 prescription. Kate's daughter told the reporter that she found the safeguards to be a roadblock and eventually a physician was found to write the prescription and Kate Cheney died from the lethal dose. S-74 would make it even harder to determine if a patient was feeling pressured or coerced and make the doctor shopping seen in the Cheney case easier. Under Act 39, not only is the prescribing physician required to do a physical examination of the patient, a second physician is required to conduct an evaluation of the patient as well. While it is not explicit in statute, the practice under Act 39 has been that this second opinion would also be the result of an in-person consultation. But S-74 would allow a physician to prescribe the lethal dose of medication without ever meeting the patient or conducting an evaluation of the patient in person. While telemedicine is a useful tool in some cases, we all know from the past two years that online communication is not the same as in-person communication, especially when you are meeting someone for the first time and don't know them at all. While it has been the practice under Act 39 that the second physician also conducts an in-person exam, the law does not explicitly require it. So under S-74, the patient would not have to be evaluated in person by either the prescribing or second physician rendering the safeguard of a second opinion meaningless. The physician may have no relationship with or knowledge of the patient other than reading a medical record. In addition, the medical records could be provided by the patient. They would not necessarily be sent by a physician who performed the exam. The patient would be able to limit the information sent, for instance, by leaving out mental health records. The prescribing and secondary physicians would not know if they had received all relevant medical records. The lack of a required in-person meeting between the physician and patient becomes even more concerning in light of Oregon's 2021 Death with Dignity Annual Report, which lists anorexia as the underlying condition for which lethal drugs were prescribed. This is very significant as it marks the first time a mental illness has been included as an underlying condition that qualifies someone for a lethal prescription. As it is literally a matter of life or death, it should be required that the prescribing physician examine and evaluate the patient in person. When Act 39 was passed, the lethal drugs commonly prescribed were secobarbital and penibarbital. However, those drugs are no longer readily available in the U.S. due to their connection to execution by lethal injection. In recent years, proponents of assisted suicide have been experimenting with a variety of lethal drug cocktails, trying to find a combination that kills most efficiently. Given the ongoing changes being made to the drug protocol, its experimental nature and side effects such as regurgitation and prolonged dying, immunity should not be given to pharmacists and healthcare providers. The pharmacist currently providing the drug combination to patients states that he requires an indemnity agreement be signed to protect himself. I would hope that agreement also makes patients aware that an expectation that the drug combination will result in a quick, peaceful death may not be what happens. In 2013, supporters of Act 39 insisted that the safeguards included were wanted and necessary. Now they have done a 180 asking for some to be stripped away. What will they be asking from this body next? Instead of removing safeguards, this committee should consider strengthening protections for patients. Is this the opportunity to vest a government agency with oversight of Act 39? Require full disclosure of the experimental nature and potential side effects of the lethal drugs being prescribed. Take action to make sure mental health conditions do not become the basis for assisted suicide in Vermont. And ensure that physicians involved have a bona fide relationship with the patient. More protections are needed, not fewer. And I urge you to vote no on S74. Thank you for your time and I'd be happy to answer any questions. Thank you very much. I'm looking for questions, comments. Formulating a question. Please. Go ahead. I'm still thinking. Oh, you're still thinking. Okay. Is she going to stay with us? Sharon, we do have a question from Representative McFawn and I'm wondering, are you going to be able to stay with us this morning? Yes, I can. No, I can stay with you. Thank you. Representative McFawn. Madam Chair, thank you. I want you to make a decision about this question. I'm going to bring people to page two, small five. And it says the physician determined that the patient, that's the heading. And the underline section under A says a physician's physical examination of the patient. And then down lower, it talks about the physician informed the patient in person or by telemedicine. Is that a question for the Legislative Council? I believe it is, although I'm not quite sure what your question is. Well, the question, my question is, is there a need for an in-person physician's physical examination? The testimony here is there isn't. And I'm looking at these two sections. One says a physician's physical examination. You can't do a physical examination over telemedicine. So I want to make sure that I want to get that clarified. Okay. And I think I'm going to ask Legislative Council to clarify what is in statute. So please. Sure. Do you want me up there? I guess we do want you there because then we can hear you. Good morning. Jennifer Harvey from the Office of Legislative Council. So looking at subdivision five there on page two, this is the requirement that the physician determined that the patient in subdivision A was suffering a terminal condition. And that is based on the physicians and under the language in the bill, review of the patient's medical records and a physician's physical examination of the