Page 8 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 **** END **** SB 19 Page 9