BILL ANALYSIS Ó
SB 19
Page 1
Date of Hearing: July 7, 2015
ASSEMBLY COMMITTEE ON HEALTH
Rob Bonta, Chair
SB
19 (Wolk) - As Amended June 2, 2015
SENATE VOTE: 40-0
SUBJECT: Physician Orders for Life Sustaining Treatment form:
statewide registry.
SUMMARY: Requires the California Health and Human Services
Agency (CHHSA) to establish and operate a statewide registry
system to collect Physician Orders for Life Sustaining Treatment
(POLST) forms, and disseminate the information in the form to
authorized users, including health care providers. Specifically,
this bill:
1)Requires CHHSA to establish and operate the California POLST
Registry once sufficient non-state funds have been received to
allow for the development of the registry and any related
startup costs.
2)Allows CHHSA to contract for the operation and maintenance of
the registry, and requires CHHSA to adopt rules necessary for
the operation of the registry, including, but not limited to
the following:
SB 19
Page 2
a) The means by which a POLST form may be submitted or
withdrawn from the registry, including a method for
electronic delivery of the information and the use of
electronic signatures;
b) Appropriate and timely methods for the information to be
disseminated to an authorized user;
c) Procedures for verifying the identity of an authorized
user;
d) Procedures to ensure the accuracy of, and appropriately
protect the confidentiality of, POLST forms submitted to
the registry;
e) The requirement that a patient, or his or her legally
recognized health care decision maker, receive a
confirmation or receipt that the patient's POLST form has
been received by the registry;
f) The ability of the physician who signed the POLST form,
or his/her designee, and of a patient, or his/her legally
recognized health care decision maker, to review the
information in the POLST form after it has been entered
into the registry, and to confirm that it is accurate,
prior to the information being available to an authorized
user; and,
g) The ability of a patient, or his/her legally recognized
health care decision maker to withdraw a POLST form from
the registry.
SB 19
Page 3
3)Requires the operation of the registry to comply with state
and federal privacy and security laws and regulations,
including but not limited to the federal Health Insurance
Portability and Accountability Act.
4)Requires a physician or his/her designee who completes a POLST
with a patient or his/her legally recognized health care
decision maker to include the POLST form in the patient's
official medical record, and to submit a copy of the POLST to
the registry unless the patient or the legally recognized
health care decision maker chooses not to participate in the
registry.
5)Provides that a health care provider who honors a patient's
request regarding resuscitative measures obtained from the
registry is not subject to criminal prosecution, civil
liability, discipline for unprofessional conduct, or
administrative sanction.
EXISTING LAW:
1)Defines a request regarding resuscitative measures as a
written document signed by an individual with capacity, or a
legally recognized health care decision maker, and the
individual's physician that directs a health provider
regarding resuscitative measures. Specifies that a request
regarding resuscitative measures is not an advance health care
directive.
2)Specifies that a request regarding resuscitative measures
includes one, or both of the following:
a) A do not resuscitate form developed by the Emergency
SB 19
Page 4
Medical Services Authority (EMSA), or one substantially
similar; and,
b) A POLST form approved by EMSA.
3)Defines a POLST form as a request regarding resuscitative and
life-sustaining measures that directs a health care provider
regarding resuscitative and life-sustaining measures.
4)Allows a legally recognized health care decision maker to
execute a POLST form only if the individual lacks capacity, or
the individual has designated that the decision maker's
authority is in effect.
5)Requires the POLST form and medical intervention procedures
offered by the form to be explained by a health care provider;
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/her legally recognized health
care decision maker. Encourages health care providers to
inform patients about the difference between an advance health
care directive and a POLST.
6)Allows an individual with the capacity to revoke a POLST form
at any time.
7)Requires a health care provider to treat an individual in
accordance with a POLST, unless the POLST requires medically
ineffective care or care contrary to generally accepted
standards. Allows a physician to conduct an evaluation of the
individual and, if possible, in consultation with the
individual or his/her legally recognized health care decision
maker, issue a new POLST consistent with the most current
SB 19
Page 5
information available about the individual's health status and
goals of care.
8)Specifies that a health care provider who honors a request
regarding resuscitative measures is not subject to criminal
prosecution, civil liability, discipline for unprofessional
conduct, or administrative sanction, if the health care
provider believes in good faith that the action or decision is
consistent with these provisions and has no knowledge that the
action or decision would be inconsistent with a health care
decision the individual signing the request would have made on
his/her own behalf under like circumstances.
