Agenda

Return

C. 30

To:	Board of Supervisors
From:	LEGISLATION COMMITTEE
Date:	May 5, 2015

Contra

Costa

County

Subject:

AB 637 - Physician Orders for Life Sustaining Treatment

APPROVE	OTHER
RECOMMENDATION OF CNTY ADMINISTRATOR	RECOMMENDATION OF BOARD COMMITTEE

Action of Board On: 05/05/2015

APPROVED AS RECOMMENDED

OTHER

Clerks Notes:

VOTE OF SUPERVISORS

AYE:

John Gioia, District I Supervisor
Candace Andersen, District II Supervisor
Mary N. Piepho, District III Supervisor
Karen Mitchoff, District IV Supervisor

ABSENT:

Federal D. Glover, District V Supervisor

Contact:

Lara DeLaney, (925) 335-1097

I hereby certify that this is a true and correct copy of an action taken and entered on the minutes of the Board of Supervisors on the date shown.
ATTESTED: May 5, 2015
David Twa,

BY:	, Deputy

RECOMMENDATION(S):

ADOPT a "Support" position on AB 637 (Campos), as introduced: Physician Orders for Life Sustaining Treatment, a bill that seeks to authorize the signature of a nurse practitioner or physician assistant acting under the supervision of the physician and within the scope of practice authorized by law to create a valid Physician Orders for Life Sustaining Treatment form (POLST form).

FISCAL IMPACT:

As currently in print, this bill is keyed non-fiscal.

BACKGROUND:

At its April 2, 2015 meeting, the Legislation Committee considered the recommendation from the Contra Costa Health Services Director to recommend a position of "Support" to the Board of Supervisors on AB 637.

BACKGROUND: (CONT'D)

CURRENT STATUS: 04/16/2015 In ASSEMBLY. Read third time. Passed ASSEMBLY. *****To SENATE.

SUMMARY: Expands the ability to sign a Physician Order for Life Sustaining Treatment Form to Nurse Practitioners and Physician Assistants. Specifically, this bill:

1) Authorizes a nurse practitioner or a physician assistant to sign a POLST form, completed by a health care provider based on patient preferences and medical indications, with either the patient, or the patient's legally recognized health care decision-maker under specified circumstances.

2) Requires that the nurse practitioner or physician assistant who signs such a form to be acting under the supervision of the physician and within the scope of practice authorized by law.

EXISTING LAW:

1) Provides that an advanced health care directive is either a document containing (1) individual health care instruction or (2) a power of attorney for health care. Existing law further 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 or her behalf. (Probate Code Sec. 4670 et seq. All references are to the Probate Code, unless otherwise indicated.)

2) Requires a request regarding resuscitative orders to be a pre-hospital "Do Not Resuscitate" form, as specified, or an Emergency Medical Services Authority (EMSA) approved POLST form. (Section 4780.)

3) Establishes the POLST form and requires 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 or her legally recognized health care decision-maker. (Section 4780.)

4) Requires the health care provider, during the process of completing the form, to inform the patient about the difference between an advance health care directive and the POLST form. (Section 4870 et seq.)

5) Protects a health care provider from liability regarding a resuscitative measures if the health care provider (1) believes in good faith that his or her action is consistent with the applicable law, and (2) has no knowledge that the action or decision would be inconsistent with a health care decision that the individual would have made on his or her own behalf under like circumstances. (Section 4782.)

COMMENTS: The POLST Paradigm is a clinical process designed to facilitate communication between health care professionals and patients (or their authorized surrogates in cases where the patients themselves do not have the capacity to make health care decisions) who are very ill or very frail. The process encourages patients and their families to participate in planned, shared, and informed medical decision-making that respects the patients' goals for care in regard to the use of cardiopulmonary resuscitation and other medical interventions. The POLST paradigm promotes the use of a highly visible, portable medical form, known as a POLST form, which transfers from one setting to another with the patient. It functions as a Do Not Resuscitate order and provides treatment direction for multiple health situations. The form itself is outcome neutral. Its options range from full treatment to comfort care only.

The POLST form is neither an advance directive, nor a replacement for advance directives. However, like an advance directive, the POLST form is helpful for communicating patient wishes to health care providers. While an advance directive is a form in which an 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), the 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. The POLST form is a complement to advance directives in that it serves as a translation tool for continuity of care.

As of January 1, 2014, 24 states offered POLST programs. In the majority of those states (14 of 24), RNs and PAs were allowed to sign a POLST form. California is one of only nine states that allow only physicians to sign POLST forms. (New Jersey allows a physician or "Advanced Practice Nurse" to sign the form. (2H-134(b)(3).)

POLST Implementation in California. As published in an August 10, 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, 82 percent of the 546 California nursing homes responding to a statewide survey of nursing homes reported that their staff received POLST education. Fifty-nine percent of responding nursing homes reported having a formal policy on POLST. Two-thirds had admitted a resident with a POLST and 15 percent of newly admitted residents over the past month had a POLST. Few nursing homes reported difficulty following POLST orders, but 38 percent 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 that 65 percent of hospitals which responded to a survey had a policy on POLST. Eighty-seven percent of the hospitals made POLST forms available, 84 percent had educated staff, and 94 percent reported handling POLST properly in the emergency department upon admission of patients. Although the POLST form is widely used in California, a significant number of hospitals remain unprepared three years after implementation.

