Once they walk in the door, drink from the fire hose. Whether democrat or republican really doesnt make much differ. 45 trillion Dollar Agency to run and a lot going on. Big issue of repeal and replace, what do we do, nothing like that i saw in aviator 2001 one of the top National Issues. Im not sure where they are going with it but secretary price who i have known for years, these guys have, too, new administrator going to be they are way ahead of the game. What are they talking about now, my experience 88 transition a long time ago. Im actually 106 years old. We didnt do anything. We got people confirmed. Nobody sat around anderson talked about health care policies. I talked to Tommy Thompson, president bush, wanted to do it, privatizing medicare, medicaid in may. Gave a list of things to do, changed the name of the agency just to make people mad. Through part d maybe in may. December ive never seen anything like this. This is way out of the normal time schedule in my experience. Do i want to go to leslie. Tom, you remind med you were the individual for changing to cms. Answer the question everybody has, why is the center for medicare and Medicaid Services cms. Whats going on with that . I changed the name largely, i was hoping leslie, if i changed the name on the building she would get confused and couldnt find her way to work. At one time i had an explanation an old friend, believe it or not, in the cms world. Everybody, pretty small world, Everybody Knows each other in both parties and friends in my opinion. I knew nancy and she replaced me in the white house when bush lost to clinton. When she came in, they would been through a rough year with y2k and stuff. For some reason i was running big hospital association, it was perceived to be big and bureaucratic. People loved acm but didnt like the agency. I said to Tommy Thompson, lets change the name. He said, youre nuts, youre going to get killed. Why do you want to do that . You want to hear the real tore. I said, youre right. Were going to get killed. I said what do you think about the name vin corps, a Nursing Agency in wisconsin. He said i hate those guys. I said youre terribly right, they are horrible people. I said what do you think about this . They are the same people, they changed the name. He said, okay. You can change the name. Nothing in the statute. Made up by secretary of health from baltimore, nice guys. Trying to get fresh perspective. Why one m. I havent heard an explanation for one m. I already mumble you can tell. Center for disease control, started out at cmms. I argued, basically me and secretary thompson, you werent there, i dont go, maybe it up. The one he liked mma, mama wasnt going to be popular. Came up with cms, cdc, lets drop. I apologize, that was not the question you asked. Leslie, let me turn it back to you. In terms of transition, maybe alter the question a little bit because in my experience i think both you and tom in terms of really implementing medicare, being responsible for Prescription Drug implementation, i think theres obviously going to be some sort of change thats doing to come about. What describe your experience leading transition in the standing of a new benefit, what that might involve, look like in terms of some sort of significant change to deal with when she takes over. If i were to give her advice, i think it would be several fold. First of all, in as much as it involved changes critical would be Health Insurers and making sure those companies are on board, appreciate the changes, appreciate if cms does something its going to have a reaction externally. That could set up success or failure of whatever the change may be doing forward. I know its a lot of what i suspect all of us are reading now in the press, making sure whether Companies Like care first or humana, aetna, anthem, all of them can really focus on if were going to have an exchange, how is this exchange successful. If youre going to have medicaid managed care, if youre changing medicaid in a way you could participate successfully. To have a marketplace, whether medicaid, medicare, or the insurance the individual Insurance Market work means that Health Care Providers can also get paid. If Health Care Providers are getting paid, youll have networks and individuals, beneficiaries will be able to participate in those programs as well. At the very least, if youre looking at changing medicaid and obama care, which i think most people see as the exchange the next session here entitled physician assisted death balancing rights of patients and other stakeholders. Im a member of the health law section. I served as cochair of the executive committee, among other things, and assistant dean for assessment at Manchester University college of pharmacy, natural and health sciences. I was asked to moderate this panel and i teach a course in bioethics. This is going to be a very interesting discussion. The panelists are going to introduce themselves. Each of them will talk for about ten minutes and well have a few remarks up here and then well open to questions from the audience at the end. If you will, please do save those questions until toward the end of our session. So going to turn the podium here or microphone over to the colleague to my left palm kaufman. Good morning, everybody. Can you hear me well . Good. Thank you. Thank you very much for having me. Im a partner at hanson bridget in san francisco. Ive been practicing there 28 years in our health law department. Over the years the emphasis of my practice has moved to senior care, longterm care settings. So i used to do a lot of hospital law, now i do a lot in the senior care space but the issues are extremely similar. So im really delighted to be here today to talk to you about what some people call death with dignity laws and other people do not. That reflects a certain bias i would say. Im here to talk about end of life laws that are beginning to get passed throughout the country. I love this topic. Ive been speaking about it since Governor Brown signed