HOUSE HEALTH, EDUCATION AND SOCIAL SERVICES STANDING COMMITTEE January 26, 1995 3:02 p.m. MEMBERS PRESENT Representative Cynthia Toohey, Co-Chair Representative Con Bunde, Co-Chair Representative Al Vezey Representative Gary Davis Representative Norman Rokeberg Representative Caren Robinson Representative Tom Brice MEMBERS ABSENT None COMMITTEE CALENDAR * HB 39:"An Act relating to the authority of mobile intensive care paramedics, physician assistants, and emergency medical technicians to pronounce death under certain circumstances." PASSED OUT OF COMMITTEE (* First public hearing) WITNESS REGISTER REPRESENTATIVE GENE THERRIAULT Alaska State Legislature State Capitol, Room 421 Juneau, AK 99801 Telephone: (907) 465-4797 POSITION STATEMENT: Provided sponsor statement for HB 39. MATT ANDERSON, Training Coordinator State Emergency Medical Services P.O. Box 110616 Juneau, AK 99811-0616 Telephone: (907) 465-3141 POSITION STATEMENT: Testified in support of HB 39. ELLEN WOFFORD, Trainer Delta Rescue P.O. Box 1357 Delta Junction, AK 99737 Telephone: (907) 895-4746 POSITION STATEMENT: Testified in support of HB 39. GARY JUDD, Emergency Medical Technician North Slope Borough P.O. Box 69 Barrow, AK 99723 Telephone: (907) 852-0265 POSITION STATEMENT: Testified in support of HB 39. CRAIG LEWIS Alaska Emergency Medical Services Association, Interior Region Emergency Medical Services, Inc. 1881 Marika Street Fairbanks, AK 99709 Telephone: (907) 456-3978 POSITION STATEMENT: Testified in support of HB 39. GREG BARCLAY Central Emergency Services 231 S. Binkley Street Soldotna, AK 99669 Telephone: (907) 262-4792 POSITION STATEMENT: Testified in support of HB 39. DR. WILLIAM COOPER Central Emergency Services 231 S. Binkley Street Soldotna, AK 99669 Telephone: (907) 262-4792 POSITION STATEMENT: Testified in support of HB 39. ROCKY ANSELL, Emergency Medical Technician P.O. Box 217 Copper Center, AK 99573 Telephone: (907) 822-5361 POSITION STATEMENT: Testified in support of HB 39. JACK HEESCH, Lobbyist Alaska Academy of Physician Assistants P.O. Box 201608 Anchorage, AK 99520 Telephone: (907) 463-3381 POSITION STATEMENT: Presented client testimony in support of HB 39. PREVIOUS ACTION BILL: HB 39 SHORT TITLE: AUTHORITY TO PRONOUNCE DEATH SPONSOR(S): REPRESENTATIVE(S) THERRIAULT,B.Davis,Bunde,G.Davis JRN-DATE JRN-PG ACTION 01/06/95 30 (H) PREFILE RELEASED 01/16/95 30 (H) READ THE FIRST TIME - REFERRAL(S) 01/16/95 31 (H) HES, JUD 01/19/95 90 (H) COSPONSOR(S): BUNDE 01/26/95 (H) HES AT 03:00 PM CAPITOL 106 ACTION NARRATIVE TAPE 95-2, SIDE A Number 000 The House Health, Education and Social Services Committee was called to order by Co-Chair Cynthia Toohey at 3:02 p.m. Members present at the call to order were Representatives Bunde, Vezey and Robinson. CO-CHAIR TOOHEY stated that a quorum was present. She announced the meeting is on teleconference with Barrow, Delta Junction, Fairbanks, Glennallen, Soldotna and Tok. Number 073 CO-CHAIR TOOHEY introduced Representative Gene Therriault to the committee. HHES - 1/26/95 Number 090 HB 39 - AUTHORITY TO PRONOUNCE DEATH REPRESENTATIVE GENE THERRIAULT, sponsor of HB 39, explained that the bill proposes to allow mobile intensive care paramedics, physician assistants and emergency medical technicians (EMTs) to determine and pronounce death under certain circumstances. Registered physician assistants, registered paramedics and certified emergency medical service may make a determination and pronouncement of death upon determining that a person has suffered irreversible cessation of circulatory and respiratory function while a physician is not immediately available for consultation by radio or telephone. REPRESENTATIVE THERRIAULT continued that currently, when a member of an emergency medical service begins CPR they are required to continue resuscitation until: The person recovers; the EMT, physician assistant, or paramedic is relieved by either a medical facility or physician; the responding parties become physically exhausted and no longer are able to continue; their physical safety is seriously threatened; or a physician pronounces the person dead. REPRESENTATIVE THERRIAULT stated that many times, particularly in rural Alaska, physicians and medical facilities are not immediately available, and emergency medical response members are required to continue unproductive resuscitation for several hours. REPRESENTATIVE THERRIAULT explained that HB 39 would allow an EMT, physician assistant or paramedic to declare death in situations where a physician is not available. This will help emergency response teams to better attend to the emergency medical needs of Alaska. Number 214 REPRESENTATIVE THERRIAULT added the bill is currently the same bill the HESS committee considered and passed out of the committee last year. Also, last year testimony