BILL ANALYSIS �
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THIRD READING
Bill No: AB 2139
Author: Eggman (D)
Amended: 5/13/14 in Assembly
Vote: 21
SENATE HEALTH COMMITTEE : 6-2, 6/18/14
AYES: Hernandez, Beall, DeSaulnier, Evans, Monning, Wolk
NOES: Morrell, Nielsen
NO VOTE RECORDED: De Le�n
SENATE JUDICIARY COMMITTEE : 5-2, 6/24/14
AYES: Jackson, Corbett, Lara, Leno, Monning
NOES: Anderson, Vidak
ASSEMBLY FLOOR : 46-28, 5/29/14 - See last page for vote
SUBJECT : End-of-life care: patient notification
SOURCE : Author
DIGEST : This bill requires a health care provider to notify a
patient diagnosed with a terminal illness, or when applicable,
the other person authorized to make health care decisions for
the patient, of his/her right to comprehensive information and
counseling regarding legal end-of-life options.
ANALYSIS :
Existing law:
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1. Establishes the Right to Know End of Life Act of 2008, which
requires, when a health care provider makes a diagnosis that
a patient has a terminal illness, the health care provider
to, upon the patient's request, provide the patient with
comprehensive information and counseling regarding legal
end-of-life care options.
2. Authorizes, when a terminally ill patient is in a health
facility, the health care provider, or medical director of
the health facility if the patient's health care provider is
not available, to refer the patient to a hospice provider or
private or public agencies and community-based organizations
that specialize in end-of-life care case management and
consultation to receive comprehensive information and
counseling regarding legal end-of-life care options.
3. Requires, if the patient indicates a desire to receive
end-of-life care information and counseling, to include
specified comprehensive information.
4. Authorizes the information described in #3 above to be in
writing and health care providers to utilize information from
organizations specializing in end-of-life care that provide
information on factsheets and Internet Web sites to convey
the information.
5. Authorizes counseling to include, but not be limited to,
discussions about the outcomes for the patient and his/her
family, based on the interest of the patient, and to occur
over a series of meetings with the health care provider or
others who may be providing the information and counseling
based on the patient's needs.
6. Authorizes the information and counseling sessions to
include a discussion of treatment options in a manner that
the patient and his/her family can easily understand.
Requires, if the patient requests information on the costs of
treatment options, including the availability of insurance
and eligibility of the patient for coverage, the patient to
be referred to the appropriate entity for that information.
7. Requires, if a health care provider does not wish to comply
with his/her patient's request for information on end-of-life
options, the health care provider to refer or transfer a
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patient to another health care provider that shall provide
the requested information, and provide the patient with
information on procedures to transfer to another health care
provider that shall provide the requested information.
8. Authorizes an adult having capacity to give an individual
oral or written health care instruction, which may be limited
to take effect only if a specified condition arises.
9. Defines advanced health care directive or advance directive
to mean either an individual health care instruction or a
power of attorney for health care. Establishes a process and
form for an individual to give instructions about health care
decision making and designating an agent to make decisions on
his/her behalf.
10.Defines health care decisions as a decision made by a
patient or patient's agent, conservator, or surrogate,
regarding a patient's health care, including the selection
and discharge of health care providers and institutions,
approval or disapproval of diagnostic tests, surgical
procedures, programs of medication, and directions to
provide, withhold, or withdraw artificial nutrition and
hydration and all other forms of health care, including
cardiopulmonary resuscitation.
This bill:
1. Requires a health care provider to notify a patient
diagnosed with a terminal illness of his/her right to, or
when applicable, the right of another person authorized to
make health care decisions for the patient, to comprehensive
information and counseling regarding legal end-of-life
options. Authorizes this notification to be provided at the
time of diagnosis or at a subsequent visit.
2. Authorizes the information and counseling sessions to
include a discussion of treatment options in a culturally
sensitive manner that the patient and his/her family, or
another person authorized to make health care decisions for
the patient, can easily understand.
3. Clarifies that the notification in #1 above is not required
if the patient or other person authorized to make health care
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decisions for the patient has already received the
notification.
4. Updates existing law to include another person authorized to
make health care decisions for the patient, as specified, as
a proxy for the patient with regard to end-of-life care
information and counseling.
Comments
According to the author's office, this bill simply seeks to
ensure that patients who have been diagnosed with a terminal
illness are notified of their right under existing law to
request comprehensive information and counseling about
end-of-life treatment options. Increasing the awareness of this
right will help terminally ill patients, their families, and
their physicians make informed treatment decisions and better
ensure the wishes of the patients are fulfilled. Research -
including surveys conducted by the California HealthCare
Foundation (CHCF), indicate that a wide discrepancy exists
between the end-of-life care that individuals say they want and
what - in practice - the terminally ill actually receive. While
an overwhelming number of Californian's (70 % in one CHCF
survey) indicate a desire to die at home and only 7% say they
would like all possible care to prolong life, the reality is
quite different. Individuals frequently receive aggressive
treatment or life-sustaining care in the last few weeks of life
and are nearly as likely to spend their last month in a hospital
as they are at home. This discrepancy is attributable to a
variety of factors, including individuals not making their
wishes clear in advance and a lack of familiarity with what
options exist outside of aggressive treatment. Existing law
requires a health care provider, when he/she makes a diagnosis
that a patient has a terminal illness, to provide the patient
comprehensive information and counseling about legal end-of-life
options, upon the request of the patient. This bill represents
a modest - but essential - step to ensure patients are notified
of this right.