patient. So a physician, whether it's this physician or another physician, must have done a physical examination of the patient. And that physical examination, I agree, a physical examination would need to be done in person. That's the physical aspect of it. But that is adding to or leading to that determination that the patient was suffering a terminal condition. So not only was in their medical records, but that must include a physician's physical examination of the patient. Am I answering your question? Yes. And that physical examination is that they were capable, was making a informed decision, had made a voluntary request, et cetera. All of that stuff is done in person. That physical examination is just modifying that determination that the patient was suffering a terminal condition. So the physician has to determine that the patient was suffering a terminal condition, was capable, was making an informed decision, that whole list. But the determination that the patient was suffering a terminal condition is based on the physician's review of the relevant medical records and a physician's physical examination of the patient. So the answer to my question is, a physician has to do a physical examination of this person. Is that correct? That is correct. Okay. That's the main thing I wanted. Thank you, Robert. Just on that same point, but it doesn't have to be the referring physician as far as I understand it could be another physician did the physical examination. And that's a concern to me. Okay. Thank you. Okay. Chopra, do you have another question right now? I can't hear you. I'm sorry, I have to get my hand down. There you go. Okay. Thank you. And Sharon, if you can stay because there may be some more questions and now we have David Engliger. Good morning, Congress committee. I'm delighted to be before you today. I see you taking away my pillow and snacks, please. So good morning. My name is David Engliger. I'm a senior policy and legal advisor at Sharp Health. The chair's indulgence, accused indulgence, I don't know how much, how much you meant your pain. There's a lot of information. Would it be okay if I could serve a brief history to locate the bill in time? Certainly. That would be helpful. That was confusing. He said certainly. Certainly. But I'm going to have to ask you to speak up. Okay. Project. I will try to project. So in 2013, I'll kind of do this straightly. Remember the table. I'm going too slowly. Okay. In 2013, when the legislature took this matter up, at that point it was being called death of thinking. The legislature for many weeks and back months, I believe, considered a Washington-style bill where there was a stepwise process for physicians and patients, where there was also comprehensive reporting that was currently required by the Washington Department of Department of Health. As things sort of took a turn, as things went to the Senate, at the final hour before the vote, that bill was changed radically. It removed the reporting requirements. It also had some imperfections that were currently living with that I think to some extent this bill addresses. So the Department of Health testified on this bill we were supported by the shuttle administration. The chair and other committee members may remember that actually Steve Shapiro of what that time was, the chief medical designer came and testified his support of the bill and the importance of having the underlying cause on death certificates and have the death certificates not reflect this. And what he said was, I think, was particularly striking, which is this is extraordinary but not exceptional to the extent that this is the last decision made between the patient and the doctor in the lifetime of the decision. So following the passage of Act 39, the Department of Health, as is on our website, it said, the member read it, it said, Jeff, he probably means I wrote that paragraph. There is no, there is no overseeing entity, but the Department of Health to the extent that anything is administered, the Department of Health administers the, we administer the act to the extent that we collect all the information from patients and doctors. But what we wanted to do, what the Department of Health wanted to do was to ease access to the, to the act so we convened a large stakeholder group, which nurses and brought ethics network, and even a medical center, we created a whole series of FAQs for doctors, for patients, and the general public. And that's, you don't have to add any words. So I've made those available to the FAQs were produced and published on all of our websites. So that's available on the Department of Health website. There are also all of the, all the requirements of the act were just turned into a form so that, so that doctors and patients didn't have to create word documents to ensure that all pieces of the activity follows. And that was a series of, it's a series of checkboxes and signature blocks. We did not add as craft, the Department of Health didn't add as craft anything, it simply, it simply follows the tenants of the act. As we sat down, the stakeholder group sat down to discuss this, we noticed rather quickly that there were not liability protections for all health care providers. So it was important to think about pharmacists that they were going to be held liable for, for providing a legal dose. We reached out to the Office of the Attorney General who provided us an opinion saying that if our pharmacists were working within the act, within the scope of their license, and were participating, you know, under the act that they would not be held liable. So that is actually in our, that's in the FAQs. Actually, that was, we got permission of the Attorney General to actually publish it under their, under their name. Two years later, so, oh, I'm sorry, a critical piece of Act 39 for passage was that the, the bathroom during the sunset three years later, the idea was that the stepwise process made out the