Legislature(2003 - 2004)
04/19/2004 01:34 PM Senate HES
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* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
HB 25-HEALTH CARE SERVICES DIRECTIVES
The committee took up CSHB 25(JUD).
CHAIR DYSON said his intention was to hear amendments on CSHB
25(JUD) and also to hear from anybody wishing to testify. He
acknowledged there was widespread support for the bill and he
had been told this product may be the best in the nation, and if
that was true it was to the credit of Representative Weyhrauch
and his staff and a lot of people working long and hard on this
bill; he said he was pleased and proud of these efforts.
KELLY CONRIGHT, M.D., medical director of two nursing homes -
Providence Extended Care and Mary Conrad Center - testified via
teleconference and said she was one of several physicians in the
state who cares for the greatest number of people in treatment
at the end of life.
CHAIR DYSON stated that neither he nor the sponsor would be
offering the draft language that Dr. Conright may have seen that
takes nutrition and artificial hydration out of the life-
sustaining sections of the bill.
DR. CONRIGHT said that Dr. Wallington had informed her of
concerns regarding changes in the language specifically related
to withholding and withdrawing nutrition/hydration. She asked
if this amendment was on the table for discussion.
CHAIR DYSON said he didn't believe it would be, but if it comes
up he would give Dr. Conright a chance to testify.
DR. CONRIGHT asked if at this point the intention was to not add
[the amended language] in.
CHAIR DYSON said that was correct.
DR. CONRIGHT responded that being the case, she didn't need to
testify, and said, "It's a fantastic bill."
MS. SUSAN MILLER, testifying via teleconference from Anchorage,
said she was the chairperson from the family council of the
Anchorage Pioneers' Home, but she was not representing the
group. She testified in support of CSHB 25(JUD) and said she
was similarly concerned about the proposed amendment, but
apparently it was not going to be brought up. She said she
would not take up time testifying unless that amendment was
going to be proposed.
CHAIR DYSON asked her to stand by; if the amendment comes up,
she would have a chance to testify.
CHAIR DYSON said there were a few people available to answer
questions, including Dr. Wallington who helped greatly on this
bill, Carole Edwards, Marie Darlin, and Sam Trivette. Emily
Nenon from ACS was also standing by in case something new was
brought up.
CHAIR DYSON asked if there were any amendments.
SENATOR GRETCHEN GUESS spoke to Amendment 1. [The amendment was
before the committee.] She referred to the pregnancy section
and an attorney general's opinion as to whether it was
unconstitutional; she told members that in order to protect this
bill, even though severability is in state law, this language
says that if any of the provisions of this chapter are
unconstitutional, the rest of the bill goes forward and won't be
held up because of a ruling or any court cases. [Amendment 1
reads:]
A M E N D M E N T 1
OFFERED IN THE SENATE BY SENATOR GUESS
TO: SCS CSHB 25(HES), Draft Version "C"
Page 23, following line 16:
Insert new material to read:
"Sec. 13.52.290. Severability. If a provision of
this chapter, or the application of this chapter to a
person or circumstance is held invalid, including being
held unconstitutional, the invalidity does not affect the
other provisions or applications of this chapter that can
be given effect without the invalid provision or
application."
CHAIR DYSON objected for purposes of discussion. He said he
understood that the sponsor was fine with this amendment. He
asked if there was further objection. There being none [his
objection was treated as withdrawn], he announced that Amendment
1 was adopted.
CHAIR DYSON said he had [conceptual Amendment 2]. He referenced
page 15, line 29, and moved to amend, by adding the following
sentence to that line: "Permanent unconsciousness must be
certified by a neurologist." He asked if there was any
objection.
SENATOR GUESS said she would object until she understood
further.
CHAIR DYSON noted that Senator Green had joined the meeting.
SENATOR GARY WILKEN said he'd like to hear Representative
Weyhrauch's opinion of Amendment 2.
