MINUTES OF THE meeting
of the
ASSEMBLY Committee on Health and Human Services
Seventy-First Session
March 19, 2001
The Committee on Health and Human Serviceswas called to order at 1:30 p.m., on Monday, March 19, 2001. Chairman Ellen Koivisto presided in Room 3138 of the Legislative Building, Carson City, Nevada. Exhibit A is the Agenda. Exhibit B is the Guest List. All exhibits are available and on file at the Research Library of the Legislative Counsel Bureau.
COMMITTEE MEMBERS PRESENT:
Mrs. Ellen Koivisto, Chairman
Ms. Kathy McClain, Vice Chairman
Ms. Sharron Angle
Ms. Merle Berman
Mrs. Vivian Freeman
Ms. Dawn Gibbons
Ms. Sheila Leslie
Mr. Mark Manendo
Ms. Bonnie Parnell
Ms. Debbie Smith
Mr. Wendell Williams
COMMITTEE MEMBERS ABSENT:
Ms. Sandra Tiffany
GUEST LEGISLATORS PRESENT:
Assemblyman Dennis Nolan, District 13
Assemblywoman Chris Giunchigliani, District 9
STAFF MEMBERS PRESENT:
Marla McDade Williams, Committee Policy Analyst
Darlene Rubin, Committee Secretary
OTHERS PRESENT:
From Las Vegas:
David Nelson, M.D., Las Vegas Pediatric Society, University Medical Center
Jonathan Bernstein, M.D., Children’s Center for Cancer and Blood Diseases
Meena Vohra, M.D., Director, Pediatric Intensive Care, University Medical Center
Diane Lipscomb, M.D., Sunrise Children’s Hospital
Karen Cross, M.D., Nathan Adelson Hospice
Sandra Evans, Private Citizen
Kelly Quinn, EMS Field Representative, Clark County Health District
From Carson City:
Barry Frank, M.D.
Mike Willden, Welfare Department
Note: Simultaneous videoconference in Room 4401 of the Grant Sawyer Office Building, 555 East Washington Avenue, Las Vegas, Nevada.
Chairman Koivisto opened the hearing on A.B. 173 with witnesses from Las Vegas.
Assembly Bill 173: Expands circumstances under which emergency life-resuscitating treatment may be withheld from patient in terminal condition. (BDR 40-437)
Dr. David Nelson, pediatric emergency physician at University Medical Center (UMC), Las Vegas, said he and other physicians at UMC believed pediatric “Do Not Resuscitate” (DNR) should be included in A.B. 173. They felt it was a neglected area and very important to be addressed.
Dr. Nelson stated the reason children should be included was, although uncommon, there were certain children with terminal illnesses whose families had worked with their own physicians, clergy, and other family members to reach a decision that when the child became worse they did not want to go through heroic measures to keep the child alive when it was not in the child’s best interest. He explained that a family with a terminally ill child got very nervous about a child dying at home. When the parents believed their child was about to die they called an ambulance, because they did not know who else to call, and when the ambulance personnel arrived they had no choice but to institute full life-saving measures, which was usually not what the parents wanted. Once the ambulance personnel started those life-saving measures they were continued until they reached the emergency department, then it would be up to Dr. Nelson to carry on with treatment until documentation was presented or until it was clear that the child would not survive despite all efforts.
Dr. Nelson said the UMC’s pediatricians felt it was not in the best interests of the child, the family, or anyone else involved. It took a considerable amount of effort to obtain a DNR order for the child, and the pediatricians felt it was between the physicians and the families and therefore would like to see that order honored by the prehospital personnel called out to such scenes.
Dr. Jonathan Bernstein, oncologist, University Medical Center, stated that often he started off with his oncology patients at the time of diagnosis discussing what would happen if, for example, the child’s condition should worsen. He said they discussed that throughout the child’s care and generally by the time it was known that therapy would not be successful, the parents would make a decision a month or two prior to the child’s death to care for the child at home, and he helped them with that care. What happened then was if the parents were unsure of something and paged him, he would go to the home to examine the child. But, if for some reason he or another physician could not get to the home, the emergency response people would be called and they had no choice but to intubate the patient. The parents were then in a difficult situation; they did not want the child intubated; they thought of it more as an assault on the child. They had already discussed with their physician, clergy, and family, and reached their decision what should be done when the end came. But suddenly they were being forced to do something else.
Dr. Nelson returned to add that the American Academy of Pediatrics (AAP), in April 2000, issued a statement for DNR orders in schools and he felt some of it applied to at-home situations. The AAP statement stressed that:
A DNR order was not synonymous with abandonment of all medical treatment, and does not of itself rescind the obligation of the health care team to provide quality care such as suction, oxygen and pain medication, rather it is dynamic part of the management plan to be reviewed with the family and the physicians.
Within that same statement, the AAP also recommended:
Pediatricians and their chapter and district members to work with local and state authorities responsible for EMS policies affecting out of hospital DNR orders to develop rational procedures and legal understanding about what can be done that respects the rights and interests of dying children.