was heard from a number of teleconference sites around the state which recounted efforts where individuals were required to perform resuscitation efforts on a person who was obviously dead, due to the presence of perhaps a fleeting heartbeat. Once the efforts were begun, they could not be discontinued until someone with authority pronounced the person dead, or the rescuer became physically exhausted or felt his or her life was threatened. Number 266 REPRESENTATIVE THERRIAULT said the passage of this bill would set Alaska ahead of other states. According to legislative research, a number of other states are considering similar legislation, basically for the same reasons. But in the state of Alaska there are many remote areas where authorized personnel are unavailable to pronounce death. Number 297 REPRESENTATIVE THERRIAULT directed the committee to read a letter from Craig Lewis, head of the Interior Region Emergency Medical Services Council, and a newspaper article from the Juneau Empire concerning the proposed legislation. The article recounts a specific story in which this legislation would have proved beneficial to all involved. REPRESENTATIVE THERRIAULT stated the bill tries to be fairly specific about when death can or cannot be pronounced, and how long cardiopulmonary resuscitation (CPR) must be attempted, taking into consideration hypothermia. Number 380 REPRESENTATIVE THERRIAULT said that some changes to the bill have been suggested; therefore, he introduced a Sponsor Substitute to HB 39. CO-CHAIR TOOHEY noted for the record that Representative Rokeberg arrived at 3:03 p.m., Representative Gary Davis arrived at 3:05 p.m., and Representative Brice arrived at 3:06 p.m. REPRESENTATIVE THERRIAULT explained that changes occur on lines 19 and 20 on page 2 of HB 39, where the words collaborative physician have been added. This is due to the fact that a mobile intensive care paramedic or emergency medical technician works with a consulting physician, but a physician's assistant works with a collaborative physician. Number 513 REPRESENTATIVE THERRIAULT discussed another change found on page 3, line 13 of HB 39, where the words "properly performed by an emergency medical technician" have been dropped. This was so the statute would apply to anyone performing rescue efforts. Number 568 REPRESENTATIVE THERRIAULT recalled that a member of the House HESS committee asked him a question earlier in the day about page 2, lines 10 and 11 of HB 39. The individual asked: If the authority to pronounce death was granted if a physician was not available for consultation by radio or telephone, did that authority to pronounce death under HB 39 continue if a doctor was available by phone or radio, or would resuscitation efforts have to continue fruitlessly? REPRESENTATIVE THERRIAULT clarified that the doctor relieved the rescuer from duty, meaning the doctor could tell the rescuer to stop CPR, bring the person to where the physician was and the doctor would pronounce the victim dead. The doctor is not able to declare the person dead over the telephone or radio; he or she is only relieving the rescuer of continued resuscitation efforts. Number 666 CO-CHAIR TOOHEY asked if the extent of the injuries which made the patient/victim incompatible with life would have to be relayed to the doctor, therefore giving the doctor the ability to authorize the end of resuscitation efforts. REPRESENTATIVE THERRIAULT responded that under the terms of the bill, if the rescuer is not in contact with a doctor, the power to declare death would be extended to the rescuer. If contact is achieved with the consulting official, the rescuer would explain the circumstances and the doctor could then authorize the rescuer to discontinue resuscitation. Number 708 CO-CHAIR CON BUNDE moved that the committee use the Sponsor Substitute for HB 39 as the working document. Representative Gary Davis seconded the motion and it was passed without objection by Co-Chair Toohey. Number 742 REPRESENTATIVE NORMAN ROKEBERG said he questioned whether or not there actually were remote places where a doctor could not be reached for consultation by radio or phone. Number 774 REPRESENTATIVE THERRIAULT responded that there are many places in his district where accidents could occur and contact could not be established. He continued that if CPR begins immediately, there is no time to travel down the road in an attempt to establish contact with an authorized physician. He reiterated that the power of the rescuer to declare death is erased upon contact with an authorized physician; however, the physician has the ability to relieve the rescuer of his or her resuscitation efforts. Number 833 REPRESENTATIVE ROKEBERG felt that the bill would be unnecessary if contact could be established in all cases. But he now understood