 All right. Good morning. This is the Senate Health and Welfare Committee meeting of January 12th, 2022. Thank you all for being here. This morning we're going to be taking up as 74 and act relating to modifying the Vermont's patient choice at end of life law. Then we'll be looking at S91 related to parent child centers. And finally, we're going to pick up on COVID issues at 11 o'clock. And we have some hard stops that we're going to have to make to ensure that folks who are available for testimony can get their testimony in. One correction that was made to the agenda. I see it's already been made. Thank you, Aaron. Mary Han Beerworth is unable to testify this morning. We'll try to get her in as early as Friday so we can finish the work that we need to do on S74. Good morning. We have with us. Diana Barnard. And why don't you go ahead with your testimony. I think we have some things. And we've seen you in this committee before and it's a pleasure to see everyone back. It's great to see familiar faces, I have to say, though. I'm just sorry we're not in the state house all cramped together in that little tiny room of ours under better conditions. Diana, welcome. Thank you. It's great to see some familiar faces and also some new ones. So I want to just briefly remind you of the qualifications that bring me here today. I am a lifelong Vermonter and I've spent my entire clinical career taking care of Vermonters. I'm board certified in family medicine, and also in hospice and palliative care. So my role in my clinical work is as the lead physician at the University of Vermont Health Network Porter Medical Center Palliative Care Service and I also work as a hospice physician. I was as Jenny was indicating actively involved in the efforts to pass our initial medical aid and dying law. I continue to be on the patient choices Vermont board, and I am also on the clinical advisory board of the Academy of Medical Aid and Dying which is based out of California. I've been working in medicine for 28 years and the last 12 years of my practice has been focused exclusively on taking care of people living with serious illness. I just feel the need to start by reminding you that how we die matters, and that we only get to do it once, and that you enter it with no previous experience. And this is true for the person who dies and it's also true for the bereaved and the loved ones that are left behind, because the experience of witnessing somebody dying has an effect on how you approach your own death and that ripple effect can go through generations so it is imperative that we continue to refine and explore ways to meet the needs of people who are dying. As many of you know we've just had a recent report from the Vermont Department of Health that has clarified our experience in Vermont over the past six years has been as expected. The numbers show that the vast majority of patients who access our law are living with cancer more than 75% of them. The next most common diagnosis is ALS, followed by other neurodegenerative diseases. We have an average of 14 to 15 people a year who are completing the process for medical aid and dying, and those numbers from the Vermont Department of Health do not show any instances of abuse, which is very important to keep in mind. So our law is working very well, however at the same time the past six years of experience has shown us that like with many laws, it's an opportunity to tidy it up and to fix some unintentional issues with the law, which I would like to briefly review with you today. The first issue is one of immunity. Other people will speak more to this, but I will simply say that our law somewhat unintentionally only focused on immunity for the physician participating in the process, and explicitly they are the only ones who are protected, even though there is implicit understanding that others would be protected. This has proven to be an issue, particularly with pharmacists who would want to participate, but worry about protecting understandably their license. And so we are asking you to make that protection for pharmacists and other members of the health care team explicit. The second issue which we are asking you to address is the final 48 hour waiting period. We have waiting periods built into our law to assure that patients have adequate time to consider their treatment options and are not rushing to a decision. It's really important to have safeguards, and it's also important to recognize that sometimes safeguards can actually become barriers. And I believe we have a mismatch in that balance in our law, which we are asking you to address today. You know, the almost every patient I meet wants to live as well as possible and as long as possible. And particularly in the setting of a serious illness. Most patients are focused like a laser beam on their illness and the treatments that are available to them to help them live well and live longer. And at the same time, as your illness becomes more advanced, your physical and emotional energy can rapidly decline. And so by the time patients are realizing that their treatments are no longer working as well as they had thought, time is short and physical and emotional energy is short at a time when people have very important issues that they want to be focused on in bringing their life to a close. I can tell you that virtually everybody that's been diagnosed with a terminal illness has thought about dying and has wishes for how they want to die, even as they're focused on living. Oftentimes those wishes have not been explicitly talked about unless the patient has had the services of an expert person to bring out those worries. And so those worries about how we die often come to the table very late in an illness. Most people who have interest in medical aid and dying have talked about it and thought about it for a long time and many times family is aware, but they haven't started the formal official