MINUTES OF THE ASSEMBLY COMMITTEE ON HEALTH AND HUMAN SERVICES Sixty-eighth Session June 5, 1995 The Committee on Health and Human Services was called to order at 1:30 p.m., on Monday, June 5, 1995, Chairman Jan Monaghan presiding in Room 330 of the Legislative Building, Carson City, Nevada. Exhibit A is the Agenda. Exhibit B is the Attendance Roster. COMMITTEE MEMBERS PRESENT: Mrs. Vivian L. Freeman, Chairman Mrs. Jan Monaghan, Chairman Mrs. Jan Evans, Vice Chairman Dr. William Z. (Bill) Harrington, Vice Chairman Mrs. Deanna Braunlin Ms. Barbara E. Buckley Mr. David Goldwater Ms. Saundra (Sandi) Krenzer Mr. Dennis Nolan Ms. Dianne Steel Ms. Patricia A. Tripple Mr. Wendell P. Williams GUEST LEGISLATORS PRESENT: Mrs. Gene Wines Segerblom STAFF MEMBERS PRESENT: H. Pepper Sturm, Chief Principal Research Analyst OTHERS PRESENT: Yvonne Sylva, State Health Administrator Sharon Ezell, State Health Division David Rowles, Clark County Health District Stephanie Beck, Washoe County Health District Lucille Lusk, Nevada Concerned Citizens Larry Matheis, Nevada State Medical Association Otto Ravenholt, Clark County Health Officer La Rue Scull, Clark County Health District Chairman Monaghan began the meeting with a work session, (Exhibit C.) ASSEMBLY BILL 522 - Requires the welfare division to establish program to impose certain educational requirements and responsibilities for academic progress and immunization of dependent children on certain recipients of aid to families with dependent children. Mrs. Monaghan had prepared amendments to A.B. 522, (Exhibit D,) and explained those to committee members. ASSEMBLYWOMAN VIVIAN FREEMAN MOVED TO AMEND, DO PASS AND RE-REFER A.B. 522 TO WAYS AND MEANS WITH NO RECOMMENDATION. ASSEMBLYMAN WILLIAM HARRINGTON SECONDED THE MOTION. THE MOTION CARRIED UNANIMOUSLY. ********* ASSEMBLY BILL 659 - Establishes procedures pursuant to which person may choose not to be resuscitated in event of cardiac or respiratory arrest. Assemblywoman Gene Wines Segerblom, representing District 22, explained she requested A.B. 659 because of incidents concerning people who had specifically requested no resuscitation but who were resuscitated to no avail. Mrs. Segerblom mentioned she sought help from Assemblymen Harrington and Nolan in drafting the language. Assemblyman Nolan expressed enthusiasm for A.B. 659. He pointed out in pre- hospital situations of terminal illness occasionally a case "falls between the cracks" and turns into a nightmare for the patient. The person might be successfully revived only to discover he had not succumbed to his terminal illness as he had been prepared to do, or the patient might not be successfully revived but had received enough advanced life saving care that the terminal condition was prolonged and the family had to pay enormous and expensive bills. Mr. Nolan indicated Mrs. Segerblom, in seeking to craft legislation on the subject, had looked at the Montana plan and structured A.B. 659 from that program. He explained the Montana plan is a very well developed, statewide program that not only issues wrist bands and written documentation orders for do not resuscitate (DNR), but also has training programs for hospice and medical facilities as well as physicians that help implement the program. He mentioned most Nevada counties had established do not resuscitate programs to some degree, however he believed there are new components to A.B. 659 that could be combined with existing programs to put together a fail-safe program. Mr. Nolan pointed out he had received testimony from health districts and other providers who requested amendments and he agreed with all the Clark County Health District's proposed changes. Mr. Nolan also proposed amending page 2, section 10, and adding "or natural progression of those events as a result of a terminal condition" to line 24 after ". . . in the event of a cardiac or respiratory arrest". Another amendment Mr. Nolan requested involved section 11, subsection 3, where he would like to include "an agent or caretaker for an individual who has become incapacitated" who may initially have been able to request do not resuscitate but had subsequently become unable to. Mrs. Monaghan indicated she would close the hearing on A.B. 659, continue with the work session, and re-open the hearing for further testimony later. SENATE BILL 153 - Makes various changes to provisions governing planning for health care. Mrs. Monaghan stated the only amendment she had for S.B. 153 was proposed by the state health division which requested deleting the figure $4,000,000 in section 4, page 2, line 41 and replacing it with $2,000,000. Mrs. Freeman inquired what the reasoning behind the amendment was. Yvonne Sylva, State Health Administrator, testified money for medical facilities and equipment did not go very far today, and there was concern on the