act would simply become a part of the standard of care, and that there was no longer, there would no longer be need for a legislative imposition of requirements. But two years later in 2015, there was no consensus among the Department of Health and stakeholder that the, that's that stepwise process was still very useful. And also that there was an interest, there's a general interest and a little bit more information about what was happening with the act, policy makers on all sides of the, of the, of the spectrum, as well as the general assembly, the administration didn't really know what was going on because all information is held with confidentiality. So Act 27 or 2015 did the two principle things. It required the Department of Health to adopt rules that would have, that would, that would provide us the ability to collect information from providers. It also required that we establish a rule for the disposal of the dose that was prescribed if it was not used. So since 2015, the Department of Health has produced a report required by the Act, I'm sorry, it was produced every two years. I believe I have, I believe you all have that now. The information, as you see, is, is fairly, it's fairly basic and a fairly high level. We say, for instance, the number of persons suffering from cancer, we don't say what kind of cancer. And that's simply to protect people's identity, that if we have Washington style reporting here, we're talking about somebody's right ethnicity, their age, specifically what they're going to be going from. In Vermont, those people were going to be identified. If somebody is a certain age, let's say hypothetically 49, and they live in Huntington or they live in Victory, that, that's my intervention to be identifiable. So the General Assembly with the Department certainly supported, created this report that gives folks, gives them law makers and policy makers in the public a view of sort of what's happening broadly, but doesn't allow you actually to identify who's actually using it, which is, which is central. I mean, it's embodied by the fact that all of making this kind of confidential and the fact that the underlying disease is not reflected in the, in the desert. I'm sorry, general disease is reflected in the desert, not the, the final intervention by the physician. Where, where this built to the Department's position, where this built fits in, is it closes the liability gap that, that, that we try to close with, with working with the Attorney General, but it makes it very clear the law and there's liability protection for health care providers. So that the policy question, to my mind, before, before the General Assembly is, is really fair, fairly narrow. It is about the use of telemedicine. And that, and from the Department's perspective, as we think, we try to think both broadly and deeply about equity, these telemedicine has been valuable, you know, in the time of COVID. There are, in the case of after the night, patient choice, there are a small number of providers across the state who will participate. And if you have persons who are not, are not located close to a, to a physician who will do this, the ability to use telemedicine lowers the, lowers the barrier to access with somebody who will live far away. And they don't have to, you know, I think that they don't have to expend it today and their family to spend the time resource in order to go to the physician multiple times. We count on physicians in Vermont to do a whole host of things. And one of those things is constantly assess the patients and their treatment. And so, to my mind, the manner in which a physician is assessing a patient under the act is not, is not so different from the way they, they make all kinds of assessments every day. Again, I will come back to that formulation of it is, it is extraordinary but not, but not exceptional. So with that, I'd be delighted to take your questions. I'm, thank you for being here this morning, Mr. Lunder. I'm just looking at the report that was submitted this year to the legislature. And so noting that over the last two years, it looks like there have been 29 confirmed deaths, 17 of whom used the prescription. However, it notes that 21 had actually built the prescription. So presumably four people either died from the underlying disease, chose not to use the prescription. And one of the things that I know in this, you also have sort of cumulative statistics from enactment. What I don't see in that, that's sort of the general, give you the general of 116. And since you have the information about confirmed deaths and whether they use the prescription, why is it that you don't include that in the cumulative information? I'm sorry, the total number of prescriptions not used? In the biennial information, you give the total number of confirmed deaths, the total number who used their prescription, people who died from the underlying disease, that sort of like break out there. But for the cumulative information, since the enactment, we only get the first level. Obviously, because we only started collecting this information relatively recently. Oh, okay. Well, that answers that question. Yeah, I apologize. All right. Thank you. So I should have said that all positions are required to fill out a form when they and get under our rulemaking. They are not required to necessarily determine the cause of death. Because sometimes the attending position is in the presence of the patients at the time of death and sometimes they aren't. But the vast majority of positions have a factor less whether or not they were the ultimate cause of death of the patient. Okay. Representative McFawn and then Representative Rosenquist. Thank you, Madam Chair. Mr. Englander, I would like to bring your attention to one of the requirements that a person has to be a Vermont resident. Um, my understanding is the act is not specifying, like does not give a definition of a Vermont resident or who qualifies