process because they are focused on living and getting treatment. So what happens is by the time people realize that treatment is not working and their time is short. Energy is also short. So just to briefly review the process that patients go through for medical aid and dying, they have to make a formal request to the prescribing physician. More than two weeks later, they have to make a second request. There has to be a consulting physician to confirm the patient's eligibility. And that patient also has to take the time to put their wishes in writing and have that wish witnessed. Our law requires at this time, after all of those steps have been completed, an additional 48 hour waiting period before the prescription can actually be written. There are no other of the 11 states, 10 other 11 states in jurisdiction that allow medical aid and dying have such a requirement. And in my experience and the experience of other clinicians that I talked to this 48 hour period offers no meaningful benefit and has created a burden. The patients have thought about the process, they've made their requests, and they are by and large by that point, ready to move forward with having that medication access in their back pocket. So we are asking you to eliminate this final 48 hour waiting period, knowing that the other safeguards will remain in place. And the other issue of course that we're addressing today is the issue of telemedicine. Telemedicines are constantly changing science. We're always learning new things. And when our law went into place, you know, frankly, telemedicine was just not at the forefront. We know that telemedicine has been used in other areas for for a number of years quite successfully. Now the best example of that is really within the VA system. I suppose, thanks to the pandemic over the past two years, we've really seen in Vermont how telemedicine can be effectively used in order to provide timely and high quality medical care to Vermonters. And, and we believe that telemedicine should be incorporated into medical aid and dying as it is in any other area of medicine. I also want to say just as an aside that in my practice as a palliative care physician and a hospice physician. I, my biggest clinical tool is my presence and my ears and my voice and responding to suffering. My eyes to evaluate the patient and my ears to listen to suffering and actually in my clinical work. It's very common for me not actually ever to have to lay eyes on the patient. Excuse me lay my hands on the patient. So my hands are useful in some clinical situations, but largely not in my clinical work. It's useful just to kind of run through what would a telemedicine visit look like. So, if I were going to see a patient to explore suffering and their end of life wishes, I would start by reviewing their medical record. I would look at all of their notes, their lab results, their x-rays. I would look for those specialty notes to tell me how the disease has progressed. I would look for prognostic data that lets me know that the patient's illness is in its final phase. Then when I'm on the telemedicine visit I would start with introductions. I would begin by getting to know my patients by exploring their values by learning who they are how have they lived their life. What has been their experience with illness. What are their biggest fears. I would always be listening for sources of suffering. What is bothering the patient most and what could possibly I do to address that suffering. So always looking for therapeutic interventions. I would be listening to their request for medical aid and dying. All of the requirements of the law in particular focusing on their understanding of the illness and their capacity to move forward with the law. During that visit I am continually looking for anything that tells me that this telemedicine visit is not accurate and I need an in-person visit and that could happen at any time. Maybe there are technical issues. Maybe there are communication challenges over the technology. All of those things would encourage me to pivot to an in-person visit. If I was continuing with the telemedicine visit I would use what I do in an in-person visit which is my ears and eyes to assess the patient. I can hear if somebody short of breath. I can hear if their voice is very weak because they're living with serious illness. I can hear them cough. With my eyes I can see if they have signs of advanced illness. Are they thin? Are their clothes loose fitting? If needed I could even have them use the camera to show me any tubes or accoutrements that are part of their body to look at their tummy, to look at their edema. It's very effective as a way to assess what's going on with the patient and continually my biggest clinical skill are my ears in listening to the patient's worries and their understanding and my words to assure them that we're going to do anything possible. At the end of that visit if all went well I would close and schedule a follow-up. So I believe that telemedicine could absolutely be effectively used to help assess the patient's eligibility to move forward with law. I think I want to close by just telling a story. This is the story of Lynn Achay who was a woman in her 60s from Arlington, Vermont. And unfortunately her case actually articulates all three of the issues that we are talking about with our law. Lynn was a competitive athlete. She actually was the first woman to bicycle to the top of Mount Washington. And she was incredibly healthy and had no risk factors for the disease which she would get in late winter of 2019 she developed a cough that was eventually diagnosed as pneumonia and she had treatment but she had a lingering cough that lasted several weeks, which prompted a more extensive evaluation which unfortunately revealed evidence of widely metastatic lung disease. As you can imagine Lynn was in shock and she and her husband Tony immediately began to