Legislature(1993 - 1994)
03/03/1994 03:00 PM HES
* first hearing in first committee of referral
= bill was previously heard/scheduled
= bill was previously heard/scheduled
HB 356 - LIVING WILLS AND MEDICAL CARE ORDERS REP. CYNTHIA TOOHEY stated that HB 356 complements current statutes pertaining to the rights of the terminally ill by adding specific recognition of do not resuscitate (DNR) orders to the existing legislation with regards to the rights of the terminally ill to make a declaration relating to the use of life-sustaining procedures. She said a new section, Section 18.12.035, that allows attending physicians to issue DNR orders requires the Department of Health and Social Services (DHSS), with the approval of the State Medical Board, to issue regulations adopting a standardized protocol governing the withholding of CPR by physicians and other health care providers and establishes the requirements under which health care providers other than physicians must comply with DNR orders. REP. TOOHEY further stated that Section 18.12.037 requires the DHSS to develop standardized designs for DNR identification cards, forms, necklaces, and bracelets to indicate that the person who is in possession of one of the items has executed a living will or that a DNR order has been issued by a physician. Other provisions of the bill amend existing provisions by including DNRs along with living wills in areas such as immunities for health care providers, acting under the provisions of living wills, DNR orders, and penalties. Rep. Toohey maintained that DNR orders are issued only in the case of terminal illness. REP. TOOHEY explained that under existing practice, emergency response providers are required to institute CPR on site even if the person has a living will. She indicated that a properly executed DNR order and procedural protocol, recognized by all concerned parties, would help to avoid futile and unwanted interventions. Similarly, within health care institutions, DNR orders are necessary in the absence of a living will when attempts at resuscitation serve only to prolong the process of dying. CHAIR BUNDE indicated that there would be testimony via teleconference. REP. BRICE asked if the memo from Craig Lewis would be addressed. CHAIR BUNDE indicated that Mr. Lewis was on teleconference. Number 825 REP. VEZEY asked Rep. Toohey to explain the penalty section, Section 5. REP. TOOHEY stated that if an individual at a hospital, where fees are being charged, resuscitates a person against a DNR order, the individual will not be paid. REP. VEZEY referred to the $1000 civil penalty. REP. TOOHEY stated that the penalty is in existing law. REP. VEZEY said he failed to see the merit of mandating a $1000 civil penalty. He asked Rep. Toohey if she thought that was in the best interest of the bill. REP. TOOHEY deferred the question to Craig Lewis. Number 861 CHAIR BUNDE indicated that Mr. Lewis would address that question during public testimony. He said that Fairbanks, Mat-Su, Petersburg, Seward, and Sitka were on teleconference. Number 865 MARK JOHNSON, Chief, Emergency Medical Services, Department of Health and Social Services, testified in Juneau in support of HB 356. He stated that emergency care providers are trained to aggressively care for patients, but he also felt there are terminally ill patients whose discomfort should not be prolonged. He said when such patients, in consultation with their physician, choose to have a DNR order in place, the emergency medical providers would prefer to respect those wishes. Number 910 CHAIR BUNDE explained to the teleconference listeners that HB 506 would probably be brought to the table by 4:00 p.m. Number 921 VONA HALL, Member, Legislative Task Force for the American Association of Retired Persons (AARP), testified in Juneau in support of HB 356. She stated that she had been told the meeting was the prior day, and at that time, had planned to give a very elaborate speech including horror stories about the financial and emotional expense endured by clients who have had devastating effects from too much terminal care. She stated that her testimony would be brief as she had found her husband the day before with a broken hip on the ice in the driveway and she was due at the hospital as he was undergoing surgery. She said her husband was alive and indicated that under different circumstances the DNR legislation could have played an important role in their lives. She also said that the legislation is not just for old people. She suggested that it is for everybody that goes snowmobiling, drives a car, or perhaps walks in front of a car. She said her children and friends are aware of her do not resuscitate orders. She strongly emphasized the importance of the living will. Number 995 REP. TOOHEY asked how her husband was. MS. HALL said he was undergoing surgery right then. CHAIR BUNDE expressed his appreciation