as a resident. Is that true? That is true. And it's unusual that that the determination of residency is actually made by the by the decision that sounds in the in the reporting forms the Department of Health provides just to be helpful. The kinds of things a physician might look at, whether it be a driver's license or a lease or a heating bill. But the but the ultimate determination of residency is determined by the by the position by the by the doctor. Which one? The first doctor that did the physical examination or the doctor that might be doing it by telemedicine? Or is it either one? It is by the it is by the original physician makes the determination who starts the process with pain. Okay. So is it a could this happen? I own a summer home in Vermont. Or I lease a summer home in Vermont. Could I leave Massachusetts and come up to Vermont and have this procedure done here in Vermont? Would that would that qualify me as a Vermont resident? That would really that decision would be made by the position whether whether they considered they considered you a resident. So basically, if any physician that is dealing with that individual, if they decide based on certain things like if I rent a property, is there any time limit on how long I have to be renting that property? Could I come up from Massachusetts and the next week start the process for a physician assisted? Because there is no time limit and because there are different kinds of residency requirements in Vermont law, it's not consistent. Like it doesn't say six months make somebody a resident. It would be up to the physician. I would say that having spoken with many of the providers who engage in this law, they take it with an extraordinary amount of gravity. And it's not something that anybody does lightly. So I think if somebody had a summer home, it's hard to imagine it's not that it's impossible because it would be allowed under the law, but it'd be difficult to imagine a physician taking somebody who is here seasonally as a resident. So that's an opinion. That's what everything else has to pure fact. Yeah. And I would think that, I mean, I don't know. I'm surprised or I'm concerned that a physician makes the decision whether or not a person is a resident of Vermont. One of those physicians, the physician that may be doing it by telemedicine, they not even know that person. Or anything about. So I could come in from Massachusetts two weeks ago and my family is here. So I came here. And okay. That answers my question. Thank you. But it is on the physicians, we rely on the physicians ethos, their morals, their ethics, the law, and the fact that their license is always on the line. So these are never decisions that are made by. I understand that. But a person coming up to Vermont to have this procedure done because they rented an apartment or maybe they came to stay with their family. I see all kinds of ways that wouldn't affect a physician's license because they're following what it says. All you have to do is rent the place, own property. You don't even have to live here. All you have to do is own property. And that could allow you to be considered a resident of Vermont. I just think it's pretty loose. So I guess I would say as a lawyer, renting doesn't make you a resident. By near fact of renting doesn't make you a resident. You do have to live here. That is what residency means. Well, it says you can lease property. But Vermont has to be your home. Okay. I have my answer. Thank you. Representative Rosenquist. Thank you, Mr. Englender. I know you gave us a little history lesson on this. Going back in history, could you fill in a little bit of why? I mean, to me, I would have thought certain communities in Vermont would have been concerned about this law because it's not equitable to all people suffering from terminal diseases and discriminatory in that way that certain people like ALSO uses, for example, would not be able to avail themselves of this procedure. And I was just curious why there wasn't more focus on that and to come up with maybe a method, not to say I agree with this, this thing anyway on other grounds, but I was just surprised that it was such a discriminatory and not equitable law to begin with for people having ended life issues. So maybe you could give us a little background on that. And you were referring to the fact that a person must, a patient must self-administer the dose. Correct. They need the physical capability to pick up, to pick up the glass to be able to be able to swallow. That's a, it was a policy decision made on the part of the general assembly that, that physical, that, that they can use a Vermont, that a word is used uniquely in Vermont law, which is, we say somebody is capable, that's not, that's not used elsewhere. And so, so my observation is that the general assembly felt that capability fold into, that was both a mental and a physical capacity. It is in dish of intent, but you're certainly right that there's a point at which patients are going to be physically incapable and they, and they, they don't have access. Yeah. I mean, to me, these people are the same with a lot of people. I think they have more of a reason to do it than people with other types of terminal diseases. It would seem like, anyway, I, it would seem, well, I guess a follow-up would be do other states allow people, they can't self-administer to, to do this, I mean, to avail themselves of this. At the, at the time there wasn't, I don't know, there may be, there may be folks in the room who know whether other states allow, I would say this, that if you allow another person to administer, there is a, there's a greater chance of, of, of, when somebody, some of the ministers, we know that they're, they're, they're making an active choice. No, I understand this. There certainly is, right, if you, if you balance that, again, the person that do that with the legislative, you balance whether you think that, that that is going