explore their treatment options and preparing for the end of her life because her disease was at such an advanced stage at the time of diagnosis. In that previous experience with dying her father had had a very difficult painful final phase of life, which had really traumatized her as a daughter, and she was very clear and articulate in her desire to not experience such a terrible situation for herself. And because of the waiver that our willing pharmacist requires physicians to sign. She could not find a willing prescriber in her area. Eventually she reached out to me in June of 2020 and I agreed to see her. This was in the middle of the pandemic and I was balancing so many clinical needs that I did not have the time to be able to travel to her. And then Tony had to drive an hour and 45 minutes each way to come to my office, and they had to do that on two occasions. I learned only after the fact that for that second visit Lynn, who remember was a competitive athlete who had a very high bar for how she wanted to live her life, actually beg Tony to call an ambulance because she was so exhausted and uncomfortable to lay down on the way to my office. And I will never forget going out to the car on that second visit to help Lynn get out of the car and Tony had fashioned a camping mattress on top of the reclining front seat in a desperate effort to get Lynn to be as comfortable as possible. During those two visits, despite advanced physical illness, Lynn's mind was very sharp and she was very clear in her wishes and clearly qualified for the law. Our last visit happened to be on a Friday. While Lynn was still interested in living as long as possible because remember she had only been diagnosed in April. And this was June so she still had things she was trying to do but also desperately wanting to plan for a death that was not going to be like her fathers. So she wanted to have the prescription waiting at the pharmacy and ready. We discussed how I had to wait the 48 hours it was a Friday. And so I said you know very first thing the next week I'm going to send the prescription off. Unfortunately, over the weekend, Lynn's condition first began to deteriorate which told her she wanted to move forward as soon as possible with the law. But second over just those two short days, her condition further deteriorated and she lost the capacity to be able to participate. And by early next week she was left in the condition and lived for 11 additional days, exactly in the kind of situation she did not want with Tony as her caregiver and witness. Despite his grief, Tony was frustrated and quite frankly angry about the ways in which Lynn had faced these barriers to the law, and he wrote many people to talk about his experience and some of you have actually probably heard this story before. I am haunted by that experience. I think anybody who knows my clinical work knows that my bar is very high and I have high expectations of my ability to offer people comfort in their dying process. And in this case, I was not adequately able to address Lynn's issues and from that time I became determined to move forward with fixing the law so that others would not have to suffer the fate that Lynn did. I actually called Tony this week to check in and see how he was doing. It's been about 18 months since Lynn died, and he was the one who encouraged me to share her story. So I think I will stop there I really appreciate you listening and I would be very happy to take any questions now or later. Thank you very much Dr Barnard. And I'm going to ask you if you can send us some written comments. If you have a few minutes, I know you're busy but if you could get that to us because I don't see it on our webpage. Yes, there's been a lot going on but I will get my written comments by the end of today. Okay, that would be terrific. Thank you so much. Committee unless you have a significant question of clarification. I'm going to suggest that we move right along in our testimony. Senator Hooker. Dr Barnard, you mentioned other members of the health team besides the, what do I want to say, besides the pharmacist. Could you just elaborate on that please. I was referring to other people who may be involved in the care of the patient. I actually need to say that I just now I'm having a little brain cramp and can't remember the specific language of the law. But we know that there are others helping to care for patients living with serious illness and I would hope that other members of my team could address that issue. We'll hear more about that. I know we're going to hear more about that particular section so that's a very good question Senator Hooker thank you. All right. Why don't we move ahead and we'll ask Betsy Walkerman thank you for being here. Why don't you introduce yourself for the record and I, and I do know that we have your testimony on our webpage. Yes, I submitted some back up documents, but if you want. Betsy, we're having difficulty hearing you. You're going in and out as you speak. Let's get this close. That was better as soon as you moved a little closer. And just moving closer to where my actual speaker is. Is that all right? Yes, it is. That's fine. Thank you. So, I. Yeah, so thank you. Good morning. Thank you for the opportunity to testify on making some improvements back 39. I'm president of patient services Vermont and I'm a lawyer. I've worked on medical aid in time for the past 20 years. Since I started work with my parents, many of you know that Walters and any Walters to law patient services Vermont. Can you all hear me all right. Yes. Okay. When you when you face directly into your, or whatever the mic wherever the microphone is we hear you perfectly. Okay, great. Yeah, that's good. I thought I had all this setup exactly right. That's good right there. Right there. Okay. So, as I mentioned, I had a patient choices Vermont. PCV is a nonprofit organization and we're focused on educating Vermont