REPORT TITLE:
End of Life Care


DESCRIPTION:
Encourages use of physician orders for life-sustaining treatment;
clarifies law regarding patient's wishes; requires long-term care
facilities to provide hospice care if requested; adds standard
relating to quality of care at the end of life; requires schools
of medicine and nursing to include pain management in curriculum.
Appropriate $      to DOH to review, collate, and rewrite state
law on final care decisions.  Upon approval; appropriation
effective 7/1/99.

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                                        
THE SENATE                              S.B. NO.           846
TWENTIETH LEGISLATURE, 1999                                
STATE OF HAWAII                                            
                                                             
________________________________________________________________
________________________________________________________________


                   A  BILL  FOR  AN  ACT
RELATING TO END OF LIFE CARE.



BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF HAWAII:

 1      SECTION 1.  The blue ribbon panel on living and dying with
 
 2 dignity was formed by the governor in late 1996 to consider the
 
 3 many issues involved in death and dying and to suggest guidelines
 
 4 for public policy.  In May, 1998, the blue ribbon panel issued
 
 5 its final report and made seven recommendations, six of which
 
 6 were made unanimously.  The fourth unanimous recommendation
 
 7 recommends that hospice care be made more available and offered
 
 8 more expediently to the dying.
 
 9      Hospice care is not a place.  It is a service that can be
 
10 delivered at home, in a freestanding unit operated by the
 
11 hospice, in nursing or care homes, or even in beds set aside in
 
12 acute care hospitals.  Hospice care is a philosophy which accepts
 
13 that an illness has progressed to a terminal stage, and death
 
14 cannot be avoided even with aggressive medical treatment.  The
 
15 goal of hospice care is not to prolong life, but to make dying as
 
16 comfortable as possible for the person dying, and for family and
 
17 friends.  The blue ribbon panel asserts that if pain management
 
18 can be improved and hospice care increased, many of Hawaii's
 
19 health care providers believe that few people would consider
 

 
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 1 physician-assisted death, which may be viewed as desirable when
 
 2 pain is not controlled and when the patient foresees being in a
 
 3 sterile or strange hospital or other residential program, rather
 
 4 than dying at home in the presence of loved ones.
 
 5      The legislature finds that hospice care not only increases
 
 6 patient satisfaction but also almost always costs less than
 
 7 either hospital care or other forms of acute care at the end of
 
 8 life.  Yet, hospice care is underutilized.  Each year, of eight
 
 9 thousand deaths in Hawaii, five thousand could have benefitted
 
10 from hospice care, yet only about one thousand five hundred
 
11 persons received hospice care.
 
12      The purpose of this Act is to implement five specific
 
13 recommendations made by the blue ribbon panel regarding hospice
 
14 care:
 
15      (1)  Add a provision to the medical treatment decisions
 
16           (living will) law in chapter 327D, Hawaii Revised
 
17           Statutes, to address the use of physician orders for
 
18           life-sustaining treatment and expand and clarify the
 
19           law regarding the patient's wishes superseding the
 
20           declaration;
 
21      (2)  Require long-term care facilities to make available
 
22           hospice care services to their patients, if the
 

 
 
 
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 1           patients so desire, by entering into a contractual
 
 2           relationship, if necessary, with a medicare-certified
 
 3           hospice service agency to allow access to hospice
 
 4           services;
 
 5      (3)  Expand standards subscribed to by health care plans to
 
 6           include quality of care at the end of life;
 
 7      (4)  Require medical and nursing schools in the State to
 
 8           include pain management as part of the required
 
 9           curriculum; and
 
10      (5)  Appropriate funding for a project to comprehensively
 
11           review and collate state law on final care decisions to
 
12           enhance coordination among health care disciplines
 
13           while respecting multicultural and multi-religious
 
14           approaches to death.
 