the bill would be necessary if contact could not be established. Number 861 CO-CHAIR BUNDE asked for testimony via teleconference and from present witnesses. Number 880 REPRESENTATIVE AL VEZEY asked Representative Therriault about the fate of the bill after it was passed out of the House HESS committee last year. REPRESENTATIVE THERRIAULT responded that the bill made it to the Senate Rules committee. He had to prioritize the four bills he had in that committee. He felt that HB 39 was so noncontroversial it would be passed out of that committee without incident. He "miscalculated." Number 917 CO-CHAIR TOOHEY called for testimony from Matt Anderson. Number 932 MATT ANDERSON, Training Coordinator for the Emergency Medical Services section within the Department of Health and Social Services, spoke briefly in support of HB 39. He felt the bill will do a great deal to help EMTs and paramedics, particularly in outlying areas and small communities where establishing contact is difficult. He added that those people preparing to testify from the Mat-Su borough and Fairbanks will agree with him. Number 966 CO-CHAIR TOOHEY recalled discussing state training guidelines last year which would assist rescuers in establishing death. MR. ANDERSON said he wasn't involved in that testimony but it was clear some training would have to take place. An entirely new EMT curriculum is being introduced throughout the state, and HB 39 would fit nicely into that new training curriculum. He felt that a great deal of education could be accomplished throughout the state in a very short time. CO-CHAIR TOOHEY wanted assurance that the additional training would not put further economic strain on the state. Mr. Anderson said it would not. Number 1016 MR. ANDERSON added that the bill has a zero fiscal note, and communication would not be a problem as quick communication can take place through a newsletter to about 4,000 people. Number 1025 REPRESENTATIVE GARY DAVIS solicited comments on the deletion of the words "the presence of post mortem lividity" on page 3, line 3 of HB 39, as requested in a letter by Donald R. Lehmann, M.D., president of the Alaska State Medical Association. MR. ANDERSON responded that he had not seen the letter before the start of the committee meeting, and declaring a position on the deletion was not within his scope of expertise. He did note that the words in question had been an issue for some time. He solicited comments from individuals at the teleconference sites. Number 1070 REPRESENTATIVE DAVIS replied he was sure the sponsor of the bill would provide an opinion on the matter and proceedings would continue from there. Number 1083 REPRESENTATIVE VEZEY recalled that he had concerns the last time the bill was heard in the HESS Committee. He stated he had difficulties finding people to train as EMTs. The training was becoming increasingly technical and contained increasing legal and health liabilities. MR. ANDERSON responded that his training classes were always completely full. REPRESENTATIVE VEZEY asked if many people dropped out of training. MR. ANDERSON replied that about 50 percent had dropped out by the end of the first two years. After that level, the attrition decreases sharply. Surveys to discover the cause of the attrition revealed that most is caused by relocation or lack of time. Indeed, some students were afraid of communicable diseases, but not many. Mr. Anderson added that the legislature has been very good to the Emergency Medical Service in terms of statutes such as AS 18.08.086, which provides immunity from liability for EMTs. Number 1151 REPRESENTATIVE VEZEY wondered whether or not it was futile for the legislature to describe the qualities of a dead person to an emergency medical services provider. He questioned whether it was beyond common sense to legally require that extra life saving efforts be performed. MR. ANDERSON said legally they were required to perform extra life saving efforts. The duty of an emergency medical services provider is to provide life saving practices until the rescuer is physically exhausted, a physician declares the person dead or the patient and rescuer arrive at a medical facility. Mr. Anderson felt this bill would definitely benefit the majority of people. He also felt the wording of the bill does a good job of taking the guess work out of the declaration of death. Number 1234 CO-CHAIR TOOHEY recounted that she had performed CPR on a dead person and she was not legally allowed to stop until a physician came on the scene. It was very difficult. REPRESENTATIVE VEZEY questioned whether they were writing more statutes to solve a problem that was created by a combination of statutes and court decisions. He wondered if they should simply look at eliminating the problem which was created. Number 1270 MR. ANDERSON