the bill in october of 2015 in california, which was a surprise to some people. It was a hotly debated law in california. So i am going to exercise as much selfcontrol as i can and give you 10 minutes of background on whats easily an hour and a half or twohour topic. This will be about my 25th presentation this year on this subject. So i really do love it. So there is a short power point that will be available through aba but i have a bias of not using power points. Hopefully this will be more of a conversational session for you. So i want to talk to you a little bit about this very decided movement thats going on throughout the country. We now have five states that have statutes and one case a state that has case law supporting the right of a terminally ill adult to take his or her own life through the use of aid and dying drugs. I practice in california but not exclusively in california. My clients are throughout the country but certainly more are on the west coast. So the trendsetter was oregon, and we have someone here today from compassion and choices in oregon. So if you want to learn more about it, you can also chat with him. So the first law was called death with dignity act. It took effect in 1998 and it was a voter initiative. And interestingly, the oregon law was actually considered by the United StatesSupreme Court because then attorney general ashcroft was trying to prosecute both pharmacies and physicians who were participating. Thats the magic word, participating. Youll hear more about that, who are participating under oregon law. The Supreme Court determined that the controlled substances act could not be used to delegitimate a state standard of health care. Kind of a states rights issue. I dont think Supreme Court was interested in commenting on the substance of the law but more about whose turf it was. That cut the Supreme Court, which is interesting. Followed by that was washington, also a voter initiative. That took effect in 2009. Vermont, 2013. That was actually through legislation. And the governor actually made the issue part of his Campaign Platform before the 2012 election, so that was noteworthy. Montana very interestingly has this right under case law. You might disagree with this statement, but the court in that case said theres little difference between removing life support and taking aid in dying drugs. I think there are people who would disagree with that statement. There have been many efforts to codify that or to overturn it in montana. But so far none of them have succeeded. That brings us to california. By the way, in november colorado also voted to pass this law, so they are next. Ill be talking to their trade association about our california experience next year. California has an end of life option act. It only took effect in june. At its heart, like all the the other statutes i mentioned, it allows a terminally ill patient to end his or her life by aid and drugs with an attending physician. Pretty much every word has a specific meaning. It the most recent and probably most refined second most recent and most refined of the laws. The same organization that put forward the oregon law put forward washington and vermont and california and most recently colorado. We keep on we, they, keep on removing the nits, so its becoming a more refined law. Very interestingly you must selfadministrator drugs. It not euthanasia. Other things you hear about are induced coma with too much morphine. Theres ways people can control drug intake. Im not a pharmacologist but presented with physicians who described that. This is very much about selfadministration. You must have affirmative, conscious and physical act of administering and in guesting the drug and you must have an express intent, kind of the normal informed consenttype dialogue with your physician. You must be mentally competent. So in my space working with seniors thinking about who that might exclude, people with alzheimers or dementia and your agent cannot request the drugs for you. So your spouse, partner or sibling of many decades could be request this for you so it has to come from you directly. So in california, and this is extremely indicative of other states, you must be a resident much easier than it sounds. You can die in california more quickly than you can get married or divorced as long as you can show you have some kind of id, like a voter id, drivers license, couple of other forms youre a resident. Theres no time requirement. You must be a resident. You must be 18. You must be able to understand the nature and consequences of the decision and the benefits and disadvantages which are pretty evident. And you must be diagnosed with a terminal disease with reasonable certainty is expected to cause your death within six months. We all know thats an art not a science. Theres a book written by art buck wald, his experience in hospice for two other three years after being eligible. The book is something funny like not dead yet or still alive he continued to entertain glitteratti until his death. Theres quite a lot of procedure in this and reflects the tremendous tension between the supporters of this law and the the detractors. The detractors included two maybe obvious and maybe one less obvious group. Certain religious organizations such as Catholic HealthCare Organizations were opposed to it. The veterans hospitals and other governmental hospitals were opposed to it. Theres actually a federal law that prohibits the use of federal funds to fund any kind of i think use the term assisted suicide, goes back to 1997. The third group that may surprise you, certain parts of the disability rights movement. The feeling among those groups that oppose the law, its bringing us one step closer as a society to euthanasia. That was unacceptable to them. This is not about euthanasia but that was a fear they had. So in exchange for having a v y very well, to address the balance, to address the tension between these two groups, there is a very large amount of process that you have to go