HB 25-HEALTH CARE SERVICES DIRECTIVES  The committee took up CSHB 25(JUD). SENATOR LYDA GREEN moved to adopt the committee substitute (CS), version V [labeled 23-LS0137\V, Bannister, 3/24/04] as the working document before the committee. [There being no objection, it was treated as adopted.] CHAIR DYSON said that after Ms. Sylvester's testimony, he would run through a list of issues still being addressed that would be included in the next version of HB 25. MS. LINDA SYLVESTER, staff to Representative Weyhrauch, explained that version V was the result of a 3/8/04 staff meeting that included the lieutenant governor's chief of staff, and Chip Wagoner from the Alaska Catholic Conference (ACC). The document they settled on had approximately 66 amendments; she said she would summarize the important ones. She began by stating that "emancipated minors" had been eliminated from HB 25. Changes were made to the role of a surrogate (noting that surrogates are a new part of HB 25) and the role of physicians was amplified in the decision-making process, when surrogates are evenly split. CHAIR DYSON offered that this serves to bring the "best interest" of the patient into the conversation. MS. SYLVESTER continued that regarding surrogates, the prominence of best interest was increased. The intention is to include a definition of best interest in the form, although it has not [yet] been included. She said the new language that amplifies the physician's role in detecting... TAPE 04-15, SIDE A    MS. SYLVESTER continued, "... that's come forward or that's been nominated, isn't necessarily an appropriate one. The protections are in place. The physician has standing already to recommend this to go to guardianship procedures, but we just want to put that in there, so we want to direct the physician to take a more proactive role in that situation." MS. SYLVESTER told members that most importantly there are new guidelines for surrogate decision-making when the decision involves withdrawal of life support. "We've used language from the Illinois statute. These are strict guidelines; our concern was we wanted to make sure if there was a 35-year old who was in a motorcycle accident and he was going to recover from his injuries but the spouse took the opportunity to push forward wishes of not being resuscitated, we wanted to make sure that this wouldn't happen." CHAIR DYSON interjected, "a big estate, and she's got a boyfriend." MS. SYLVESTER continued that regarding anatomical gifts, updates were made so that the role of the hospital was taken out somewhat, because Life Alaska has stepped into that role. Ms. Sylvester referenced Section 4 of the 1987 Uniform Anatomical Gift Act, and noted that changes had been made to verify that Alaska is not an opt-out state. If ever that were to change, a bill would need to come through the Legislature; it would be a policy decision of its own. MS. SYLVESTER said portability was of concern; it's important that all advance directives outside of Alaska are recognized to the extent that Alaska law is not violated. The committee reviewed those Sections and regarding the "do not resuscitate (DNR)" order, one more clarification needs to be made so that it's perfectly clear that EMTs in the field who are sure there's a DNR in place can act in good faith. She gave the analogy of somebody obtaining a driver's license in Montana where the speed limit is 75 mph; although that license is valid in Alaska, that person can't drive at 75 mph. MS. SYLVESTER said that some changes were made to the [optional] form itself. A helpful reminder was added indicating that euthanasia and mercy killing is not legal in Alaska. A change was made to the pain relief option so that space in the form is given for the principal to state his/her wishes regarding pain relief. Also, the intent is to add some critical definitions to the form, but the drafter missed those. Witness requirements were modified somewhat; "witnesses need to be in place and there are criteria for who the witnesses can be because that will be the protection that foul play isn't a part of this." MS. SYLVESTER said that interestingly enough, HIPAA [Health Insurance Portability and Accountability] concerns were raised and have been addressed in two places: in the institution's immunity for providing medical records, to make sure that surrogates and agents have access to those records; also, hospitals sometimes cannot give medical records to individuals because of not knowing if the principal has lost capacity - it's a loop because the person needs to see the records - so that's been fixed, she said. MS. SYLVESTER said the committee was mindful of the policy considerations; there were six, and the bulk of them have been addressed. Language has been added so that there is a presumption in favor of life in the absence of someone's stated intent that they presume to be kept alive. The role of the surrogate and the agent has been clarified regarding life support. Reciprocity has been addressed, although it still needs some work. The question, "At what point does the definition of a 'qualified patient' kick in?" has been addressed by stipulating the conditions necessary for a surrogate to make decisions relative to life support. "Anatomical gifts" has been clarified and corrected. She noted that she couldn't read her notes on the last one, number six. CHAIR DYSON said excellent work has been done on the bill, and he understands that there is still work being done on the issue of nutrition and hydration to more clearly differentiate between persons who are unarguably terminal and those who are just injured, maybe incapacitated or comatose. There may be a little more work to do regarding surrogates, as there is still the question of limiting the authority of the decision-makers and strengthening the best interest of the patient. Also, there is the issue of reciprocity. There are ongoing discussions on those three items, he said. DR. MARIA WALLINGTON, a medical ethicist at Providence Alaska Medical Center, said she could be available at the bill's next hearing, that she was available to answer questions. CHAIR DYSON asked if she had a copy of the latest version. DR. WALLINGTON said she has not seen it, but she conversed with Ms. Sylvester about it. CHAIR DYSON suggested that she contact his office or Representative Weyhrauch to get a copy. He announced there were copies available for those wanting to see the latest version of the bill. SENATOR GUESS noted concern about the intended timeline and asked if there would be sufficient time to ask questions pertaining to the different versions. CHAIR DYSON assured her that there would be time for questions, saying, "We're not going to railroad this thing, it's too valuable and too sweeping." HB 25 was held in committee. There being no further business to come before the committee, Chair Dyson adjourned the meeting at 3:28 p.m.