Legislature(1993 - 1994)

03/03/1994 03:00 PM HES

Audio Topic
* first hearing in first committee of referral
+ teleconferenced
= 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                      
  REP. BRICE asked if the memo from Craig Lewis would be                       
  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                                
  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                         
  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                       
  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                      
  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                   
  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                  
  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                 
  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.                               

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