felt the current duty guidelines for resuscitation efforts were standard, and he could not think of another way, other than HB 39, to spare people from performing resuscitation efforts in a futile situation. REPRESENTATIVE VEZEY surmised that something could be added to the statute as outrageous as "If the EMT thinks a person is dead...." MR. ANDERSON felt that would result in many people expressing concern over the consequences. It would put EMTs and others at much more risk for litigation. REPRESENTATIVE VEZEY asked if that problem would be solved if something was added about absolution from liabilities. MR. ANDERSON responded that standards by which decisions about death were made would have to be present, and such standards exist currently in HB 39. Medical directors would not want people arbitrarily making decisions on life and death based simply on judgment. Specific criteria would be necessary. Number 1350 ELLEN WOFFORD, Trainer, Delta Junction Rescue, spoke via teleconference on behalf of the Delta Rescue Squad in support of HB 39. Number 1371 GARY JUDD, an emergency medical technician in Barrow, Alaska, testified via teleconference and expressed support for HB 39 on behalf of the emergency services workers of the North Slope Borough. He felt the bill would alleviate many problems for emergency workers in very rural areas. He asserted that in many rural areas it is very seldom that radio or telephone contact can be established with physicians. The toll extended resuscitation efforts takes on providers is great. He felt the bill constituted good judgment and applauded the committee's support of this bill. Number 1438 CRAIG LEWIS, of the Alaska Emergency Medical Services Association and the Interior Region Emergency Medical Services Inc., testified on behalf of those groups via teleconference from Fairbanks. He felt the bill was sound and competent. He reiterated previous testimony that establishing contact with physicians is very difficult in outlying and rural areas. In such a situation, the relatives of the deceased are traumatized, the competence of the EMT is questioned and the EMT often questions his or her ability to save lives. A dead person, according to the criteria in the bill, should be treated as if they are dead, not alive. He hoped the bill would again pass out of committee. Number 1518 CO-CHAIR BUNDE asked those testifying via teleconference to comment on the letter written by Dr. Lehmann and the deletions he recommended. The letter says the members of the Alaska State Medical Association oppose any dilution of the clear guidelines listed in Section 2 of this bill. Some members also have expressed concern and request that line 3 of page 3, item C, the presence of post mortem lividity, be deleted. They feel that pathologists feel this criteria can be problematic and should not be used by EMTs in the field as a signifier of death. Number 1597 MS. WOFFORD responded via teleconference that post mortem lividity is a clear indicator of death, and the criteria should be left in the bill. Number 1619 MR. JUDD also felt the bill should be left as is. Post mortem lividity is identifiable and would probably not be as large an issue as the letter implies. MR. LEWIS testified that he remembered this discussion from last year. Many scientists feel the need to criticize semantics and language and science, and practicality should be separated in this case. Post mortem lividity may not stand alone as the singular indicator of death, it may be in a list of indicators. However, some living individuals may exhibit this state and in that case, he would encourage training for emergency medical service providers on post mortem lividity. Number 1698 GREG BARCLAY, Central Emergency Services, Soldotna, was called upon by Co-Chair Toohey to comment via teleconference on the section concerning post mortem lividity. He was very supportive of the bill, but wished to let a present physician testify concerning post mortem lividity. Number 1730 DR. WILLIAM COOPER, Medical Director of Central Emergency Services and emergency physician, testified via teleconference that he has been in Alaska for 12 years dealing with paramedics and emergency services. He felt the bill was long overdue for all the reasons stated by those testifying before him. He reiterated there were many remote areas in the Kenai Peninsula and many areas were unreachable by radio and telephone. He felt it was pragmatically impossible to get patients from these places to areas where consultation could be achieved. DR. COOPER continued that those conditions place a large burden on EMTs. The resuscitation times stipulated in the bill for cold water drowning were very reasonable, and Dr. Cooper applauded the bill. Concerning post mortem lividity, he said the determination of death involves