residents and the medical and caregiving communities about medical aid and dying and our volunteers answer. Oh, about 6 to 10 calls per month from patients and doctors. And we connect any doctor who has not participated in act 39 before with knowledgeable colleagues such as Diana Barnard, and we train hospice and medical personnel. And the PCV website, patient choices.org has extensive resources, including videos of Vermonters who have used medical aid and dying. I would encourage you to listen to the voices of the people who made this choice. It's made such a huge difference for people working. We're working with terminal illness. You know, there's a real family and a real person behind every one of the 116 people who have filed for medical aid and dying since 2013. We've received a lot of notes of gratitude, which actually really should be forwarded to all of the legislators who made this possible. Vermont now has experienced doctors and hospice nurses and an excellent pharmacy, a compounding pharmacy, which is what's needed to develop the drugs and the medications that are used in medical aid and dying. And that pharmacy delivers the prescriptions where needed all over the state. In parallel, I would say that hospice use in Vermont increased 26% since 2013. I know this was a topic of discussion when the law was being considered. So there's been a very big increase in hospice use and so that today almost half of the people dying in Vermont are using hospice services. I would like you to hear directly from the patient. So I'm going to play a short clip from a young cancer patient named Karen Olschlager. So let me just hit the go button. And I knew that right now is like it's thicker and thicker. It looks more likely to that would be true. I'll actually need a lot. But I've been grateful to have it there in the two books on the left. I am so grateful this is something I worked through mentally and emotionally two years ago. I think there can be a lot of pressure in our society to keep fighting, keep fighting, keep fighting, especially as a young cancer patient. And I think what folks don't always realize is sometimes that keep fighting is really just a lot of so long physical suffering. I am just I am grateful for all the providers who have agreed with me that this is a valid option, you know, to take some control during this process, which is such a profound law. I hope you can hear that. Yeah, so, so Karen's whole video is on our website under the video section. And it's really, it's really enlightening about what actually goes on for for a patient who's considering act 39. So when act 39 was drafted legislators gave a lot of attention to preventing improper use of the law. And as a result, there's quite a list of requirements. There are five qualification requirements. There's an eight step procedure that the patient and the doctor have to go through and there's full documentation that is filed with Vermont Department of Health. Every person qualifying for eight and dying has to go through must be diagnosed by two doctors as having a terminal illness with six months or less to live and they must be capable of making their own medical decisions. And participation in the law is completely voluntary. So just by way of background I filed with in the written testimony a graphic flow chart which shows the procedure for your reference. Medical aid and dying is much more established across the country than it was in 2013 and Kim Kalin and from compassion is twice this is going to speak to that. In our eight years of experience PCV has not received a single report of suspected abuse. Yet we do know how onerous the process is for dying people. So we really think it's time to make improvements and appreciate your consideration. So I'm going to just run through the three aspects of the law and perhaps fill in any gaps that that there might be an understanding. The first the first change is that it would remove the requirement that request for eight and dying be in the physical presence of the doctor. And we have included in our testimony and a table comparing the the laws in the 11 states across the country and looking at the specific provisions that are in Senate bill 74. And you can see that Vermont is the only state among the 11 where requests for eight and dying have to be made in the physical presence of the doctor. And it can you just give me a thumbs up or a thumbs down I would I would play a quick clip from Karen all schlager again about her experience trying to get to the doctor when she was so debilitated. I have to physically go get myself in front of the doctor, which is on your time. So I was profoundly malnourished and dehydrated and vomiting pretty much constantly. So it's rough to drive 45 minutes and sit in a waiting room and, you know, have to get dressed and engage with someone who you know you might keep in front of the time of talking to the actual position I thought about it for literally years. So I yeah I think the removal of that requirement would be just a huge relief. Yeah, I having listened having had conversations with Karen through this whole process it's, it hits me pretty hard and I think it you'll find the same if you listen to Karen's video on our website on the video page, as well as the recording from the Allen who you may know she was the Resolutions clerk at the State House for many years, and she used after 39 last year. So then, so then the second part of Senate bill 74 which fixed the technical error that Diana Barnard mentioned, which provides explicit legal immunity only for the doctors in the process, and it would clarify that all the parties who act in accordance with the law which could be family members it could be hospice workers and it and of course the pharmacist would be free from claims of immunity. So, I'm going to take just a minute more on the pharmacist because that's where the real issue has come up. Because the, the, the