Dr. Meena Vohra, Director of the Pediatric Intensive Care Unit (ICU), UMC, stated that after children with chronic diseases were resuscitated they came into the ICU and were held there for a day or two while everyone was trying to decide what to do, or getting to know the family if they were new to the system, or attempting to find out what was going on. It was very stressful for the family and the staff, notwithstanding how expensive it was for the family or for state insurance, if that was a factor, when the situation could have been handled out of the hospital in a more peaceful environment. A DNR order was not something taken lightly, especially with children. Physicians had not reached that conclusion until they had explored all other options. Ms. Vohra said the DNR order existed in all other states and it was time Nevada began to honor the wishes of the family, and make sure those children were not unnecessarily put through aggressive measures.
Assemblywoman Leslie thanked the witnesses for appearing from Las Vegas and said their testimony was very helpful. She noted that Dr. Nelson had stated how difficult it was to obtain a DNR for a child; accordingly she wanted to know if a judge was involved in the process. Also, she asked if there was any oversight.
Dr. Nelson deferred to Dr. Bernstein to answer. Dr. Bernstein explained that first there was a discussion with the parents, and generally in those situations he had a longstanding relationship with them. He went over the fact there might be no other way to treat and cure the child, then they discussed what kinds of actions they wanted to pursue medically should their condition worsen. He then filled out a letter for them that they kept at home.
Dr. Nelson added that under no circumstances would parents, for example, of a mentally retarded child who seemed to be a lot of work, approach a physician and say “I’m tired of taking care of this child, can I get DNR orders?” That was not something that was taken lightly. He did not believe there was a physician anywhere who would sign a piece of paper for that. He emphasized the orders were written for patients with cancer or congenital heart illnesses, and although not very common it did come up once or twice a month in the emergency department, and probably the same in the ICU. He added he had spoken with Dr. Jim Christensen, who took care of a large majority of UMC’s pediatric AIDS patients, and Dr. Christensen said he had just two patients currently with DNR orders. Nevertheless, it was an issue for the physicians and families concerned.
Dr. Nelson reported he had also spoken to a number of physicians who had patients with problems, specifically pediatric cardiologists, pulmonologists and other subspecialties who were overwhelmingly in favor of changing the legislation for the benefit of their patients and their families.
Dr. Bernstein added that when discussions were held with the patient’s family there was always one other medical care professional in attendance at the same time; usually a nurse or another doctor. Dr. Vohra also emphasized the decision was made by a committee of medical personnel involved in the care of the child.
Assemblywoman Leslie felt that was very helpful. She asked also, had there ever been a conflict between what a child wanted and what the parent wanted, and how would that be handled. She clarified that to mean in the case of an older child who did not want the DNR and the parents who did; had a conflict like that ever arisen, and if it had whose wishes would be followed.
Dr. Bernstein said the child’s wishes would be followed as far as the DNR. Then the parent’s wishes if the child was incapacitated and there was no way to find out what the child’s wishes were. Generally the situation was the opposite; several situations had arisen where a child had wanted DNR but the parents had not wanted it. In those situations it was a combination of both the parent’s and child’s wishes. If either one said they did not want DNR, Dr. Bernstein said he was bound by whoever said they did not want it.
Dr. Barry Frank, Medical Director of the Pediatric Intensive Care Unit at Washoe Medical Center, said he was not representing Washoe Medical Center or the Pediatric Intensive Care Unit, but rather testifying as a pediatrician who specialized in intensive care. He stated he was also a member of Paramedic Advisory Committee (PMAC) for Regional Emergency Medical Services Advisory (REMSA), and neither was he representing those agencies. He had practiced in Reno for over 20 years. He echoed the statements of his Las Vegas colleagues in support of the pediatric amendment. Further, he believed it was as important to allow DNR orders to be honored in the outpatient setting as they were in the inpatient setting for pediatric patients. There were pediatric patients who had terminal illnesses and if a mistake was made and 911 was called by someone who was unaware of the plan to die peacefully, then the paramedics or EMTs should be allowed to honor a properly executed DNR order when signed by appropriate family members as well as responsible physician.
Next, from Las Vegas, was Dr. Diane Lipscomb, pediatric critical care physician, Sunrise Children’s Hospital. Dr. Lipscomb reported many medical technologies gave children a chance to have wonderful lives, however, there were still many conditions physicians were unable to cure (Exhibit E). Unfortunately technology did not help those children but created more pain and suffering. Recognizing and allowing children, teenagers, and babies to have DNR orders that were recognized by prehospital personnel was vitally important because many of those children would be at home. When the child’s condition worsened many families wanted the comfort of a hospital or hospice setting, and needed the transport of prehospital personnel. However, they did not want their child to undergo resuscitative procedures that would be painful and create more suffering in their last moments of life, or in the terminal phases of their illness. Therefore, it was very important pediatric patients be given the same dignity and respect as adults in terms of recognizing DNR policies for those children.