9)Requires the Secretary of State (SoS) to establish a registry
system for advance health care directives (AHCD) and make the
information in an AHCD available upon request to health care
providers, the public guardian, or the legal representative of
the registrant.
10)Provides the format for an AHCD form, which outlines the
options for a person to designate medical decision making
responsibility to another, specify his or her wishes regarding
instructions for health care in the event he or she is unable
to communicate; including whether or not to the person wants
to prolong his or her life as long as possible, or withhold,
or withdraw treatment if he or she has an incurable or
irreversible condition. Does not require that the exact form
be used when a person is creating an AHCD.
FISCAL EFFECT: According to the Senate Appropriations Committee
(as approved on May 28, 2015): Start-up costs of about $2.5
million over the first three years to develop the system
(private funds). The California HealthCare Foundation (CHCF) has
commissioned a feasibility report to examine the concept of a
POLST registry. According to a draft of the report, it will
SB 19
Page 6
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, the 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.
COMMENTS:
1)PURPOSE OF THIS BILL. According to the author, a 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. The author notes, 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 and there isn't a central database or registry that
first responders can access in an emergency situation. The
author states, a statewide electronic POLST registry in
SB 19
Page 7
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. The author
concludes, several states are developing and a few states have
already completed a statewide registry to access POLST forms
more effectively.
2)BACKGROUND.
a) National POLST Paradigm. According to the National
POLST Paradigm, the program is an approach to end-of-life
planning emphasizing: advance care planning conversations
between patients, health care professionals and loved ones;
shared decision-making between a patient and his/her health
care professional about the care the patient would like to
receive at the end of his/her life; and, ensuring patient
wishes are honored. As a result of these conversations,
patient wishes may be documented in a POLST form, which
translates the shared decisions into actionable medical
orders. The POLST form assures patients that health care
professionals will provide only the treatments that
patients themselves wish to receive, and decreases the
frequency of medical errors.
b) POLST vs. AHCD. The National Paradigm does not
recommend a POLST for everyone. Only patients with serious
illness or frailty, for whom a health care professional
would not be surprised if they died within one year, should
have a POLST form. For these patients, their current
health status indicates the need for standing medical
orders. For healthy patients, an AHCD is deemed an
appropriate tool for making future end of life care wishes
SB 19
Page 8
known.
------------------------------------------------------
| POLST | AHCD |
|-------------------------+----------------------------|
|For seriously ill/frail, | For anyone 18 and older |
| at any age | |
|-------------------------+----------------------------|
| Specific orders for | General instructions for |
| current treatment | future treatment |
|-------------------------+----------------------------|
| Can be signed by | Appoints decision maker |
| decision maker | |
------------------------------------------------------
Both documents are helpful for communicating patient
wishes. An AHCD is a form in which an individual appoints
a person to make healthcare decisions for the individual if
and when the individual loses that capacity. An AHCD is
from the patient, not a medical order. POLST is a set of
medical orders, signed by a health care provider that
addresses a limited number of critical medical decisions.
c) POLST use in California. POLST use in California is
fairly wide spread. According to a 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," a survey of 546 nursing homes
SB 19
Page 9
found that 82% of responding skilled nursing facilities in
California have participated in training sessions about
POLST and 59% reported having a formal policy on POLST.
Few nursing homes reported difficulty following POLST
orders, but 38% 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, sixty-five% of hospitals had a policy
on POLST, 87% had available POLST forms, 84% had educated
staff, and 94% reported handling POLST properly in the
emergency department on admission.
d) AHCD use in California. The SoS maintains the AHCD
registry, which allows a person who has executed an AHCD to
register the directive with the SoS. An AHCD can be made a
part of the SoS's registry by attaching a copy of the AHCD
to the Registration of Written Advance Health Care
Directive filed with the SoS. As of April 3, 2015, there
are 4,907 AHCDs on file. In the past five fiscal years, a
total of 2,152 written AHCDs have been filed for an average
of 430 filings per year. This information is made
available upon request to the registrant's health care
provider, public guardian, or legal representative. The
annual cost to maintain the registry is approximately
$45,000, excluding overhead costs. 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 pool of money paid by businesses and
individuals that are required or permitted to file
documents with the SoS's office.