15      SECTION 2.  Chapter 304, Hawaii Revised Statutes, is amended
 
16 by adding a new section to be appropriately designated and to
 
17 read as follows:
 
18      "§304-     Pain management for the dying; required in
 
19 curriculum.  (a)  The legislature finds that death is often
 
20 accompanied by pain which is severe enough to make living
 
21 unbearable.  On the other hand, an interdisciplinary approach to
 
22 the palliation of pain can in most instances bring relief,
 

 
 
 
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 1 comfort, and dignity during a person's final days.  Other
 
 2 symptoms which may contribute to an unbearable end of life
 
 3 experience include depression, anxiety, shortness of breath,
 
 4 nausea, constipation, diarrhea, wasting, and delirium.  The
 
 5 legislature also finds that an adequate level of pain control is
 
 6 not always instituted.  One contributing cause is the
 
 7 misunderstanding and lack of knowledge on the part of physicians
 
 8 and nurses regarding pain management.  Physicians and nurses
 
 9 sometimes have unreasonable concerns regarding the activities of
 
10 the United States Drug Enforcement Administration, are influenced
 
11 by fear of lethal side effects of pain medication, and often
 
12 underestimate the impact of pain on the lives of their patients.
 
13 The purpose of this section is to require the school of medicine
 
14 and the school of nursing to include pain management as part of
 
15 the required curriculum in the respective schools.
 
16      (b)  Prior to January 1, 2000, the school of medicine and
 
17 the school of nursing shall include pain management as part of
 
18 the required curriculum of each respective school."
 
19      SECTION 3.  Chapter 327D, Hawaii Revised Statutes, is
 
20 amended by adding a new section to be appropriately designated
 
21 and to read as follows:
 
22      "§327D-     Physician orders for life-sustaining treatment.
 

 
 
 
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 1 (a)  All health care providers who provide care to patients in
 
 2 health care facilities are encouraged to use a physician order
 
 3 for life-sustaining treatment pursuant to subsection (b).
 
 4      (b)  A "physician order for life-sustaining treatment" is a
 
 5 document that is intended to assist health care providers and
 
 6 health care facilities to honor the desires of their patients
 
 7 with regard to treatment decisions.  A physician order for life-
 
 8 sustaining treatment is intended to:
 
 9      (1)  Promote patient autonomy by documenting patient
 
10           treatment preferences and coordinating these
 
11           preferences with physician orders;
 
12      (2)  Clarify treatment intentions and minimize confusion
 
13           regarding patient treatment preferences;
 
14      (3)  Reduce repetitive activities in complying with the
 
15           Patient Self-Determination Act;
 
16      (4)  Facilitate appropriate treatment by emergency medical
 
17           service personnel;
 
18      (5)  Enhance the quality of patient care and to complement
 
19           the patient's declaration, if a declaration has been
 
20           executed; and
 
21      (6)  Centralize information, facilitate record-keeping, and
 
22           ensure the transfer of appropriate information,
 

 
 
 
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 1           including medical records, among health care providers
 
 2           and health care facilities.
 
 3 The physician order for life-sustaining treatment document shall
 
 4 not replace either a patient's declaration executed pursuant to
 
 5 this chapter, or other physician orders."
 
 6      SECTION 4.  Section 327D-7, Hawaii Revised Statutes, is
 
 7 amended to read as follows:
 
 8      "[[]§327D-7[]]  Patient's wishes [supersede declaration.]
 
 9 have priority at all times.  The desires of a declarant [shall],
 
10 at all times, shall supersede the effect of the declaration.
 
11 Unless a declaration is revoked or superseded by the desires of
 
12 the declarant, the patient's wishes as expressed in the patient's
 
13 declaration shall prevail over the wishes of any other person or
 
14 document.  Specifically, the patient's wishes as expressed in the
 
15 patient's declaration shall be followed as closely as possible by
 
16 the patient's attending physician even if the patient's wishes
 
17 differ from the wishes of the patient's:
 
18      (1)  Family or friends; and
 
19      (2)  Lawfully appointed proxy, surrogate decision-maker,
 
20           guardian, attorney-in-fact for health care decisions
 
21           appointed by the patient in a durable power of attorney
 
22           for health care decisions pursuant to chapter 551D, or
 

 
 
 
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 1           any other lawful representative."
 