law is just implicit not explicit about their immunity, the principal pharmacist who who fills prescriptions in Vermont requires doctors to sign an indemnification agreement. And many doctors are not willing to sign it is a very unusual requirement for a doctor. So this has reduced the number of physicians who are willing to prescribe and it's created pockets in the state, especially in southern Vermont and up in the Northeast Kingdom, where patients have trouble finding, finding a doctor who will prescribe and who will work with you at 39 with the Senate bill 74 amendment, the indemnification agreement would no longer be required and the pharmacist has confirmed to us that that is the case. And so we would expect the number of participating doctors to increase and especially local doctors and doctors who might have longer relationships with the patient. So you'll see in the table that compares the state laws, all of the other state laws provide immunity for all the people who are involved in the process in compliance with the law. The third part of Senate 74 would adjust the steps required to get a prescription. The proposed amendment keeps the 15 day period between the two request. It keeps the requirement for two doctors and a written request, but it removes this unnecessary and burdensome last 48 hour delay. 48 hours may not seem like much but the severely ill patient can make the difference between being able to qualify or not. And Vermont's timeline again looking at the comparison of the state. We were early in the process, you know we Vermont was the first state that that passed an aid in dying law through legislative action. So now that they're 11. There's really much more experience across the country and our process is one of the longest. If you look at the other laws, some of them do have a 48 hour period during the process but they overlap with the 15 days, whereas ours is tacked on to the end. So that makes our process a month the longest across the country. So, Betsy I'm going to ask if you could get to some closure simply because we're going to be pressed for time. And we and we may be able to come back with questions or further testimony going forward. Yes, yes, I certainly can. I would just add to that comment. I'm going to read these words of D Allen son, whose video is on her website, and he calls the last 48 hours, a nightmare. And that pretty much says it all for her case I won't go into more details you can listen to it if you like. So, please consider removing that last barrier. And we certainly appreciate all the consideration that you're giving we think that s dot 74 would remove needless suffering while keeping at 39 strong and consistent with best medical practice across the country. So thank you for your consideration. Thank you and thank you for your work on this I know it's been a long, a long time, including with your parents who many of us know when worked with. Thank you. Questions of clarification. Okay. All right. So next on our list is charity Clark of the Attorney General's office and charity thank you for being here. I know you have some specific comments to make about the bill and I think that's going to be helpful to the committee. Sure. Thanks for inviting us to testify on this bill today. Just a couple of things we were asked to testify as to the immunity portions of the bill. So I see those as the, the good faith section and see that was added. I first wanted to comment on the change in telehealth which we fully support and it's actually really wonderful to hear the testimony today about that. We would just suggest that safeguards be put in place. Obviously, it's, it's different to be in the room with the patient versus on on the screen, and would be happy to work with you on this or legislative council thinking about what those safeguards might look like. But also with telehealth wanted to lag an issue that I probably came up in 2013, but maybe with telehealth is going to be more of an issue that you might want to think about, which is the potential implications for where the healthcare provider charity or frozen if you can hear us. And sometimes it helps to turn off the video. It's probably the, the windy weather. Okay, so what I'm going to suggest is that we move to Kim Kalan and Kim you're not frozen. I'm good. Okay, Aaron is maybe you could communicate with charity and let her know that we know she's frozen and we'll try and get her back in. We'll do. Okay, thank you. Kim wanted to go ahead. Great. Thank you so much for being here today for allowing me to be here today. My name is Kim Kalan and and I lead compassion and choices, and we are the largest national organization that works to improve care and expand options at the end of life, including working with different states to authorize and then implement medical aid and dying laws and we worked closely with patient choices Vermont on the authorization of this law along with of course the legislature, as well as the early implementation efforts. So I'm delighted to be here today and my specific unique role will be to be able to share with you the experience in the other authorized states where we work across the vast majority of them. And what I thought I would do is start out and share with you. Oh, it looks like I cannot share my screen so I'll just in my testimony I think there are some slides you can refer to them there and I will just go ahead and and talk through them. So, first, just to give you guys some context and Betsy went into this a little bit in her testimony. But right now, across the United States, one in five adults have access to the option of medical aid and dying across 10 states and Washington DC. Vermont has played a very important role in the authorization of medical aid and dying be the being the very first state legislature to authorize the option in the states that became came before you, or again in Washington were authorized by