many criteria including pupil response, respiration, and monitored responses to resuscitation. He would not place much emphasis on that one line. He felt that whether that line was included in the bill or not was not as important as the whole bill being passed. Number 1822 CO-CHAIR TOOHEY asked for a definition of post mortem lividity from the doctor. DR. COOPER explained that post mortem lividity occurs when circulation ceases and gravity settles the blood into the appendages of the body. It looks like a bluish area. Most EMTs recognize this as an indicator that a person has been dead for any length of time. When this state appears is variable according to temperature and conditions. He reiterated his confidence that all emergency medical service providers he has dealt with could deal with post mortem lividity effectively. REPRESENTATIVE ROKEBERG asked Dr. Cooper to repeat his comfort with the times established in the bill for resuscitation efforts. DR. COOPER responded that he realized there is some controversy about those times, especially in the areas of hypothermia and cold water near-drowning. However 60 minutes, along with the temperature level of the individual, is what he uses to base his resuscitation times upon. By and large, the training of Alaskan EMTs is such that they are well aware of these situations. REPRESENTATIVE ROKEBERG also questioned if 30 minutes was reasonable concerning pulmonary resuscitation as it relates to cardiac arrest. DR. COOPER felt that actually, if a person who had a normal body temperature did not respond in 10 or 15 minutes, he or she was not going to respond. Thirty minutes provided plenty of response time. REPRESENTATIVE ROKEBERG asked about cases in which a person had been submerged in cold water, and what was a reasonable length of time to attempt resuscitation. DR. COOPER answered in such a case, resuscitation will be attempted for 60 minutes. He assured the committee that training teaches rescuers that circumstances may extend that time period. Sixty minutes is simply a guideline. The EMTs he is associated with would not stop resuscitation efforts at an exact set time if they felt there was a chance to save a life. Number 2008 ROCKY ANSELL, EMT, Copper River Medical Services, testified via teleconference from Glennallen. Testifying as an EMT in rural Alaska where response times may be quite extensive, he supported HB 39. He also had been involved in futile resuscitation efforts and had he been able to pronounce death legally, it would have been a blessing; not only to him but to the family members and the entire medical team. The family members knew their loved one was deceased, and if death could have been pronounced, the grieving process could have begun. As it was, the entire family was further traumatized by the actions of the medical responders who were doing their job as prescribed by the current law. MR. ANSELL continued that such a situation is unacceptable in Glennallen. He added that the section on post mortem lividity should be left in the bill, as it is just one of the many signs of death. He assured the committee that if a medical responder has any doubt about whether death has occurred, he or she attempts resuscitation. Number 2080 JACK HEESCH, President of the J.R. Heesch Company, and lobbyist for the Alaska Academy of Physician Assistants testified in person. He read into the record a letter which stated: "The Alaska Academy of Physician Assistants is in support of HB 39. This bill will give the authority to physician's assistants to pronounce death. While in urban areas, where physicians, coroners and law enforcement personnel are available, pronouncement of death is not generally a problem. But since our state is mainly rural and these personnel are often not available in the bush, it has become an issue. A number of villages and remote industrial sites have physician assistants available to perform the duty of pronouncement of death. Please give your support for the bill. Thank you." CO-CHAIR TOOHEY asked for any further testimony from the audience. Number 2117 REPRESENTATIVE TOM BRICE asked for clarification from Representative Therriault on the sectional analysis. He asked if it corresponds to the committee substitute bill or to the original HB 39. REPRESENTATIVE THERRIAULT responded that the sectional analysis was to the original bill. He felt it should still apply. CO-CHAIR TOOHEY closed the bill to public testimony and asked for the pleasure of the committee. Number 2140 CO-CHAIR BUNDE moved that CSHB 39 be passed from the HESS committee with the accompanying zero fiscal note onto the next committee of referral. Hearing no discussion, Co-Chair Toohey announced that the bill had been passed out of the committee. ADJOURNMENT CO-CHAIR TOOHEY adjourned the meeting at 3:46 p.m.