for her testimony, and wished Ms. Hall's husband the best. Number 018 CRAIG LEWIS, Executive Director, Interior Region Emergency Medical Services Council (IREMSC), testified via offnet in support of HB 356. He stated that he had several suggestions to make that perhaps would improve the legislation and asked if he should summarize or do a line by line analysis. CHAIR BUNDE asked him to summarize and said the committee would ask specific questions if necessary. MR. LEWIS indicated that the words "attending physician," which are used throughout the bill, should be enhanced because in some rural areas there is no attending physician. He asked that the definition of attending physician be expanded and clarified. He also explained that the term cardiopulmonary resuscitation (CPR) is a process of hands on patient care. Regarding the term, he suggested that artificial exchange of oxygen needed to be specified. He said that if the change is not made, an emergency care provider may conclude that an oxygen mask should not be put on the patient's face. He said that withholding resuscitation needs to be very specific. MR. LEWIS expressed his concern that the legislation is not as "rurally oriented" as it could be. He said a very specific mechanism needs to be in place to address the unique emergency treatment needs of rural areas. Mr. Lewis explained that an Emergency Medical Technician (EMT) could have administered hours of aggressive treatment and not be able to get the patient anywhere near a physician, let alone an "attending physician." TAPE 94-35, SIDE B Number 000 MR. LEWIS further indicated that on page 2, lines 11-17, the word "qualified" was very unclear. Number 050 REP. TOOHEY stated that the word "qualified" means that the person who possibly would be undergoing emergency treatment has already signed a living will and has proof on their body that they do not want resuscitation. MR. LEWIS read lines 11-17 on page 2 to indicate the vagueness of the term qualified. He continued on with his summary and stated that he did not want the legislation to only address health care facilities. He said rural Alaska has many situations where DNR orders are relevant and appropriate. Rural Alaska does not have health care facilities if the definition means hospital or multi- physician clinic. He felt that the definition had to be more rurally oriented. MR. LEWIS further suggested that the provision on page 3, lines 10-12, is not a realistic approach in rural settings. He said he was unsure of the necessity of the provision on page 4, lines 7-15. Mr. Lewis expressed further concern regarding page 5, lines 4-8, which addresses the issue of complying with the DNR orders from other states. He said to his understanding the legislation would allow an Alaskan medical provider to recognize other DNR orders from other states. He felt that it may be a regulation issue and related that EMTs are trained to aggressively treat patients, not to withhold treatment. Number 195 ERNEST LINE, Concerned Citizen, testified via teleconference in support of HB 356. He stated that the committee should consider possible future legislation regarding physician assisted suicide. He then addressed the bill. He maintained that the State Medical Board may be opposed to the provision on page 1, line 9. He suggested that the legislature could approve the regulations. He further indicated that on page 2, line 18, the provision would actually compel compliance if the facility is a state run operation. Mr. Line suggested that the phrase "shall not attempt resuscitation until all provisions of Section 3, paragraph b, are exhausted" should be inserted. Mr. Line also supported the idea of increasing the $1000 fine to violators of DNR orders, citing that it would ensure compliance. Number 300 REP. TOOHEY asked if Mr. Line knew of people whose DNR orders were not carried out. She asked if he thought it was a major problem in medical facilities. MR. LINE stated that he has read about cases where the physician did not personally believe in DNR orders. Number 327 SANDY TACKETT, Nurse, testified via teleconference in support of HB 356. She stated that health care people needed to have the information within HB 356 to carry out the wishes of a patient. Number 345 CHAIR BUNDE asked witnesses to limit their testimony by associating themselves with the similar positions of prior testifiers and by adding any yet unheard testimony. Number 350 JULIE RENWICK, Coordinator of Social Services, Wesley Rehabilitation and Care Center, testified via teleconference in support of HB 356. She stated that she was concerned about the definition of qualified patient. She indicated that she originally thought the legislation was only addressing the terminally ill. She also said she hoped the provision regarding protocol would be written to protect the wishes of the individual and/or family guardian. She also said