Among consumers, a 2010 survey commissioned by the California Healthcare Foundation regarding POLST use in California nursing homes found overall satisfaction with the forms among residents. The survey also revealed that more than one third of nursing homes reported difficulty in obtaining physician participation in POLST completion and having physicians sign the POLST. (Wenger et al.: POLST Dissemination in California Nursing Homes, J Gen Intern Med 28(1): 51-7; http://www.polst.org/wp-content/uploads/2013/01/wenger_JGIM.pdf )

ARGUMENTS IN SUPPORT: In support of the bill, the California Medical Association writes that the POLST improves communication between patients and health care providers:

POLST also helps patients talk with their healthcare team and loved ones about their choices. In this way, POLST can help reduce patient and family suffering by making sure that patient wishes are known and honored. While patients discuss POLST with other members of the healthcare team, NPs and PAs, in addition to their physician, currently the POLST does not become actionable until signed by both the patient or their health care decision maker and their physician. Therefore, to help increase POLST utilization and availability, this bill allows NPs and PAs under a physician's supervision to also sign POLST forms.

In support of the bill, the author writes,

The POLST is viewed by health care professionals as useful, helpful, reliable and most importantly, very effective at ensuring preferences for end-of-life care are honored. Physicians recognize and appreciate the value of the multiple member health care team and support efforts to increase productivity while ensuring quality of care. NPs and PAs are currently having conversations with patients about their end-of-life care options and preferences, and in some instances are able to sign off on other immediately actionable documents under supervision, such as drug orders and medical certificates. By allowing NPs and PAs under physician supervision to sign POLST forms, this bill will improve end-of-life care by increasing the availability of actionable medical orders for medically indicated care consistent with patient preferences.

ARGUMENTS IN OPPOSITION: The California Right to Life Committee criticizes the bill for "not only replac[ing] the physician with a lower level of medically trained health care decision maker but even further remov[ing] the patient himself from the decision making process by assigning the title of "legally recognized health care decision maker" to nurse practitioners and nursing assistants who will determine when or if this person's life is no longer to be considered worthy of restorative health care treatment."

However, the California Association of Nurse Practitioners points out that "Nurse practitioners (NPs) are advanced practice registered nurses who are licensed by the Board of Registered Nursing and have pursued higher education, either a master's or doctoral degree, and a certification as a NP." Other supporters, such as the AARP, point out that "health team members such as NPs and PAs . . . are already discussing health care decisions with patients and/or their decision makers regarding the levels of medical intervention identified on the POLST form. The Right to Life Committee mistakenly assumes that the bill assigns the title of "legally recognized health care decision maker" to nurse practitioners and nursing assistants. In fact, the decision maker is always the patient himself or herself, except when the patient lacks capacity, in which case the "legally recognized health care decisionmaker" is empowered to make decisions on behalf of the patient. A legally recognized health care decisionmaker is only allowed to execute the Physician Orders for Life Sustaining Treatment form if and when the patient lacks capacity, or the individual has designated that the decisionmaker's authority is effective pursuant to Section 4682. (Section 4680(b).) Finally, the California Right to Life Committee is mistaken in its conclusion that it is "nurse practitioners and nursing assistants who will determine when or if this person's life is no longer to be considered worthy of restorative health care treatment" because physicians do not currently make such decisions for patients and the bill does not propose that RNs and PAs make those decisions in the future. End of life treatment decisions are only made by the patient or, if the patient lacks capacity, a "legally recognized health care decisionmaker," who is likely to be the patient's family member or loved one.

Prior Related Legislation: AB 2452 (Pan, 2014) would have required the Secretary of State (SOS) to establish an electronic process for submittal and retrieval of advance health care directives (AHCDs). Died in the Senate Judiciary Committee.

SB 1357 (Wolk, 2014) would have required the California Health and Human Services Agency, on or before January 1, 2016, to establish and operate a statewide registry system, to be known as the California POLST Registry, for the purpose of collecting POLST forms received from health care providers, who would be required to submit the forms to the registry unless a patient or his or her health care decisionmaker chooses not to participate. Died in Senate Appropriations Committee.

AB 300 (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.

AB 1676 (Richman, Chapter 434, Statutes of 2005) created the Advance Directives and Terminal Illness Decisions Program, which required the development of information about end of life care, advance health care directives, and registration of the advance health care directives at the Advance Health Care Directive Registry.

AB 2442 (Canciamilla, Chapter 882, Statutes of 2004) required the Secretary of State to receive and release a person's advance health care directive and transmit the information to the Advance Health Care Directive Registry of another jurisdiction upon request.

AB 891 (Alquist, Chapter 658, Statutes of 2000) established the Health Care Decisions Law which also governs advance health care directives.

SB 1857 (Watson, Chapter 1280, Statutes of 1994) required the Secretary of State to establish a central registry for power of attorney for health care or a Natural Death Act declaration. This legislation was repealed and replaced by the Health Care Decisions Law.

REGISTERED SUPPORT / OPPOSITION:

Support

California Medical Association (sponsor)
AARP
American College of Emergency Physicians, California Chapter
Blue Shield of California
California Assisted Living Association
California Association for Health Services at Home
California Association of Nurse Practitioners
California Long-Term Ombudsman Association
LeadingAge California
Several individuals

Opposition

California Right to Life Committee

CONSEQUENCE OF NEGATIVE ACTION:

Contra Costa County would not have a position on the bill.