REPRESENTATIVE BRUCE WEYHRAUCH, sponsor of HB 25, testified that
he and Chair Dyson had talked about this, and his concern was
that, although accessing a neurologist is not a problem in a
metropolitan area with a hospital, access is not available in
smaller villages and, to comply with this provision, access
would need to be through a phone or fax and it might be
difficult. He referred to the need for involving technology to
keep someone alive until the next day when a telephone call
could be made to a neurologist.
CHAIR DYSON said what's being talked about is a qualifying
condition for the withdrawal of life support and his
understanding is this is not a situation with a lot of time
pressure. Every rural medical facility has, not only a phone
connection, but also Internet connection, and with today's
telemedicine, x-rays and electrocardiograms can also be
exchanged. He said he had a copy of a document, "Model Standing
Orders for Treatment Protocols," which lists protocols necessary
when making medical decisions in emergency and very difficult
situations, and it appears to be very carefully thought out. He
quoted from page 5: "These protocols are fairly liberal. They
do not require contact and medical control for many orders.
This is in recognition of the communication difficulties in the
state." He said the treatment procedures listed follow Alaska's
curriculum with few exceptions.
REPRESENTATIVE WEYHRAUCH said that it needs to be clear this is
about a qualifying condition regarding a person whose death is
imminent; the consultation could be via phone, Internet, or
mail, and the person wouldn't necessarily need to observe the
patient. Representative Weyhrauch expressed concern that the
environment of dying be both legally and personally satisfying
to the person's involved family, suggesting something such as
short consultation with a neurologist, confirming that the
neurologist concurs that the person will die.
CHAIR DYSON said, "All of us are driven by anecdotal but true
stories of people who have apparently been in a coma, in a
vegetative state, for days, weeks, months or longer. Something
happens and they're there, and we're wanting to err on the side
of being respectful of life and make sure that we get somebody
who is qualified in the area, i.e. a neurologist, to make the
determination that to the best of our understanding now, this
person is in a permanent, irreversible condition of being
unconscious."
SENATOR WILKEN removed his objection.
SENATOR DAVIS asked why it would have to be a neurologist and
not some other type of doctor.
CHAIR DYSON responded because determination of permanent
unconsciousness is a difficult diagnosis to make and "when
you're talking about letting someone die, an irreversible
decision, it's important to get the best information and
expertise available."
REPRESENTATIVE WEYHRAUCH asked Chair Dyson about the use of the
word "certified." "Certified doesn't mean notarized with a gold
stamp on it. Does it mean, 'I discussed it, put it in the
patient's chart or records, or the neurologist stated to me?'"
He asked how this was envisioned.
CHAIR DYSON said perhaps "licensed" would be a better word.
SENATOR LYDA GREEN suggested using "determined, validated, or
confirmed."
REPRESENTATIVE WEYHRAUCH said Providence Alaska Medical Center
in Anchorage might have a suggestion, according to protocol.
CHAIR DYSON asked Dr. Wallington for input.
MARIA WALLINGTON, M.D., medical ethicist at Providence Alaska
Medical Center, responded that since this is about permanent
unconsciousness, "we're not talking about an emergency position
as much as somebody in a long term situation, so the urgency is
not there." She said it was a good idea to provide for the
input of a neurologist, but "I wouldn't use certified because it
sounds like there is some kind of legal thing involved." She
suggested using "consultation ... verified, or determined."
CHAIR DYSON asked Representative Weyhrauch which of those words
he preferred.
REPRESENTATIVE WEYHRAUCH suggested using "verified" as it
signifies to acknowledge or concur.
SENATOR GUESS stated that she had two issues, and one goes back
to the conversation about telemedicine. "To be honest with you,
we haven't even dealt with issues of billing in telemedicine,
let alone liability and other issues that this brings up.
