SB 291 - LIV. WILLS/ANATOMICAL GIFTS/PATIENT CARE RALPH BENNETT, legislative aide to Senator Robin Taylor, sponsor of SB 291, read the sponsor statement. SB 291 revises Title 18, Chapter 12, which pertains to rights of the terminally ill. The current statute offers little assurance that an incapacitated person's wishes will be carried out because it states that living wills are operative only if the declarant's condition is determined to be terminal. SB 291 clarifies that an advance directive or living will is given operative effect only if it has been medically determined that the declarant is in a serious medical condition. The bill defines "medically determined" as a determination from two physicians who personally examined the patient, one of whom is the attending physician. The bill defines "serious medical condition" as: a) a terminal condition; b) a permanently unconscious condition; c) a condition in which the administration of life-sustaining procedures would not benefit the patient's medical condition and would cause permanent and severe pain; and d) a progressive illness that will be fatal and is in an advanced stage; the person is consistently and permanently unable to communicate by any means, to swallow food and water safely, to care for the person's self, and to recognize the person's family and other people, and it is very unlikely that the person's condition will substantially improve. SB 291 was modeled after Oregon law. That law was cited in a Journal of the American Medical Association study as respecting the wishes of the patient. Section 7 of SB 291 clarifies that nothing in this chapter is intended to condone, authorize, or approve mercy killing or assisted suicide. Section 8 sets out conditions under which life-sustaining procedures can be withheld when an individual does not have a living will. CHAIRMAN WILKEN noted Mark Johnson of the Department of Health and Social Services (DHSS) and Joe Ambrose of Senator Taylor's staff were available to answer questions. Number 125 BRIDGET CARNEY, Corporate Director of Ethics for PeaceHealth, a Catholic health care system in Alaska, Washington, and Oregon, testified in favor of SB 291 via teleconference. Under Oregon's Self Determination Act, Peacehealth is able to offer to all patients, entering its hospital facilities, the opportunity to complete an advanced directive. When a patient expresses interest, a social worker is available upon request to help complete the documents. This approach has been very successful as far as patient understanding of his/her options in terms of withholding and withdrawing treatment and it forces patients and physicians to communicate about the advance directive options in a thorough manner. It also gives the person with durable power of attorney the ability to withhold and withdraw treatment as needed if the patient is unconscious. Staff clearly explain the difference between an advanced directive and assisted suicide, given that Oregon has such legislation. MS. CARNEY said an advance directive does not substitute for conversation, because one might be kept elsewhere in a clinic file without the knowledge of the attending physician, so the document is not useful. She reiterated she strongly supports this approach and the way it has been adapted in SB 291. Number 174 VIRGINIA PERI made the following comments on her own behalf. Current Alaska law pertaining to living wills is overly broad, speaks only to terminal illness, and needs clarification. She has had five operations in six years but her wishes as a patient, as stated in her Alaska living will, were not honored in Alaska hospitals because she was not terminally ill. She chose to prepare a second living will in Oregon that speaks to serious medical illness which was accepted in Washington State by the University of Washington Medical Center Hospital while she was treated there. In addition, current Alaska law contains no definitions for life- sustaining procedures and nutrition and hydration, and treats all equally. Many persons enter a hospital without a living will and are not aware of their rights as a patient. SB 291 clarifies the law to give greater understanding to those people using a living will. DEBORAH RANDALL, an attorney with the law firm of Davis and Davis, stated she worked with Virginia Peri on this legislation. She and Ms. Peri believe tremendous advancements in the area of advanced directives and health care powers of attorney have occurred over the last few years. Linda Emmanuel, working with the American Medical Association, recently published a 12 page advanced directive that outlines several medical conditions and the medical treatment options a person can choose to have or have not applied. Alaska's statute addresses one condition: a terminal condition, defined as "a progressive incurable or irreversible condition that, without the administration of life-sustaining procedures, will, in the opinion of two physicians, result in death within a relatively short time." She stated under that definition leaves a lot of room for misinterpretation and could result in withholding CPR on a 40 year old who had a heart attack because a heart attack can be considered