 2      SECTION 5.  (a)  The legislature finds that many patients
 
 3 receiving medical care in long-term care facilities can also
 
 4 benefit from hospice care.  To further the goal of providing a
 
 5 seamless continuum of care to patients near or at the end of
 
 6 life, it is important to ease the transition between "curative"
 
 7 medical treatment to hospice care.
 
 8      (b)  Prior to January 1, 2000, all long-term care
 
 9 facilities, as defined in chapter 349, Hawaii Revised Statutes,
 
10 shall make available hospice care services to their patients, if
 
11 the patients so desire and, if necessary, enter into a
 
12 contractual agreement with a medicare-certified hospice service
 
13 agency to provide the hospice care.
 
14      SECTION 6.  (a)  The legislature finds that the quality of
 
15 hospice care needs to be assured to the same extent that other
 
16 types of health care are assured.
 
17      (b)  Prior to January 1, 2000, all health care providers and
 
18 health care facilities, including hospitals, medical clinics, and
 
19 health maintenance organizations that subscribe to the standards
 
20 of the Joint Commission Accreditation Health Organization, shall
 
21 independently subscribe to, without the need for permission,
 
22 agreement, or confirmation by the Joint Commission Accreditation
 

 
 
 
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 1 Health Organization, an additional quality assurance standard of
 
 2 quality of care at the end of life to include:
 
 3      (1)  Symptoms;
 
 4      (2)  Function;
 
 5      (3)  Advance planning;
 
 6      (4)  Aggressive life-extending treatment;
 
 7      (5)  Patient satisfaction;
 
 8      (6)  Family satisfaction;
 
 9      (7)  Quality of life;
 
10      (8)  Family burden;
 
11      (9)  Survival time;
 
12     (10)  Provider continuity and skill; and
 
13     (11)  Bereavement.
 
14      SECTION 7.  (a)  The legislature finds that although chapter
 
15 327D, Hawaii Revised Statutes, relating to medical treatment
 
16 decisions, enables individuals to execute declarations to direct
 
17 the provision, continuation, withholding, or withdrawal of life-
 
18 sustaining procedures, most residents of the State still do not
 
19 execute such declarations.  The blue ribbon panel on living and
 
20 dying with dignity found that, even when such declarations are
 
21 made, a significant percentage is ignored or not followed by
 
22 health care providers.  The panel suggested several contributing
 

 
 
 
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 1 factors to this phenomenon, namely, that existing statutes
 
 2 dealing with end of life care:
 
 3      (1)  Provide few incentives to execute declarations;
 
 4      (2)  Provide few sanctions to encourage compliance; and
 
 5      (3)  Contain no mechanism to determine whether the law is
 
 6           being complied with.
 
 7 Furthermore, the legislature finds that existing state laws
 
 8 dealing with end of life care are fragmented and scattered
 
 9 throughout the Hawaii Revised Statutes.  The purpose of this
 
10 section is to appropriate funds to carry out a comprehensive
 
11 collation, reorganization, and rewriting of state law on end of
 
12 life care decisions in order to enhance coordination among health
 
13 care disciplines while respecting multicultural and multi-
 
14 religious approaches to death and to encourage the use of
 
15 declarations, encourage compliance with state law, and establish
 
16 a mechanism to monitor and determine compliance with state law
 
17 with regard to end of life care.
 
18      (b)  There is appropriated out of the general revenues of
 
19 the State of Hawaii the sum of $         , or so much thereof as
 
20 may be necessary for fiscal year 1999-2000, to carry out the
 
21 purposes as stated in subsection (a).  The sum appropriated shall
 
22 be expended by the department of health for the purposes of this
 

 
 
 
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 1 Act.
 
 2      SECTION 8.  Statutory material to be repealed is bracketed.
 
 3 New statutory material is underscored.
 
 4      SECTION 9.  This Act shall take effect upon its approval,
 
 5 except that section 7 shall take effect on July 1, 1999.
 
 6 
 
 7                              INTRODUCED BY:______________________