Also from Las Vegas, Kelly Quinn, Emergency Medical Services (EMS), Clark County Health District, reiterated his testimony given at the previous hearing of A.B. 173, on March 7, 2001. He did offer a new issue of concern which was the MedicAlert tag or bracelet and medallion, and having the requirement for the information to be contained on that identification item to be set forth in regulation rather than in statute.
Assemblywoman Leslie asked to clarify the issue of using regulations or statute to spell out what should be on the bracelet. She asked Mr. Quinn if he was testifying in favor of doing it through regulation rather than statute. Mr. Quinn responded “yes.”
Sandra Evans, a Las Vegas resident, was representing her 90-year-old mother who lived in the TLC Care Center, Henderson, Nevada. When she moved her mother to that facility in April 2000, the social worker had Mrs. Evans complete paperwork that gave Mrs. Evans authority over her mother’s medical care; everything had to be spelled out exactly. At the time she was placed there her mother was capable of telling the staff what she wanted done. Mrs. Evans’ concern was that although her mother had given DNR orders, the facility called 911 for emergency situations and the EMTs would not look on her chart, where the DNR order was listed. She said if her mother’s condition deteriorated she might not be able to fill out another paper. She believed the emergency personnel should abide by the existing statute that said the DNR orders had to be complied with, and, further, that her mother should not be required to wear a bracelet or tag that she might take off or did not have on her person at the time.
Chairman Koivisto asked if the paperwork Mrs. Evans referred to was a medical power of attorney. Mrs. Evans said it was. Mrs. Koivisto said that was not the same thing as a DNR order. Mrs. Evans said she also had a DNR order on her chart. Mrs. Koivisto was unclear about Mrs. Evans’ concern. Mrs. Evans said her concern was that if something happened to her mother, the facility called 911 and she would be transported to a hospital; what would be done to her mother in transport. If the EMT followed the standard operating procedure then she would be kept alive if she should go into cardiac arrest. There was a 20-minute period when her rights were being ignored, when she could not say she did not want to be resuscitated.
Chairman Koivisto asked Assemblyman Nolan, for many years an EMT and the sponsor of the legislation, to respond.
Assemblyman Dennis Nolan, District 13, noted he had been joined on the bill by Assemblyman John Oceguera, District 16, who was an active first respondent firefighter. Mr. Nolan believed the issue Mrs. Evans had addressed was the fact that the bill and the DNR orders applied to those people who had been deemed and qualified as terminally ill people. It did not address people who did not have a terminal illness, and in her mother’s case, a 90-year-old woman who could expire from any number of acute causes at any given time in the future. If the facility called 911 to transport her to an acute care facility and in the process she went into cardiac arrest, without a DNR order as authorized in statute through one of the health divisions, the emergency medical service personnel would be obligated to begin resuscitative efforts.
Mr. Nolan stated the issue had been dealt with under A.B. 29 of the Sixty-Ninth Session, which established procedure that authorized a qualified patient to choose not to be resuscitated in event of cardiac or respiratory arrest. It was felt that terminal illnesses as diagnosed by a physician, and after the patient had gone through the scrutiny of the DNR process, would be the focus of the legislature’s attention. He added there were so many unknown acute disorders that could cause sudden death and cardiac arrest that they could not be identified, and there were so many variables; such as people who would want their 90-year old mother resuscitated if an acute situation occurred, yet others who felt it would not be in their best interests. Mr. Nolan said A.B. 173 addressed those people who had been determined to have terminal illnesses.
Chairman Koivisto tried to clarify the issue further by explaining there were two groups of people and further legislation would be required in order to take care of people such as Mrs. Evans’ mother. Mr. Nolan said that was correct. The two groups were those with terminal illnesses and others who did not wish to be resuscitated at the time of their death. It was a deep, moralistic question as to how to apply the standard.
The Chair then asked Mrs. Evans if she felt her question had been answered. Mrs. Evans said “to a point.” Her main question, she said, was her mother was in a skilled nursing facility, licensed by the state, and her mother had completed all the proper paperwork, and Mrs. Evans had had no part in the decision of whether or not her mother should be resuscitated. Her mother had chosen DNR, therefore, Mrs. Evans did not understand why the facility could not call the health district or other authority and explain the situation; namely, that a 90-year-old patient, in sound mind, had signed a DNR order, that her daughter knew of the situation, and the facility needed a DNR card for her. What, Mrs. Evans asked, prevented the authority from issuing a DNR card when everything was in order.
Chairman Koivisto said it sounded like Mrs. Evans’ mother might have an advanced directive, and the situation would depend upon whether or not the emergency personnel were aware of the directive and followed it. Mrs. Evans said her mother did have an advanced directive, also in her chart. Mrs. Koivisto felt that would probably deal with the situation. Mrs. Evans pressed that “until they walked out the front door of the facility, put her into an ambulance and took her to a hospital.” That might take 20 minutes or more, and that was Mrs. Evans’ concern. During that period it was up to the discretion of the EMT or paramedic, in full awareness of what she had on her chart, because she might not have the paper or card a patient needed with her to alleviate the EMT from responsibility if they did not resuscitate. Mrs. Evans understood that. She still felt, however, if that was the case they needed to find a solution for the treatment facility. Perhaps when the facility called for transport, they could fax the DNR information to the response personnel so they could see the signature, or hand it to the emergency personnel upon arrival, so the patient’s wishes would be recognized. Mrs. Koivisto said she had been advised that under current law, that should be taken care. The advanced directive should prevent heroic measures.