part of rural hospitals if the threshold were set at the higher figure it would be too high. They wanted to be assured another facility would not be coming into their market to compete. ASSEMBLYWOMAN VIVIAN FREEMAN MOVED TO AMEND AND DO PASS S.B. 153. ASSEMBLYWOMAN DEANNA BRAUNLIN SECONDED THE MOTION. Assemblywoman Krenzer disclosed she works for a health maintenance organization (HMO) however she did not believe it would be impacted more than any other HMO and she would be voting on S.B. 153. Assemblyman Harrington stated he preferred S.B. 153 without the amendment. What the bill is addressing is the creation of new health care facilities without so much bureaucratic overhead and expense. Lowering the threshold, he maintained, would simply create additional red tape. Assemblyman Goldwater indicated bureaucratic red tape is sometimes a necessary part of the checks and balances in executing a state health plan. THE MOTION CARRIED. (ASSEMBLYMAN DAVID GOLDWATER VOTED NO.) Mrs. Monaghan requested Dr. Harrington make the floor statement. ********* ASSEMBLY BILL 637 - Revises provisions governing crimes related to tobacco and licensing of cigarette dealers. Mrs. Freeman requested Mr. Sturm explain amendments proposed by the subcommittee which met on May 30, 1995. Pepper Sturm, Chief Principal Research Analyst, presented the subcommittee report and proposed amendments to A.B. 637, (Exhibit E.) Mrs. Freeman explained the subcommittee heard from everyone who had an interest in the bill, and they felt by removing some of the language in the bill, it had a better chance of passing this session. Discussing the final amendment concerning appropriation of $120,000, Mrs. Freeman indicated the state simply does not have the money to administer programs that would prevent sales of cigarettes to minors. She also mentioned even though the $120,000 was not in the budget, the Governor's office had stated it would support the appropriation. She mentioned A.B. 637 would have to be re- referred to Ways and Means. Assemblywoman Steel, referring to page 3, lines 1 and 2, asked why the signage for smoking and non-smoking areas was being reversed. She explained the other 49 states utilize "no smoking" signs rather than "smoking permitted" signs and worried tourists and other visitors to Nevada might be confused. Mrs. Freeman stated it fits with the rest of the bill and is an integral part of it. The bill assumes all public buildings are non-smoking so the smoking areas would be designated. Ms. Steel inquired whether "public buildings" also meant casinos. Mrs. Freeman pointed out line 16, page 3 eliminates casinos. Larry Matheis, representing the Nevada State Medical Association, believed the issue to be quite straightforward. He stated it is dangerous to go into an area where smoking is permitted, so in Nevada it would be assumed the area that would be polluted (with cigarette smoke) would be the area that would be marked. Ms. Steel reiterated it would be more logical to place "no smoking" signs where it is against the law. Assemblyman Williams commented A.B. 637 does not prevent the posting of "no smoking" signs in a facility. ASSEMBLYWOMAN BARBARA BUCKLEY MOVED TO AMEND, DO PASS AND RE-REFER A.B. 637 TO THE ASSEMBLY COMMITTEE ON WAYS AND MEANS. Dr. Harrington emphasized A.B. 637 would be the best bill the committee would be able to pass from a political standpoint. He pointed out how many people are dying as a result of the tobacco industry, and stated we must start the process of protecting our children and each other. A.B. 637, he felt, would go a long way toward starting that process and placing Nevada in compliance with the federal government. Passage of A.B. 637 would also allow Nevada to continue to receive federal aid for the Bureau of Alcohol and Drug Abuse. ASSEMBLYMAN WENDELL WILLIAMS SECONDED THE MOTION. THE MOTION CARRIED. (ASSEMBLYWOMAN DIANNE STEEL VOTED NO.) ********* ASSEMBLY BILL 584 - Creates advisory committee on health care planning to provide advice to the legislative Committee on Health Care. Mrs. Braunlin disclosed she would not be voting on A.B. 584 per her statement on May 31, 1995. Mrs. Evans, referring to section 2, subsection 2 which states ". . . the advisory subcommittee consists of . . .", stated the new language would read ". . . the advisory subcommittee may consist of . . .". Further, the list of categories to be included in the advisory subcommittee was changed, so at section 2, line 10 the wording was changed to read, "Organizations that provide managed care". By request, Mrs. Evans added items (q), which is "the Division of Insurance, Department of Business and Industry"; (r) "local government" and (s) "a person with a disability" to the list. She also changed item (p) to item (u) and the new item (p), by request, would be "the State Board of Health". The new item (u) will