ballot, and Montana was authorized through the courts and it looks like Aaron told me I can share my screen now so I'm going to go ahead and do that. Can everybody see that okay. Yes, great. So you can see that after Vermont authorized the option that right after that a flurry of other states followed suit. So California authorized by the legislature Colorado was another ballot initiative but then DC Hawaii New Jersey Maine and New Jersey all authorized through the legislature so on behalf of all of those other states I would like to profoundly thank the lawmakers of Vermont for your leadership. You've really not just brought a compassionate end for the residents of Vermont but you've helped pave the way in other states as well. It's important to know that while this option for brings a profound peace of mind to lots of terminally ill residents that very small numbers are going to choose to use the option and this is true in the other authorized states that already have the policies that we're hoping that the Vermont legislature will pass today. So, as Betsy mentioned it's 116 residents of Vermont have used the option across the years it's been authorized in Vermont but across all of the authorized jurisdictions all 11 jurisdictions in many many years decades combined, just over 5000 terminally ill adults have used the option. It's important though to know that what the data shows us is even those small numbers of people are using the option it's bringing peace of mind to lots of other people. And it also as you've seen in Vermont it improves end of life care across the board by creating better conversations between doctors and patients and encouraging earlier enrollment into hospice care as well. In terms of who uses the law data is collected across the vast majority of the authorized states, and we see pretty consistently the same trends and patterns. So you have about three quarters of the people who are using the option are over the age of 65 with the median age being in the mid 70s. There's an equal percentage of male and female which I always find to be particularly interesting and people give a large number of reasons why they're choosing to use the law we really think about it as being the entire experience of what something what happens to somebody at the end of life. It's everything from the loss of autonomy to fear about suffering to reduced quality of life. And the totality is why people are choosing to use the option. And as Dr Barnard said in her testimony the vast majority of people who use this option. Well before they were terminally ill were already clear that they wanted to be able to die on their own terms and that this is the option that they wanted so people don't come to this and make the decision lightly. It's something that sort of is a core part of who they are as a person. Most are receiving palliative care or hospice care at the time of death and it helps more people be able to die where they want to die which is in their home. And generally speaking the family is very involved in the decision people who do choose the option tend to be have advanced education and the vast majority are insured. So that's just a little bit about what the data across the other authorized state shows about who chooses to use the option in terms of the specific provisions that you're talking about doing here in the state of Vermont. And I think what's most important to understand is that those are already the law across all of these other authorized jurisdictions so you're not asked we're not asking for changes here that are outside the practice that's taking place across all these other jurisdictions just like in Vermont there aren't you know substantiated incidences of abuse or coercion. What we do know is there are a lot of regulatory road box that 12 step process that somebody has to get through to be able to access the law when a person is terminally ill. It's quite an extensive process and the changes that we're making here are not going to make it any so that patients have more vulnerable populations are it doesn't change the experience for them. So specifically in terms of telehealth it's important to remember that all of the laws that govern the practice of medicine also govern medical aid and dying. So by removing the language within your provision related to telehealth what you're simply saying is the laws in place that govern telehealth in general will also be in place to govern medical aid and dying. And so what does this mean it means that video only appointments will have to be used in order to establish a relationship for the person, which gives that you know experience that Dr Barnard was talking about. It means that you know a person can't get through that whole process without those video appointments and it means that you're treating the practice of medical aid and dying in the same way we're treating other medical practices. This is what is done across all the other authorized jurisdictions and again what the experience has been especially in the time of COVID is it has actually helped to protect vulnerable populations because you haven't forced them to risk getting COVID and leaving their homes, which actually is a pretty horrific death in order to access the option that they want. So I would say it brings a lot greater compassion, especially for a person in a state like Vermont that has lots of rural areas. It takes away the burden of having to travel several hours in order to be able to get the care and the experience that they want. The second provision around the 48 hour timeframe, the trend across the country is actually to move. I don't want to interrupt, but we're running into some time issues this morning, and your, your written testimony that you have provided us is very clear. So if you could just give a couple of sentences about the last provisions and then wrap up that would be terrific. Great. I will do 30 seconds on the, on