Dennis Nolan said the paramedics had telemetry capabilities with the hospitals they were transporting to. Unfortunately, in the documentation, doctors used different types of advanced directives, worded differently, and different types of powers of attorney, and that was the reason for the DNR bill, to standardize the language so emergency medical professionals from any agency would recognize one type of standard order. If the paramedics and EMTs were in a situation where they had been informed by the medical staff at the outset that a DNR order or an advanced directive was on file, and they transported a patient who went into cardiac arrest, more than likely in contacting the receiving hospital and notifying them of the situation, usually the instruction given back was to “provide respiratory assistance until you arrive in the emergency room and we will make an assessment.” Upon arrival, the hospital went through the documentation and the doctor would be the one to give the DNR order.
Chairman Koivisto suggested that Mrs. Evans discuss her concerns with Mr. Kelly Quinn, in Las Vegas.
Mr. Quinn said the situation with all those legal documents, DNR order, advanced directive, and so on, was exactly the issue that was being addressed by A.B. 173. Currently the statute did not allow emergency personnel to honor those documents.
The Chairman closed the hearing on A.B. 173 and opened the work session on A.B. 15.
Marla McDade Williams, Committee Policy Analyst, provided a work session document (Exhibit C). Four bills were scheduled for the work session; A.B. 15, A.B. 52, A.B. 173, and A.B. 196. The committee had intended to address A.B. 195; however, the bill would be set for a later date.
Assembly Bill 15: Requires establishment of program to provide supportive assistance to certain persons who obtain legal guardianship of their grandchildren. (BDR 38-368)
Ms. Williams stated that an explanation of the proposed amendment to A.B. 15 was provided on page C-3 of Exhibit C. The summary of the amendment, proposed by Assemblywoman Giunchigliani, specified the key differences between the bill and the amendment, as follows:
The fiscal note analysis, prepared by the DHR, was also included (C-10, 11, and 12 of Exhibit C).
Vice Chairman McClain asked about the deletion (4) that no parent could reside in the same household as the child. She believed the concept was that the parents were out of the picture, the grandparents were taking over as the parents, and the idea was to provide them some assistance as a foster parent. By removing that condition it was possible the parent and child would move in with the grandparents so the grandparents could collect money.
Assemblywoman Giunchigliani, District 9, responded to that and stated that initially the bill was under Department of Child and Family Services (DCFS). After the hearing it was clear that besides wanting the money for foster care, the main objective was to get the state out of their home and affairs, namely the visits by social workers and regulatory agencies. Therefore, the amendment was drafted so that they would be moved under the Temporary Assistance to Needy Families (TANF), in the Welfare Division (WD) instead of DCFS. Regarding the parent living in the home, Ms. Giunchigliani did not believe that would be recommended under TANF. However, after a parent had been released from prison, which was often the case, some of the judges were starting to look at getting the rebonding started between parent and child so sometimes there might be a reason for them to allow the parent to reside in the home with the grandparent, because the grandparent still maintained the legal guardianship. If that parent turned their life around and became successful they would reapply for legal guardianship and the money to the grandparent would cease.
Mike Willden, Welfare Administrator, said Ms. Giunchigliani had answered correctly, that TANF rules did not allow the grandparent and parent to be in the same home and to receive TANF. However, there was a provision in TANF rules that when reunification of child and natural parent was in process there could be up to a six-month period that allowed for that reunification. Therefore, the division did not want to prohibit the parent of the child from being in the home during that up to six-month reunification period for the reasons outlined above.
Assemblywoman Leslie remarked that Assemblywoman Giunchigliani had done a good job with a difficult bill. She asked what had been the rationale for the age 62 or older provision, and the specified relative provision. Ms. Giunchigliani said the original concept was “kinship care.” Many used the term “grandparents” and the language had been drafted that way. However, in discussions with various groups it had been decided that it should not only be for grandparents. But because she was fearful there would be no money for the bill, the idea was to start small. By shifting the bill from DCFS to TANF there was a greater opportunity and thus the change to “specified relative.” That category was defined as: Grandmother, grandfather, aunt, uncle, nephew, niece, first cousin, first cousin-once removed, stepfather, stepmother, stepbrother or stepsister, but they had to be related within certain degrees of consanguinity. That allowed the department the flexibility to accept someone who wanted to take their relative into their home. Regarding the age 62 or older, enough TANF money was found to be able to get the program off the ground. If and when new revenue came forward the age could be lowered.