in Section 3 individuals need to be more involved with the decision making with the doctor. She further stated in regards to DNRs in other states that there is a nationwide organization called Right to Life that issues small living will cards to people who travel throughout the nation. She questioned whether the cards would comply with any single state with living will provisions. Number 424 LINDA SWENSON, Nurse, Seward General Hospital, testified via teleconference in support of HB 356. She stated that in regard to the oral DNR order provided for on page 2, line 2, the DNR order should never be given orally in an urban hospital. She also expressed concern as to what is a qualified patient. She stated that people make living wills with DNR orders anticipate that they, at some time, will not be able to speak for themselves. Number 475 RICHARD JONES, Administrator, Wesley Rehabilitation and Care Center, testified via teleconference in support of HB 356. He asked what protocol would be if an individual who had previously provided a DNR order is in need of emergency treatment at a hospital and is unable to express their wishes at that time. He asked if the prior DNR order would be honored or would a physician have to order another DNR. He asked who was responsible for the legislation, and expressed his thanks. Number 526 CHAIR BUNDE stated that Rep. Toohey was responsible for introducing HB 356. Number 528 NANCY JO BLEIER, Director of Social Services, Southeast Alaska Regional Health Corporation, testified in support of HB 356. She stated that she also had concerns with the terms "qualified" and "health care facility." Number 570 REP. TOOHEY read for the record from statute 18.15.010: "A qualified patient means a patient who has executed a declaration in accordance with this chapter and who has been determined by an attending physician to be in terminal condition." CHAIR BUNDE said his understanding of the issue is that the legislation addresses terminal patients only and perhaps it could also include someone who is in the peak of health but meets with a catastrophic accident. Number 587 CAPTAIN STEVE IHA, EMS Coordinator, Capital City Fire/Rescue, testified in Juneau in support of HB 356. He stated that Juneau has had DNR protocol in place for 3-1/2 years, and it has been quite successful. He said it was his understanding that a living will can be initiated by anyone regardless of that person's health condition. However, he said the living will is not enacted until a physician (or perhaps two) determines that the patient is terminally ill. He said that stipulation creates a Catch 22 situation. He asked what protocol would be in the case of a healthy, 35 year old man who chokes on a piece of meat. He said that technically he could be in a DNR state. He felt that the legislation needs to be more specific. CAPT. IHA also said there is no way for EMTs to really know the validity of an out-of-state DNR order. He said that for the most part his EMTs honor DNR orders within the Juneau system. He suggested that the term "qualified" be more clear. Number 648 REP. TOOHEY asked what the medical protocol would be if Capt. Iha found a person collapsed on the street corner of the capitol with a DNR arm band on. CAPT. IHA said there is no protocol for such an instance. He stated that the DNR patients in Juneau have been determined to be terminally ill by a physician and have filled out a form that has been sent to Fire/Rescue dispatch. He said that it is understood that those patients on the DNR list at dispatch would be responded to at their home. REP. VEZEY asked what the protocol would be if he choked on a piece of meat. He asked how an EMT would know he had a living will. CAPT. IHA said, "If you're talking about putting do not resuscitate type bracelets or identifications, then it would become an issue." REP. VEZEY said that he never thought that executing a living will would put himself in the position of not receiving medical attention. CAPT. IHA said if DNR orders are part of the living will, it must be very clear. Number 696 CHAIR BUNDE said there is a difference. He then asked Rep. Toohey how she would like to address all the aforementioned concerns. REP. OLBERG said that Rep. Vezey would fall under the Do Not Resuscitate Legislators provision. CHAIR BUNDE said he wanted to amend that to specify minority legislators. REP. TOOHEY clarified that the legislation is a companion bill to a living will in a hospital. It would allow EMTs who have found a terminally ill person collapsed on the street corner to respect that person's DNR order. Number 744 MR. JOHNSON stated that all the aforementioned concerns could be dealt with quite easily. He referred to testimony from Mr. Line and indicated that he has every confident in working with the medical board and felt there would be no problems in doing so. CHAIR BUNDE closed public testimony on HB 356.