Telemedicine is far from a place that would be able to verify
information in many locations ... let's not kid ourselves that
we have this really enhanced telemedicine system in the state,
because we don't at this point, which I think does bring back
the issues of what happens when you're not near a neurologist.
So I still have issues about its applicability statewide."
SENATOR GUESS asked why this amendment was included in this
particular section, and then realized it was because "permanent
unconsciousness" was within the definition of "qualifying
condition" [a terminal condition or permanent unconsciousness in
a patient].
REPRESENTATIVE WEYHRAUCH suggested the sentence, "Permanent
unconsciousness must be determined in consultation with a
neurologist." He said this would hopefully address the implicit
liability concern, but also make it clear that "what we want is
this touching [base] with a neurologist who is qualified to
opine on the status of the person who is dying."
CHAIR DYSON said he would accept this as a friendly amendment.
The new sentence on page 15, line 29, will read: "Permanent
unconsciousness must be determined in consultation with a
neurologist." He asked if there was any objection.
SENATOR GREEN said, "I just have one thing to say. With some
scans and tests given to an unconscious person, does it actually
take a neurologist to read the scan to determine that there is
permanent unconsciousness?"
REPRESENTATIVE WEYHRAUCH said that generally, permanent
unconsciousness has to do with brain function, which is more the
purview of a neurologist than a cardiologist or urologist. The
implication is that a licensed neurologist will probably not
venture into territory if indications are such that somebody
else should be consulted with.
CHAIR DYSON asked if either Dr. Conright or Dr. Wallington had
any input on this issue.
DR. CONRIGHT said, "You do not need technology necessarily to
determine that someone is unresponsive, [in a] vegetative state.
This is a clinical decision that is made at the bedside and
could probably be done even long distance as in the language of
the proposed amendment - consultation with a neurologist - but
you do not need technology to come to that determination; it's a
clinical bedside assessment."
REPRESENTATIVE WEYHRAUCH referred to Senator Green's question of
whether a neurologist was needed to determine unconsciousness,
and reiterated, "Is a neurologist in the best position to
determine unconsciousness or is there some other practitioner
that should be consulted, as to unconscious versus conscious
state?"
DR. CONRIGHT said she believed that "most primary care
providers, not necessarily specialists, but internists, family
practitioners, this should certainly cover most physicians
throughout rural Alaska, including, even in Anchorage, that they
can determine that, and if [indisc.] they could consult with
neurologists, but having a neurologist at the bedside to make
that determination, I think, would be overkill, no pun
intended."
CHAIR DYSON said that he has listened in on radio conversations
at sea where doctors from the University of Washington and other
places have advised medical practitioners and less skilled
people: "Check for this. What do you get when this happens?
Here's what to do, and so on." That type of telemedicine
communication is pervasive and useful in the state and whoever
has to make decisions will be able to get that kind of counsel.
The WAMI [Washington-Alaska-Montana-Idaho Medical School]
Program makes expertise from the University of Washington
available throughout the state and works remarkably well.
REPRESENTATIVE WEYHRAUCH mentioned a critical situation that
occurred last week in Kodiak. A ground line on a fishing vessel
snapped and hit a crewmember in the back; he walked around, went
below, became unconscious, and then died. The crew administered
CPR for 45 minutes until having a consultation with medical
people.
CHAIR DYSON asked if there was any further discussion. He
acknowledged that the objection[s] had been withdrawn, and
announced that [conceptual] Amendment 2 was adopted. He asked
if there was any further testimony or amendments. [There were
none.]
SENATOR GUESS moved to report Senate CS for CSHB 25(HES),
version C as amended, out of committee with individual
recommendations and the attached zero fiscal note.
CHAIR DYSON asked if there was any objection. There being none,
it was so ordered.
CHAIR DYSON repeated that it had been mentioned to him that when
this bill becomes law, it might be the finest law in the nation
and may be a model that others could follow.
There being no further business to come before the committee,
Chair Dyson adjourned the meeting at 2:05 p.m.
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