Ms. Giunchigliani noted that in her own classrooms grandparents were often in their 40s to 50s. She said no one felt comfortable with the older age kick-off but it had been a way to get the program off the ground. If the committee desired, she would be glad to work with Marla Williams to see how language could be crafted to allow for the lower age in the future.
Mike Willden said they had tried to put some language in that would allow a reduction in the age requirement if funding was available. Further, having an age under 62, those grandparents or other relatives were not prohibited from participating in the Non-needy Caretaker Program. TANF operated that program and there was no age limit so those younger caretakers could qualify for that program. The difference was that guardianship was not involved and the payment would be less than in the Kinship Care Program.
Ms. Giunchigliani said if the committee did take action she would like to have Senator Bernice Mathews added to the bill, because she was sponsoring a similar piece of legislation. Chairman Koivisto felt that might be an amendment.
Assemblywoman Smith asked where in the language it stated the program followed the TANF guidelines. Ms. Giunchigliani said that was contained in Section 2 of the bill as defined by 45 C.F.R. § 233.90.
Ms. Giunchigliani then asked to enter as Exhibit D a letter from John W. Jackson, President of Grandparents Raising Grandchildren (GRG), regarding his objections to the age limit, which had now been dealt with, and also to the deletion of the child heath care. As now written, they would automatically get the Medicaid money, so the GRG felt comfortable knowing they would now be getting that benefit. Additionally, any paperwork in applying for legal guardianship would also be taken care of and contained in the fiscal note.
ASSEMBLYWOMAN LESLIE MOTIONED TO AMEND AND DO PASS A.B. 15, WITH AMENDMENTS AS OUTLINED IN THE WORK DOCUMENT, AND THE ADDITIONAL AMENDMENT OF ADDING SENATOR MATHEWS TO THE BILL.
VICE CHAIRMAN MCCLAIN SECONDED THE MOTION.
THE MOTION CARRIED UNANIMOUSLY.
Chairman Koivisto closed the hearing on A.B. 15 and opened the hearing on A.B. 52.
Chairman Koivisto recused herself from hearing the bill because her husband was employed at University Medical Center (UMC), therefore, in order to avoid any appearance of impropriety Vice Chairman McClain would take the gavel.
Assembly Bill 52: Limits fees which providers of health services that accept insurance payments may collect from patients and requires legislative audit of University Medical Center of Southern Nevada. (BDR 40-655)
Marla McDade Williams reported the measure was referred to a subcommittee and two subcommittee hearings were held. The subcommittee report (C-13 of Exhibit C) had a suggested amendment. Assemblywoman Smith chaired the subcommittee with Assemblywoman Gibbons and Assemblywoman Parnell.
The subcommittee made a recommendation that the committee consider a motion to amend and rerefer A.B. 52 to the Assembly Committee on Ways and Means. In addition to the amendments as outlined in the report, members of the subcommittee considered asking the bill drafting staff to analyze whether this measure might be included in some other chapter or title of the NRS. There was also an attached document titled “Assembly Bill 52 Subcommittee Working Document” (C-16 of Exhibit C) Ms. Williams had prepared for the subcommittee and it discussed the reason for that recommendation.
A number of people suggested language for the subcommittee and there was some difficulty in crafting that to make sure everyone’s concerns would be met. The subcommittee agreed to go forward to the bill drafters with the concept that:
The measure should insure the law did not preempt a contract between a health care provider and a health plan, which might include a managed care organization, a self-funded plan for health insurance, or any other entity that might contract for health insurance. The measure should insure that a health plan was not precluded from allowing a health care provider to collect copayments or other cost sharing pursuant to the contract between the health care provider and the health plan. Further the measure should not prohibit a health care provider from collecting from a patient if the patient had not complied with the health plan’s prior authorization procedures. Finally, the measure should not prohibit a health care provider from collecting payment from a patient if the patient received a service that was not covered by the patient’s health plan. The amendment would retain the concept contained in subsection 1(b) with the only change being that the language was consistent with the preceding concept and definitions.
The amendment would require that the definitions as they were listed in the bill now be reviewed so that they were also consistent with the concept.
The amendment would delete lines 5 and 6 on page 2 of the bill and insert language that gave the legislative auditor the discretion to choose the billing records that would be audited and the suggested language was:
The auditor would perform an examination of the methods and procedures used for the billing of a selected set of health plans and patients for the provision of health services. The legislative auditor will have the discretion to determine which billing and patient records are chosen for review.
The amendment would add a new section to the bill that required the UMC of Southern Nevada to respond to the findings of the legislative auditor and following was suggested language:
The UMC of Southern Nevada shall within six months after the period for submission of plans pursuant to paragraph c of subsection 1 of NRS 218.8235 submit to the legislative auditor a report specifying the extent to which the recommendations of the legislative auditor have been carried out, the extent to which the recommendations have not been carried out and the reasons for any failure to carry out the recommendations.
Further, on page 2 line 23, delete the figure $15,000 and replace it with $25,000. The subcommittee discussed the amount it would cost for the audit. Based on input from the legislative auditor it was estimated at about $50,000 and the sponsor of the bill came forward with a suggestion that the Legislative Counsel Bureau pay half of that fee and that UMC be responsible for the other half.