the immunities again they're across all of the other authorized states and in the 48 time period. This is just consistent with the other states so you know happy to answer any questions of people have them and I appreciate the opportunity to be here. Thank you. And thank you that you're the information that you provide is extremely helpful. And we greatly appreciate it. We have a question of clarification from Senator Hardy. Thank you madam chair. Kim you, you brought up an issue that I hadn't. Unfortunately, I hadn't thought about before in that in your statistics about who accesses medical aid and dying. Specifically people who tend to be more educated and and insured. And I'm wondering if there are provisions in other states that could improve that we might consider that would improve sort of health equity and access to this medical care. Yeah, that's a great question. I think from an access perspective. First of all I do think it's important we want to get these changes through so I wouldn't want to do anything to the bill this time around that would slow things down in any way. But some of the other states their state Medicaid program covers the law and that does help to bring about greater access to the law. Thank you that's helpful and one does our state not does our Medicaid program not cover it. I will defer to Betsy on that. Right. After the nine patients in general have to pay for the medication. You know what I'm going to suggest Betsy thank you. Yeah, I think we'll get clarity from our legislative council. Okay, yeah, that I think that that would help and and Ruth is a great Senator Hardy is a great question so we'll try to get some clarity on that. Great. Thank you. Thank you. Sure. All right. Yes, thank you for your testimony. So charity Clark is with us by telephones charity. Why don't you go right ahead with your testimony. And I know. Yeah, go ahead. I'm going to keep my camera off one because I'm on my camera and you always look gigantic when you turn your camera on but also I'm nervous about the connection maybe because of the wind. So I was just flagging I hope that you heard me start this but to think about what the implications might be for where the health care providers physically located. In other words, are they out of state in a state that does not have a law that would provide the immunity. So I wanted to flag that as an issue. And then the second kind of main topic is this prevent this addition to a paragraph dealing that that references good faith. So currently as others have discussed there is this regimented process for facilitating patient choice at end of life, and any good faith is implied in that. So the new section makes good faith explicit and from a criminal perspective the current process is very strict is regimented so long as these steps are taken. The report is made the Department of Health, the physician isn't subject to criminal liability. The proposed subsection introduced introduces explicitly this new element of good faith. So I'm wondering if this might raise questions about the process, because it does introduce this new element, and you know for prosecutors or the Office of Chief Medical Examiner Department of Health. I'm not sure if there was, it sounds like the reason for the section relates to making sure that pharmacists are explicitly included in the immunity, and it might be simplest just to add pharmacists or others to the list with physicians to the new section which I think does raise some questions about the paradigm right now as the law exists. I'm happy to speak with legislative council about particulars on this but those are the, you know, couple of things I wanted to flag for the committee, and I'm sorry again for my connection issues but glad I was able to finish the testimony today thank you. Thank you and and again this this sounds like something that our ledge council may be interested in helping us understand so we will. It would be helpful to have you connect with ledge council and we'll work through that and try and make that happen. Great happy to thank you. All right, thank you. Who is next on our list, I think it's Sarah teach out a blue cross and blue shield and Sarah thank you for being here. Great, thank you Sarah teach out the government and media relations person for blue cross and blue shield of Vermont. I will be quite brief. Blue cross supports the passage of s 74. And in particular we believe that the provision about immunity that applies more broadly is very important for this bill what we've noticed in trying to support our members who are looking to fill the prescription is that there's only one pharmacy in the state of Vermont that can do so right now, or is willing to do so. And we believe that this is one of the reasons that pharmacists have not been participating. And so if you broaden this immunity piece, there might be more options for patients for filling the script, and that's something that we work on with our members when they've requested it. And again, we really do try to support our members with all of their health care choices and we believe that this will make the law work better for patients in Vermont. Thank you. Thank you. Okay. So we'll move along unless there's a question of clarification. And David Englander is here from the Department of Health. Welcome. Madam chair it's wonderful to see you. Good morning members to see you. My name is David Englander I'm the senior policy and legal advisor to the Department of Health. I think we're a little short on time so I will uncharacteristically try to be brief, the Department of Health supports these proposals for the reasons articulated earlier. Actually, this is the act 39 in 2013 was the first piece of legislation that I worked on. I'm in my role the Department of Health. So I built long the department has a long history so folks know the role the Department of Health is to collect the information provided by doctors