still read, "other categories of representation deemed relevant by the committee". As Mrs. Evans pointed out in her initial testimony, the intent of A.B. 584 was to include all interested parties. ASSEMBLYMAN WENDELL WILLIAMS MOVED TO AMEND AND DO PASS A.B. 584. ASSEMBLYWOMAN VIVIAN FREEMAN SECONDED THE MOTION. Dr. Harrington reiterated his previous comment that a number of providers and recipients are represented on the advisory commission but there would be no representation by the taxpayers who would be paying for it all. Mrs. Evans agreed that was a good suggestion and when she discussed it with the bill drafters, they believed it was assumed taxpayers would be represented under the new category "(u) other categories of representation deemed relevant by the committee". If the committee wanted a specific statement to that effect, Mrs. Evans reiterated she had no objection. She pointed out the list was getting very long. Mrs. Monaghan noted the people represented by the categories are already taxpayers and stated that should be sufficient. Dr. Harrington reiterated without taxpayer input from the start, any plans the advisory committee might develop stood a good chance of rejection just as the Clinton health plan had been rejected. Mr. Goldwater mentioned members of the legislature, who would be members of the advisory commission, do represent the taxpayers of Nevada and would be representing their constituents' interests. He agreed the advisory committee was a good idea because health planning in Nevada is lackluster and inadequate. Mr. Williams wondered if category (e) included non-profit organizations and Mrs. Evans asserted it did. THE MOTION CARRIED. (ASSEMBLYWOMAN DEANNA BRAUNLIN ABSTAINED FROM VOTING.) ********* Mrs. Monaghan re-opened the hearing on A.B. 659. Dr. Harrington stated A.B. 659 was an excellent concept, however it did need some amendments, primarily changing the language from "resuscitation" orders to "do not resuscitate" orders. He pointed out hospitals currently use bracelets, which are universally recognized. Mrs. Freeman inquired how one would take advantage of A.B. 659 once it becomes law. Dr. Harrington replied a patient with a terminal illness would need to see his physician who, at the patient's request, would sign legal forms and then the physician would issue a bracelet engraved with the do not resuscitate information. As long as the patient is wearing that bracelet emergency personnel would be aware he had requested not to be resuscitated in the event of a cardiac arrest. At any time the patient may remove the bracelet and then resuscitation would be attempted. Mrs. Freeman asked where the legal papers could be obtained. Dr. Harrington responded attorneys and physicians would have them. Mrs. Freeman inquired what current regulations are. Dr. Harrington explained Clark County provides two forms, one for the physician and one for the DNR declaration. As long as one had the paperwork on their person and emergency medical personnel found the papers and ascertained they were valid and in force, they would not attempt resuscitation. He noted in reality very few people carry that paperwork around everywhere they go. Dr. Harrington pointed out the problem is that people who do not want to be resuscitated, are resuscitated. Sometimes they survive and sometimes they do not, but either way they receive a big bill which is what A.B. 659 is trying to avoid. Mrs. Freeman inquired what might occur if hospital protocol did not fit with the "do not resuscitate" philosophy. Dr. Harrington explained the bracelets were strictly for "out of hospital" use. Once admitted to a hospital, hospital protocol would be followed. Mrs. Freeman mentioned the penalty portion of A.B. 659 and wondered under what circumstances that might occur. Dr. Harrington replied physicians under law have a responsibility to honor the "do not resuscitate" request. If a physician believes that to be morally wrong, he has the obligation to transfer that patient to a physician who does not have those beliefs. Mrs. Monaghan mentioned the bracelets would only be available through an attorney or licensed physician. Dr. Harrington explained a concern bill sponsors had was if the bracelets were readily available, it might open the door to potential mischief. He noted other states also use a controlled format to be certain a person has a terminal illness that would warrant the do not resuscitate order. It also provides protection for the paramedics and any other emergency personnel that there is documentation of the DNR order. Ms. Tripple inquired why A.B. 659 is limited to terminally ill people. Dr. Harrington replied everyone can get a living will and establish that they do not want to be resuscitated once they get to a hospital. He mentioned unless a person is terminally ill, the presumption in medicine is