New language in Section 3 would require UMC to share in the costs and the suggested language was:
Upon the request of the legislative auditor the UMC of Southern Nevada shall transfer to the audit division of the Legislative Counsel Bureau the sum of $25,000 to carry out the provisions of this act. Any remaining balance of the sum transferred pursuant to subsection 1 must not be committed for expenditure after June 30, 2003, and must be transferred to the UMC of Southern Nevada as soon as all payments of money committed have been made.
Finally, on page 2, Ms. Williams said line 31 would be deleted and a new effective date, October 1, 2001, would be inserted. Section 2 of the act would become effective on July 1, 2001, and that was to accommodate the legislative auditor.
Assemblywoman Leslie said she was having some trouble understanding the first amendment. Was the recommendation from the subcommittee to ask the bill drafters to take that concept and write the language? Ms. Williams said that was correct. Ms. Leslie asked if the committee would be able to look at the amendment. Ms. Williams said the committee could if desired. Also, Mrs. Leslie asked if the amendment was the result of a general consensus of the subcommittee and witnesses. Ms. Williams answered that there had been no opposition to it. At the close of the hearing the sponsor of the bill had suggested the amendment be adopted with the new language and then, if there were concerns, it would come out in bill form and be addressed in the Committee on Ways and Means.
Assemblywoman Smith reiterated for Mrs. Leslie’s better understanding that the subcommittee had tried to work with all of those who had concerns about the amendment in the first meeting, and felt all the issues that were raised had been addressed. She noted the last sentence added to the concept was to satisfy one of the concerns about not being able to bill for something that was not covered. Everyone who had participated in the first hearing had some input and seemed comfortable with the outcome.
ASSEMBLYWOMAN GIBBONS MOVED TO AMEND AND DO PASS A.B. 52 AND REREFER TO THE COMMITTEE ON WAYS AND MEANS.
ASSEMBLYWOMAN SMITH SECONDED THE MOTION.
THE MOTION PASSED UNANIMOUSLY.
Vice Chair McClain turned the meeting back to Chairman Koivisto who opened the work session on A.B. 173.
Marla McDade Williams continued with the work document and page C-19 (Exhibit C) containing discussion points and proposed amendments. Three amendments had been proposed, one from Clark County Health District, one from representatives of REMSA, and another from MedicAlert:
The second option further proposed adding a definition for qualified pediatric patient. Ms. Williams felt members of the committee might wish to discuss whether it was necessary to add a specific definition for children if the reference to 18 or more years was removed from the definition of a qualified patient.
Assemblywoman Smith commented she had a difficult time following the bill and the amendments and asked if the essence of it was moving from inhouse DNR to outpatient or transfer DNR.
Assemblyman Dennis Nolan, the bill sponsor, said the intent of the bill had been to establish a DNR order for preparation and transfer from one facility to another facility, and while at those facilities, or at home or outside the hospital, under the care of the emergency medical services. There were situations even in in-care facilities, once the emergency medical services arrived, the care was transferred to those providers at the point they made contact and made an assessment of the patient. It could be in an urgent care facility even with a doctor present, but that would fall under the emergency medical services and the physicians who worked within that system.
Mrs. Smith understood the need from personal experience, but she asked if it would be appropriate for the family member or caretaker to have the DNR order with them; was that too simple. Mr. Nolan said it was not too simple, if they had a copy of the official order that would suffice. The bracelet was a secondary and backup device. If there was a DNR on a patient and they could not find the order, which happened frequently even in extended care facilities, then the authority-approved bracelet was on their person.
Assemblywoman Gibbons asked about a situation where a patient had the bracelet and died, what would happen to the bracelet. How could it be safeguarded from falling into the wrong hands afterwards. Mr. Nolan answered that it was considered personal jewelry and would be returned by the coroner’s office or mortuary to the family. Also, the information on the bracelet had identifying information for the person to whom it was issued.
Assemblywoman Parnell remarked that in reviewing the original bill it appeared there was little controversy over it at the time. She understood that what needed to be added was the issue of transporting. However, now it seemed to have gone far beyond what the initial language in A.B. 173 had addressed, and in so doing the bill had become confusing and one that now she would hesitate to support, although she had supported it initially.
Mr. Nolan appreciated her comments and said the bill as conceived and initially drafted dealt with the real life situations EMS personnel were having in the field. There were some oversights in the initial drafting in 1997, and then some cleanup in 1999, but there seemed to be new issues that cropped up that were now being addressed. The pediatric issue came in after the initial drafting and there was not another bill in which to include that issue. If it was not addressed in A.B. 173, or in the 2001 Session, then on those occasions where a child with a terminal illness reached the end stage, and the parents called 911, the child would be resuscitated, as the law directed.