SB 19
Page 10
e) Other states. 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 on a regional basis).
f) California Pilot Project? In early 2014, CHCF
interviewed a wide range of health care stakeholders and
POLST leaders regarding the adoption of a POLST registry in
California. Those interviewed included representatives of
hospital emergency departments, acute care facilities,
hospices, skilled nursing facilities, emergency medical
services, and other care providers. Next steps identified
by interviewees included:
i) Pilot the registry in a community, with the intent
to scale rapidly;
ii) Develop a technology platform for the registry that
supports multiple forms of input and output, from paper
to fax to mobile devices;
iii) Expand existing POLST education infrastructure to
include education about the registry;
iv) Engage state administrative leadership and consider
development of an independently operated registry, based
on the approaches of other successful California health
SB 19
Page 11
registries, such as the California Cancer Registry; and,
v) Identify funding sources to build and sustain the
registry.
CHCF is currently exploring the idea of sponsoring a POLST
pilot project. They have received nine community
proposals, representing seven counties throughout
California - north and south. The next step is for CHCF to
meet with the sponsors of the proposals and assess the
level of engagement of the provider community - hospitals,
nursing homes and emergency medical services. A decision
by CHCF's Board on whether to move forward is not expected
until September or December 2015.
3)SUPPORT. The Coalition for Compassionate Care of California
(CCCC) is the sponsor of this bill and states; a POLST is a
physician's order that gives seriously-ill patients more
control over their care. Produced on a distinctive bright
pink form and signed by both the doctor and patient, POLST
specifies the types of medical care that a patient wishes to
receive at the end of their life. CCCC notes, in so doing,
POLST helps ensure that patients receive the care they want,
and avoid the care they don't.
The California Assisted Living Association (CALA) supports this
bill because an online database will help make POLST forms
more accessible for health care and emergency professionals,
especially in the event that the paper POLST form is not
present. CALA concludes this accessibility will be a positive
step to ensure that individuals' wishes regarding end of life
medical treatments are honored.
AARP supports this bill because they believe an electronic
registry will successfully address the issues of portability
of the POLST document and respecting and abiding by the wishes
SB 19
Page 12
of a patient regarding life sustaining treatment.
4)OPPOSITION. California Advocates for Nursing Home Reform
(CAHNR) is opposed to this bill unless it is amended to
include AHCDs. CAHNR states they have no objection to
creating a POLST registry; however, utilizing state resources
to create this registry without including AHCDs represents a
significant missed opportunity and threatens to further
relegate AHCDs to second class status when it comes to advance
health directives. CAHNR states that currently POLST is used
for patients who do not have anything resembling a terminal
illness or a chronic condition likely to end their lives, and
they believe AHCDs are superior to POLSTs for advance care
planning.
5)RELATED LEGISLATION.
a) SB 128 (Wolk and Monning), permits a competent,
qualified individual who is a terminally ill adult to
receive a prescription for aid in dying drug in order to
end their life in a humane and dignified manner. SB 128
is scheduled for hearing in the Assembly Health Committee
on July 7, 2015.
b) 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 pending a vote on the Senate
Floor.
c) AB 791 (Cooley) requires the State Medicaid Health
SB 19
Page 13
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 was heard in
the Assembly Health Committee on April 21, 2015, but no
vote was taken.
6)PREVIOUS LEGISLATION.
a) SB 1357 (Wolk), of 2014, would have established a POLST
registry at CHHS. SB 1357 was held on the Senate
Appropriations suspense file.
b) AB 2452 (Pan), of 2014, would have required the SoS to
transfer the contents of its advance health care
directive's registry to the Department of Public Health
(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.
AB 2452 was never scheduled for a hearing in the Senate
Judiciary Committee.
c) AB 3000 (Wolk), Chapter 266, Statutes of 2008, created
POLST in California, which is a standardized form to
reflect a 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.
7)DOUBLE REFERRAL. This bill is double referred; upon passage
in this Committee, this bill will be referred to the Assembly
SB 19
Page 14
Judiciary Committee.
REGISTERED SUPPORT / OPPOSITION:
Support
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 of the American College of Emergency
Physicians
California Commission on Aging
California Hospital Association
California Long-Term Care Ombudsman Association
Dignity Health
Long Term Care Ombudsman Services of San Luis Obispo County
On Lok Senior Health Services
Partnership HealthPlan of California
Providence Health & Services, Southern California
Riverside Family Physicians
St. Joseph Health - Eureka, Redwood Memorial Hospital, Santa
Rosa Memorial, St. Jude, Petaluma Valley, Orange, and Queen of
the Valley
Opposition
SB 19
Page 15
California Advocates for Nursing Home Reform (unless amended)
Analysis Prepared by:Lara Flynn / HEALTH / (916)
319-2097