and patients. That information is held confidentially, and then we produce a buy in report that I've provided my testimony. We also provide support to doctors and patients, the extent that they have questions regarding the law, although largely this is, you know, decisions made between, between doctors and patients. With that, I'm happy to take the communities questions. I do have a question and you've you've given us the full report which is terrific it's four pages long so we won't have any difficulty getting through it. And then you've also given some other information, but I guess my question for you is there anything in the report or the reporting that you have seen that was a surprise to the department in terms of how the process is going or the data collection. A surprise. No, it has been, it has been so I would say I've been surprisingly smooth from the department's perspective understanding that doctors and patients are leading that the complex lives involved with with end of life decisions. There certainly has been. There's a lot of work on the department side trying to gather this information sometimes there's a misunderstanding about how the law works so we do a lot of outreach to providers. The law is so familiar with the law know it lays out a stepwise process that doctors and patients have to go through the Department of Health did produce forms so that all providers can use those rather than trying to generate them themselves. So, on the whole it's been it has been a fairly smooth the the calls with questions regarding the law tends to ebb and flow with reporting. So, you know, in cases, you know, patients brainly coming out and talking about their experience, and then we when we get more calls and then that that kind of that tails off. Okay, thank you. And you have your frequently asked questions there which is very helpful. Senator Hardy, I think Senator Hooker you had your hand up first and then Senator Hardy. Actually, Senator Hardy did. Okay, thank you. This is not necessarily a question for David but a charity who is not on the screen anymore. Raise this question and maybe Dr Barnard knows the answer about telehealth and medical licensure. My assumption is that that just like with any physician they would have to be licensed in the state of Vermont to provide telehealth for this for this service. So it seems to me that it would be covered already under medical licensure law in another part of the statute. Maybe this is a question for our legal counsel as well but is that your understanding Dr Barnard. I guess listen I'll let Dr Barnard answer but I think the Department of Health can answer that based on the board of professional regulation but go ahead Dr Barnard. Yes, I agree with what you said Ruth about the issues being guided and and deferred to others with more expertise in the legal realm. Okay. I agree Senator Hardy that is the case. Okay, so there's not like we don't need another separate provision for this new telehealth it's already covered under the fact that physicians have to be licensed to practice in Vermont. Well, cherry and I haven't spoken in detail with regard to the age of concerns so I so I wouldn't want to opine that broadly but certainly on its face that would appear to be the case. I just want to make sure we get clarity on that before we move the bill forward but it seems like it probably is already covered, but thank you. Right, so this is another let's let's I'll give that task to David Englander will I'm going to add that to our list of clarification with our ledge counsel. And also on my list is to determine whether Medicaid covers these services I've already reached out to my colleagues and we'll get the answer by the end of the day. Thank you so much. Senator Hooker. Thank you and actually Senator Hardy asked the question that's very similar to the one I had and I was just wondering if in the reporting you differentiate between doctors who are located in the state and those who are located in states. We don't they that the in order to participate they have to be Vermont license positions. Okay, and we will, we will, of course work with ledge counsel as we go through the bill again and look at some of the responses that we're getting. So once we get Medicaid that'll be helpful and then we'll learn further what language might be necessary on the pharmacists, how much language have been we'll have charity Clark, working with ledge council initially initially and then we'll bring it back into committee, talk and committee. And that's one point if I may, which is that the issue of concerns about liability coach for pharmacists arose immediately after passage of the bill, the department actually reached out to the office the attorney general. And you can see on the, the penultimate question of the FAQ we have the statement of the attorney general that if a pharmacist acts within the scope of her practice that actions of the law are covered by liability. So, what I 74 does is it makes explicit what has been implicit understood, I just want to be clear that that it codifies the status quo. In a way that that's we now have positive we would now have positive law, but it's not it doesn't represent a shift, legally speaking. Thank you. Thank you for that clarity helpful. Okay. Committee any other questions for the witnesses today. And just as I indicated earlier we do have one witness who's who is unable to be here because of a family emergency. And so we will add that testimony. As quickly as we can. And we'll try to get responses back on this legislation and go through it for some final discussion and markup as quickly as we can as well. Okay. Thank you all for being here I we're, we're, we're in a mode of switching gears and turning a corner. And we're going to be looking next at parent child centers and a bill called s 91. So I'm not sure you need to stay around but thank you all for your testimony has been excellent.