Ms. Parnell did support the part of the bill that dealt with transfer of the patient and also the pediatric issue. She cited her own experience as a teacher where there had been students at school with a DNR order. There was always a great deal of confusion and hesitation on the part of school personnel when told they had a student enrolled with a DNR order; what should be done when something happened. Therefore, it was important to clarify that issue. However, the other issues like the bracelet, she felt needed to be dealt with somewhere but she did not want the less integral parts of the bill to weaken the serious intent of the legislation.
Chairman Koivisto clarified the issue, stating the committee had the choice of accepting option 1, which would change the definition by taking out “18 or more,” which would make the definition include pediatric patients. She asked Ms. Williams if that was correct. Ms. Williams said she did not believe they wanted to amend 449.585; instead consider a new definition if that was what the committee was going to do for 450B. Amending that definition in 449 would affect the advance directive and durable power of attorney, and she did not believe the committee was prepared to do that. By taking the language of that definition and adding it to the bill for a new definition for 450B, consideration would have to be given to deleting the reference to “18 or more years of age.”
Mrs. Koivisto asked Ms. Williams to explain option 2 again. Ms. Williams said option 2 was there to say “we need to clarify what a patient is for purposes of DNR.” Option 2 allowed NRS 449.585 to be left alone, and add a new definition to Chapter 450B of the NRS. But in considering what a qualified patient was, the existing definition stated “a qualified patient is a patient 18 or more years of age who has executed a declaration and who has been determined by the attending physician to be in a terminal condition.” That section applied to advance directives and durable power of attorney. If the simple concept was included, that a qualified patient was one who had executed a declaration and been determined by the attending physician to be a terminal condition, the one option in option 2 was to adopt that definition as well as add a second definition of a qualified pediatric patient. Ms. Williams felt a definition of a qualified pediatric patient was not needed if the reference to “18 or more years” was deleted.
However, she added, if there were two separate definitions, one would be a qualified patient; which would be a patient 18 or more years of age who had executed a declaration, and the other would be a qualified pediatric patient, who was a patient under 18 years of age for whom a parent or legal guardian had executed a declaration and been determined by the attending physician to be in a terminal condition. The difference would be, in one case, a qualified pediatric patient had that relationship with a parent or legal guardian, whereas in the other there would be no relationship with a parent or legal guardian.
Vice Chairman McClain felt that option 2 would be the best because it would stay in the same chapter, and 449, as Ms. Williams noted, ventured into the other area of the declarations, and so on. Ms. McClain supported the DNR language in 450B as being where the change needed to be made. Ms. Williams asked if that would mean leaving the “18 or more years of age” in the definition, or taking that out. Mrs. McClain felt 449 should be left alone, because under option 2 the qualified patient was defined as was the qualified pediatric patient. Thus, the only place pediatric patients was addressed was in the chapter that dealt with terminally ill cases that wanted the DNR order.
Ms. Williams said there was an option of creating two levels: one, a patient 18 or more years of age who had executed a declaration, and two, the qualified pediatric patient. Mrs. McClain said that was the way she saw it.
Assemblywoman Gibbons commented that she would be more comfortable with the qualified patient definition, because that would include those under 18 years of age. Chairman Koivisto said the issue was that it would not include those 18 years and younger and that was the reason for the second paragraph under option 2.
Assemblyman Nolan said the wording on the second suggestion was in defining pediatric patient as “18 years of age or under for whom a parent or legal guardian had executed a declaration,” was language essential to defining the relationship between the parent, the child, and the physician.
Chairman Koivisto felt that if the committee amended and passed the measure it would have to be referred back to the committee to make sure it was what they thought they had done. Ms. Williams said the other option was that once the amendment was drafted she would bring it back to the committee for review and to make sure they were comfortable before taking it to the floor. Mrs. Koivisto felt that would be the quickest way.
Assemblywoman Parnell did not want to shortcut this bill because of the subject matter and would like to see the bill brought back as a complete document. Mrs. Koivisto felt that was the consensus of the committee, they wanted to see the entire bill.
ASSEMBLYWOMAN GIBBONS MADE A MOTION TO AMEND A.B. 173 TO INCLUDE THE QUALIFIED PEDIATRIC PATIENT DEFINITION AND IN SECTION 1, LINE 2, ADDING “WHILE THE QUALIFIED PATIENT IS BEING” PREPARED FOR OR DURING TRANSFER, AND REREFER.
Ms. Williams asked if she wanted to include whether the health authority should have the authority to adopt regulations allowing a private vendor to issue a bracelet or medallion. Mrs. Gibbons felt it should not be included in order to keep the bill simple.
ASSEMBLYWOMAN SMITH SECONDED THE MOTION.
Vice Chairman McClain asked why the bracelet and medallion was being omitted. Mrs. Koivisto said that would be done by regulation. Ms. Williams said that as it now stood the Clark County Health District was not issuing bracelets for identification; they wanted the authority to draft regulations to do that with a private vendor. If that was not included in the bill now, patients would not have access to a bracelet or identification other than in the paper form.