through. So just to give you the highlights, you have to make two oral requests 15 days apart for the drugs. You have to make a written request. It must be witnessed by two witnesses and certain obvious people cannot be one of those witnesses, people who stand to benefit from your will, spouses, siblings, so on. You then need to go to a cast of three characters. Number one is your attending physician. He or she must confirm your terminal diagnosis, your capacity, residency and informed consent. This is interesting, the doctor must tell you have the right to change your mind, other options such as hospice and palliative care. The doctor can recommend but not require you to tell your family of your plans, to have someone present with you at ingestion and not to consume the drugs in a public place. This has created a quandary for my clients because residents are not required to tell them they plan to take these drugs. A big part of my practice is trying to get my clients to have an environment of open disclosure and open discussion, because you want people to tell you they have these plans. Unlike the hospital where you go in for a few days and leave, this is home for my clients clients. That makes a big difference how they confront this law. You get through number one, doctor two is consulting physician, basically second opinion, goes through the same steps. Both doctors if they see a Mental Health issue have to recommend Mental Health. If i had six months to live, im pretty sure i would feel a whole bunch of emotions and im sure one would be emotion, anxiety, fear, confusion, a lot of emotions. I dont think they are really necessarily focusing on that group. There are people who have chronic depression. There are people who are bipolar and have psychosis. Maybe they are not on their medication and maybe they are not going to make a sound decision because of the magnitude of the issue. So once you go through all those steps, youre able to get the prescription. And then the question for my clients and your clients will be will we participate in the act. Its probably the most important term in the statutes. It means sectionally are you going to prescribe the drug, handle the drug, deliver it, dispose of it, receive it, have your hands on any part of the chain of custody of the drug and will you be present at the moment of ingestion. Thats really what it boils down to. There are other details but thats the heart of it. So you can diagnose it, give people information about it if youre a dr. You can tell them what their prognosis is. The real key is are you going to, as health care provider, let your if youre a company, let your employees and your contractors be present at the moment of ingestion . And are you going to handle the drugs. And just to give you a sneak preview, most of my clients are not participating. Ill explain more when i get into the q a why that is. Another very interesting part of this law is theres a provision protecting you whether you participate or not. So if youre a physician or hospital or School Nursing agencies, hospice or a number of other health care provides you can let your employees and contractors participate or prohibit them from participating providing you give notice and tell them the consequences which could be discipline up to including termination. If you are an individual, and you want to take these drugs in accordance with the act, it is not considered suicide, assisted suicide or homicide. Why is that so important . Insurance is a very big issue. It doesnt invalidate Life Insurance or Health Insurance or any other insurance. Insurance companies cant discriminate against you based on these plans to take these drugs or not take these drugs or rescind your decision. Thats also essential. Its kind of a live and let live law, to live or die. You it parts eight or not participate. I tell my employers if you dont participate you have to give a disclosure and acknowledgement to your people. The last point i want to make is that there are very interesting utilization data coming out of these states. Every state is required to maintain this data. Just to tell you the highlights, this is basically an old persons law. Most of the people who are taking these drugs are over 65. Most of them have cancer, they might have copd or another very serious illness. For the most part they are telling their families, 90 to 95 telling their family of their plans. Interestingly the vast majority are white people with college degrees, which might have something to do with how information gets conveyed. And the other interesting thing is almost everybody is dying at home. So that also raises interesting issues when you represent hospitals as to where this is going take place. Medicare will not pay for these drugs but medicaid, the state portion of medicaid may depending on your state. In oregon the state component pays for it. California has already set aside money for it. But medicare will pay for end of Life Counseling you get from your physician. So im going to turn this over at this point to father grogan and hes going to talk much more about philosophical issues involved. Thank you very much. If i can get this organized, it will be for the day but its not working for me. Ill tell you a little about who i am. Im father William Grogan attorney in chicago. These slides will be downloaded so follow the good example of pam and just speak from my text. I work as an ethicist. I go around the country answering questions around ethic committees. While theres a lot of questions in Health Care Related ethics both clinically also many questions organizationally. Im going to speak, as it were, at the start at the 10,000 foot level and drill this down to the matter at hand. I think the first thing we have to keep in mind on this conversation is we provide advice and council to people. So individual clients and my presumption in this regard as were speaking about organizations, some of which are secular in nature, some of which are religious in nature including n