End-of-life cancer care in California . According to an August
2013 report by the CHCF, compared to the country as a whole, in
2010 California's patients with advanced cancer were more likely
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to die in the hospital, spend time in an intensive care unit
(ICU), receive life-support procedures in the last month of
life, and receive chemotherapy in the last two weeks of life.
Some regions saw a steep increase in the percentage of patients
receiving life-sustaining procedures in the last month of life,
while others saw no change or a decrease. In 2010, nearly
one-third of Californians with poor-prognosis cancer spent their
last days in hospitals and ICUs, a decline of 7% compared with
2003-07 but still 20% higher than the national average. More
than 10% of Californians with poor-prognosis cancer who were in
the last month of life received advanced life-support procedures
in 2010. About 6% of cancer patients were given chemotherapy in
the last two weeks of life in 2010; in some regions of the state
and in some hospitals, the rate exceeded 10%. The percentage of
dying cancer patients in California who received hospice care
increased slightly between 2003-07 and 2010, but remained below
the national average. In some California hospitals, referral to
hospice care occurred so close to the day of death that it was
unlikely to have provided much assistance or comfort to
patients.
Prior Legislation
AB 2747 (Berg, Chapter 683, Statutes of 2008) seeks to
facilitate meaningful end-of-life care communication between
doctors and their patients by enacting the California Right to
Know End-of-Life Act of 2008 to ensure that health care
providers provide critically-needed information in
carefully-circumscribed instances.
AB 891 (Alquist, Chapter 658, Statutes of 1999) streamlined and
updated the provisions governing health care decisions for
adults without decisionmaking capacity. Specifically, the bill
repealed the provisions governing durable powers of attorney for
health care and the Natural Death Act, and revised and recast
these provisions as part of a new Health Care Decisions Law.
FISCAL EFFECT : Appropriation: No Fiscal Com.: No Local:
No
SUPPORT : (per Senate Health Committee analysis of 6/18/14 -
unable to reverify at time of writing)
American Cancer Society Cancer Action Network
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California Commission on Aging
Compassion & Choices
National Association of Social Workers, California Chapter
OPPOSITION : (per Senate Health Committee analysis of 6/18/14
- unable to reverify at time of writing)
Association of Northern California Oncologists
California Medical Association
Medical Oncology Association of Southern California
ARGUMENTS IN SUPPORT : Compassion & Choices believes this bill
improves the existing California Right to Know End of Life
Options Act in a few reasonable, simple ways. Having the
physician notify a patient improves the law because a provider
might otherwise be reluctant to provide such notice. According
to the American Cancer Society Cancer Action Network, learning
that a cancer is advanced and that treatment is not helping is
more than any person should be forced to endure but it is at
this time that information about end of life options becomes
most important. This bill ensures that all California patients
with a terminal diagnosis or their caretakers are aware of their
right to comprehensive information or counseling about their
end-of-life options as the standard of care. The California
Commission on Aging writes that by offering to provide the
information, the physician opens the door for an important
conversation that can strengthen the patient's ability to make
wise decisions at such a crucial time.
ARGUMENTS IN OPPOSITION : The Association of Northern
California Oncologists and the Medical Oncology Association of
Southern California oppose mandates and similar efforts to
legislate the specifics of the physician-patient relationship
because state law cannot address the complexity and nuance of
that relationship, especially during the end-of-life period.
This bill undoes a carefully negotiated agreement codified in AB
2747 (Berg, 2008). There is no evidence that this current
system is not working, or would need to be changed.
The California Medical Association (CMA) writes that physicians
support informing and educating patients regarding end-of-life
issues, but generally are opposed to legislation mandating the
specifics of how this occurs within the physician-patient
relationship given the varying complexities particular to each
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individual patient and each individual diagnosis. CMA requests
that this bill be amended to clarify that the notification would
not be required at these times if deemed inappropriate by a
physician. This amendment would ensure there is flexibility
within the statute to allow a physician to use their
professional assessment of that patient's physical, emotional,
and psychosocial needs to make sure these conversations occur
without causing undue emotional distress to the patient.
ASSEMBLY FLOOR : 46-28, 5/29/14
AYES: Achadjian, Alejo, Ammiano, Bloom, Bocanegra, Bonilla,
Bonta, Bradford, Brown, Ian Calderon, Campos, Chau, Chesbro,
Cooley, Dahle, Daly, Dickinson, Eggman, Fong, Fox, Frazier,
Garcia, Gomez, Gordon, Hall, Roger Hern�ndez, Jones-Sawyer,
Levine, Lowenthal, Mullin, Muratsuchi, Nazarian, Olsen, Pan,
Perea, John A. P�rez, Quirk, Quirk-Silva, Rendon,
Ridley-Thomas, Salas, Skinner, Stone, Wieckowski, Yamada,
Atkins
NOES: Allen, Bigelow, Ch�vez, Conway, Dababneh, Donnelly, Beth
Gaines, Gatto, Gorell, Gray, Grove, Hagman, Harkey, Holden,
Jones, Linder, Logue, Maienschein, Mansoor, Medina, Melendez,
Nestande, Patterson, V. Manuel
P�rez, Ting, Wagner, Waldron, Wilk
NO VOTE RECORDED: Buchanan, Gonzalez, Rodriguez, Weber,
Williams, Vacancy
JL:k 6/27/14 Senate Floor Analyses
SUPPORT/OPPOSITION: SEE ABOVE
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