Mr. Nolan stated the language as written was permissive, stating “board may adopt.” The benefit of having a bracelet was that the emergency personnel traveled within the community and to schools, and so on. If a child on a field trip had a problem and the documents were back in the nurse’s office at school, or a senior citizen outside the home or facility had a problem and the DNR order was not on their person, the bracelet provided the security of having the patient’s wishes honored. Vice Chairman McClain felt that provision should be included, that it was vital to the program.
Chairman Koivisto then asked Mrs. Gibbons if she wanted to restate her motion to include the bracelet. Mrs. Gibbons was not completely convinced and said that in the scenario stated above, if a child was well enough to go on a field trip then it would seem he or she should be resuscitated. She preferred to leave the bill as it was in that regard since it would be rereferred and it could be reviewed at that time.
Mrs. McClain suggested leaving it in the bill and taking it out later if the committee did not like it. Mrs. Gibbons said she would rescind her motion and restate it including the bracelet provision as Mrs. McClain requested.
Mrs. Koivisto asked Mrs. Smith, who seconded Mrs. Gibbons’ motion, if that was agreeable to her. Mrs. Smith said she was only agreeable because the amended bill would be coming back to the committee. She did have a problem with complicating the bill and did not feel it would be the perfect solution to the problem. Further, there would always be an issue about who had the identification bracelet and who had the papers.
ASSEMBLYWOMAN GIBBONS RESCINDED HER PREVIOUS MOTION AND MADE A NEW MOTION TO AMEND A.B. 173 TO INCLUDE THE QUALIFIED PEDIATRIC PATIENT DEFINITION; ADD IN SECTION 1, LINE 2, “WHILE THE QUALIFIED PATIENT IS BEING” PREPARED FOR OR DURING TRANSFER, AND REREFER; AND THE PROVISION FOR ISSUANCE OF A DNR BRACELET.
ASSEMBLYWOMAN SMITH SECONDED THE MOTION.
THE MOTION PASSED UNANIMOUSLY.
Chairman Koivisto reported there were two bill introductions. The first was suggested by the Legislative Health Care Committee:
BDR 40-181 - Revises provisions relating to transportation by fire-fighting agencies of sick or injured persons to medical facilities. (A.B. 488)
ASSEMBLYWOMAN LESLIE MOVED FOR COMMITTEE INTRODUCTION
OF BDR 40-181.
ASSEMBLYMAN MANENDO SECONDED THE MOTION.
THE MOTION CARRIED UNANIMOUSLY.
The second was a resolution from the Health and Human Services Committee:
BDR R-1484 Urges Congress to amend Social Security Act to modify certain reductions in social security benefits that are required for spouses and surviving spouses who are also receiving certain federal, state or local government pensions. (A.J.R. 10)
ASSEMBLYWOMAN LESLIE MOVED FOR COMMITTEE INTRODUCTION
OF BDR R-1484.
ASSEMBLYWOMAN PARNELL SECONDED THE MOTION.
THE MOTION CARRIED UNANIMOUSLY.
The Chair then opened the work session on A.B. 196.
Assembly Bill 196: Prohibits department of human resources from considering assets of child or pregnant woman or family of child or pregnant woman to determine eligibility for child health assurance program. (BDR 38-224)
Marla McDade Williams returned to the last item on the work document (Exhibit C), the fiscal note (C-28 of Exhibit C) which was prepared by staff of the Division of Health Care Financing and Policy (HCFP) of the Department of Human Resources (DHR). The amount in the bill for eliminating the assets test was $3.7 million and $4.2 million respectively over the biennium. The amount as listed by the division was $1.9 million and $3.4 million over the biennium. There were three options: One would be to amend and rerefer to the Committee on Ways and Means with the new appropriation amounts. The second option would be to just amend out all references to money and vote on the bill as a policy matter. The third option would be to adopt and rerefer to the Committee on Ways and Means without changing the appropriation amounts.
Chairman Koivisto asked Ms. Williams to explain the ramifications of each option.
Ms. Williams said the first option to amend and rerefer to Ways and Means Committee with a new appropriation amount meant that the $3.7 million would be changed to whatever the new fiscal amounts were. The second option would eliminate all references to the money and just have a policy of the assets test. The assets test was listed in the Governor’s Budget. The third option would be amend and rerefer to the Ways and Means Committee without changing the appropriation amounts.
Vice Chairman McClain asked if the committee could actually pass a bill without any money on it. Ms. Williams said it could be adopted but she was uncertain whether the Assembly Ways and Means chairman felt it would have to go to that committee. Mrs. McClain felt she would like to try to pass a policy bill and see what happened.
VICE CHAIRMAN MCCLAIN MOVED TO AMEND OUT THE FISCAL NOTE AND DO PASS A. B. 196.
ASSEMBLYWOMAN PARNELL SECONDED THE MOTION.
THE MOTION PASSED UNANIMOUSLY.
There being no further business before the committee, Chairman Koivisto adjourned the meeting at 3:15 p.m.
Darlene Rubin
Committee Secretary
APPROVED BY:
Assemblywoman Ellen Koivisto, Chairman
DATE:
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