to go all out to save life. Mr. Goldwater reiterated medical personnel would never err on the side of not resuscitating someone. Sharon Ezell, Chief of the Bureau of Licensure and Certification, explained A.B. 659 would require the health division to be responsible for maintaining the registry of those people who have the bracelets. They would also be responsible for ordering the bracelets and getting them to the right people and would be allowed to charge a fee for manufacturing of the bracelet. Ms. Ezell indicated if the bill continues to only apply to the terminally ill, the health division would be capable of conducting the program for the first biennium. However, if the number of applicants is more than anticipated or if the process becomes more complex due to legality issues, the division may require fiscal support for the necessary staff and legal support. Ms. Ezell also submitted her proposed amendments to A.B. 659, (Exhibit F,) and she also mentioned Clark County had additional amendments to propose which she was in concurrence with. David Rowles, Director of Administration for the Clark County Health District, explained for over a decade they have developed a fine pre-hospital system that provides emergency medical services to the citizen taxpayers as well as the approximately 24 million visitors a year who enter Clark County's locale. Mr. Rowles distributed copies of the Clark County Health District's letter to Mrs. Segerblom outlining their support for A.B. 659 and indicating areas of the bill they believed required amending, (Exhibit G.) Otto Ravenholt, Clark County's Chief Health Officer and Emergency Medical Services System Director, also spoke in favor of A.B. 659 and provided samples of "do not resuscitate" orders currently being used in Clark County, (Exhibit H.) He agreed with the bracelet option as added identification for individuals, however he believed it might be a mistake to mandate a bracelet as the only means of signifying a DNR position. La Rue Scull, Emergency Medical Services Coordinator at the Clark County Health District, mentioned he had discussed A.B. 659 with the fire and ambulance services in Clark County and all had agreed addition of the bracelet would be beneficial because it would be something that would be easily identifiable as opposed to trying to read a five or six page document such as a living will. Commenting on DNR orders, Mr. Scull wondered if there would be any reciprocity with other states, however no one answered him. Stephanie Beck, Emergency Medical Services Coordinator for the Washoe County District Health Department, testified the health department had developed a one page form similar to the one Las Vegas uses, (Exhibit I.) She added there need not be a terminal condition for the paperwork Washoe County had developed. Ms. Beck said initially there was confusion over exactly what "do not resuscitate" meant so they came up with a specific definition and protocol, (Exhibit J.) She stated it would be very clear to everyone exactly what DNR would mean if the bracelet were utilized. Lucille Lusk read a letter in opposition to A.B. 659 from Patricia Glenn, representing Nevada Right to Life, (Exhibit K.) Ms. Lusk, representing Nevada Concerned Citizens and herself, then proceeded to speak in favor of A.B. 659. She stated the bill allows a person to determine their own medical care while in a competent position to do so and to die of natural causes. Ms. Lusk, referring to page 2, lines 42 and 43, states a physician's DNR order is effective only if the patient has agreed to its terms either orally or by signature while he is capable of making an informed decision. She requested the word "orally" be removed explaining if the person was competent, a signature could have been obtained. Further on page 3, Ms. Lusk noted there is protection from liability for a doctor or medical emergency personnel if they observe the bracelet and do not resuscitate, or if they do resuscitate in response to motions from the patient. However, she questioned the ramifications if emergency personnel should accidentally fail to observe the bracelet. She wondered whether there were protection for that individual for making a good faith effort. Referring to page 4, line 31, Ms. Lusk stated A.B. 659 does not condone, authorize or approve mercy killing or euthanasia and she requested the phrase "assisted suicide" be added to that list right after the phrase "mercy killing". Mrs. Monaghan stated her intention to work with Mrs. Freeman and all concerned parties on amendments to A.B. 659. There being no further business, the meeting was adjourned at 3:15 p.m. RESPECTFULLY SUBMITTED: Terry Horgan, Committee Secretary APPROVED BY: Assemblywoman Vivian L. Freeman, Chairman Assemblywoman Jan Monaghan, Chairman Assembly Committee on Health and Human Services June 5, 1995 Page