an irreversible condition. The Oregon statute is much more thorough and has passed the test of time. It allows a patient to tailor his/her wishes to many different situations; i.e., it allows the patient to decide whether he/she wants every life saving measure taken for a terminal condition unless he/she is in a persistent vegetative coma. She suggested combining Alaska's living will statute with the health care power of attorney provision which currently consists of two lines in the general power of attorney law. In addition, she asked that provision be amended to allow an agent to withhold life-sustaining procedures. Ms. Randall stated her support of SB 291 and said it will create a win-win situation for all Alaskans. Number 249 RICHARD WILLIAMS, senior representative of the Older Alaskans Commission, testified via teleconference from Anchorage. MR. WILLIAMS said death does not frighten him, dying does. Recent advancements in the field of medicine allow doctors to draw out the process of dying as long as they wish. SB 291 gives individuals the opportunity to determine how they want to die in certain circumstances. FRAN MCNEILL, Family Care Coordinator for Life Alaska, stated support for SB 291 for the following reasons. SB 291 honors the patient and family by allowing the patient the right of self- determination and preserving the patient's autonomy. It enables the family and patient to look at some of the most pressing and difficult issues surrounding the possibility of death prior to a crisis. It also supports the community and gives people the opportunity to choose whether to donate tissue and organs. SB 291 clarifies some of the complex issues we face resulting from advancements made in the field of health care. TOM BULLER, Ph.D., a member of the Department of Philosophy at the University of Alaska, Anchorage, concurred with remarks made by previous witnesses, and added the following comments. SB 291 has an ethical/moral basis and provides evidence of our respect for self-autonomy, self-determination, and individual well being. Advance directive legislation allows an individual to determine the conditions under which he/she wishes treatment to be discontinued. The bill fosters physician/patient communication and allows for discussion about expectations of the quality of one's life. He agreed with Ms. Carney that SB 291 in no way endorses assisted suicide. It deals with the right to refuse treatment. The Supreme Court stated in two rulings last year that the right to bodily integrity is very different from the issue of assisted suicide. Number 328 MELBA COOKE, a case manager with the ALASKANS AIDS ASSISTANCE ASSOCIATION, stated support for SB 291. At present, her clients must write out everything they wish in regard to life-sustaining procedures; SB 291 speaks to everything her clients would appreciate. She agreed with previous speakers' comments and encouraged committee members to pass this legislation. SENATOR ELLIS pointed out the Legislature passed legislation relating to advanced directives for mental health care by former Senator Reiger two years ago. The Legislature is not plowing new ground in terms of the advanced directive aspect of SB 291, but is reviewing the current living will statute which is unworkable and inadequate. He congratulated the sponsor for putting the bill forward, and said he is glad to be a co-sponsor. Senator Ellis maintained that advanced directives are allowed in the realm of mental health care, therefore the same reasoning should be applied to other areas of health care. SENATOR GREEN questioned whether the new advance directives are complex and will have to be completed in consultation with an attorney. MS. CARNEY answered no, the paperwork does not require a patient to meet with an attorney. The Sacred Heart Hospital has prepared an educational booklet that contains definitions of terms and other detailed information for patients, and the hospital's social workers review the documents with patients. Number 371 MR. AMBROSE indicated the new advance directive is actually less complicated than the medical directive packet compiled by the AMA. The AMA packet gets into areas that most people do not even want to think about. The problem with the current law is that it is so broad, specific instructions are frequently not carried out. The Chase Review reports that a living will should state completely and explicitly those areas of health care about which the individual wants to make decisions. He reminded committee members under state law, any attorney in Alaska must assist a person with a living will on a pro bono basis. He noted committee packets contain a copy of the documents offered to clients. MS. CARNEY indicated PeaceHealth is investigating how to put advanced directives on to a computer system so that patients' wishes are readily available because sometimes records are not accessible in emergency situations. Number 394 SENATOR GREEN asked whether SB 291 mandates that educational materials be provided to the patient. MR. AMBROSE replied it does not. SENATOR ELLIS moved CSSB 291(JUD) out of committee with individual recommendations. There being no objection, the motion carried.