to create a problem for people who aren't, who aren't capable. Right. And there was, I mean, there was, and stakeholders did express, as it was expressed today, express the concern about coercion. I, I do want to know that my name, that there are, there are, there, there have not been any instances I'm aware of in Vermont where a weird coercion has been brought up as an issue. In 2015, I'm sure the chair will remember, there was a floor amendment on, on the act that would have had the Department of Health report done to do an annual report saying how many times persons who were not supposed, were not authorized to sign, sign. And what I said, I think sitting right there is, there's no, there was a chair there, I don't know, anyway, is that there didn't need to be a report because if that happened, we would immediately contact law enforcement because something was in danger. So, you know, there have not been, there have not been any instances of that in Vermont. Okay. I know that you also talked about this question, I just. Okay. All right. I don't know what to say, I just think it strange that they wouldn't have tried to come up with some method that somebody could self-administer or anyway, I just surprised. Dane and then Topper, I see your hand up. So, you will be after Dane. Oh. Thank you, Madam Chair. And thank you Mr. Engler for being here. This is a question I've raised a few times and my understanding is you might be the person to provide some context, the rulemaking regarding disposal, if somebody does not administer the medication, could you just describe a little bit about the process? Sure. I mean, to be honest, the rule is as broad as DEA regulations allow. So, essentially, you have to destroy the medication so it can't be, it can't be new. So, a common method. So, there's two things, we want to destroy it, we also don't want it in the environment. So, typically that means something like being mixed with coffee grounds or kitty litter, the two most frequently mentioned, and we all have them in abundance family, and then putting those things in an air, in a liquid type bag, you're mostly a teacher way to say that, and then just going to get in the trash, or can be brought to, you know, disposal site. I think the idea was that we wanted patients to know that there was an expectation that that would be disposed of. So, it's not, it's not more restrictive or more detailed than DEA regulations, simply a clear notice. Carl. Yeah, just, if I could follow up to something that Ms. Toobard brought up was the fact that the, I guess, most common drugs are not readily available anymore, and I'm trying to come up with some other concoctions. And so, what sort of level of testing would have to be done before those, that new concoction would be distributed or used. I recall several years ago, there's lots of discussion on end-of-life things at correctional facilities that they went through a whole dream of different chemicals on almost everybody. Almost all of them got voted down or were not allowed, and I don't even know what to use these days, but it was a big process, and I was wondering what sort of referring back to her issue there that some people may die more slowly than they'd really like to because they're using some cocktail that isn't as quick as people would like it to be. So, what sort of protections do we have on that from a pharmaceutical standpoint, I guess? Sure, and just to breathe through the history of that is that there was the most common, the most common dose that was used was also made by a German manufacturer that was also used in prisoners' executions, and so the German company stopped exporting to the United States because of their more opposition to the death penalty. So, we did what spurred the need for this to explore other options, and to answer your question, the answer is that all drugs would require FDA approval. For that intended use, right? End-of-life, okay, and I always said FDA would have to approve a brand of life? Well, that's actually a good question. I think, I don't want to get over my skis. I don't think FDA approves drugs for end-of-life, because there is a prohibition on use of federal dollars, I'm sorry, end-of-life, excuse me, a patient choice. So, I don't know off the top of my head, and I want to guess, but I can certainly get that for you. I don't think that FDA says this can be used for. Yeah. I mean, usually when a manufacturer comes, they say what the intended use of the drug is, and FDA determines that it will do what they purport it to be, and that's one of the things we see on the back of FDA approved to do what it says it's going to do. So, just a curious issue. I believe if we go on our web page, there is something from the pharmacist that references this, and I'm not quick enough to find it right now, but I believe the answer of as much of an answer as we have is on, we've got that testimony in both verbally and in writing, verbally from the lawyer, and a letter from the, I believe, single pharmacist who is providing medication. And I believe that a hand is going up by representative Taylor Small. Thank you, Madam Chair. I did that quick research for you to find it on our web page. It would be under Jeff Hockberg, which you can either go to Friday, April 1st to find that, or under the witness list. Are there other questions right now for the health department in David Englander, or do you have anything else you want to say? I'll be here all day to answer the committee's questions. All right. Thank you very much. We will go to Sarah Teachout. Good morning. Good morning. Nice to see everyone here. I'm Sarah Teachout, and I represent Blue Cross and Blue Shield of Vermont. And I want to say thank you for considering this legislation. Blue Cross and Blue Shield of Vermont very much supports it. In particular, this section that provides pharmacists some protection, some legal protection specifically. Our role, just to step back, is when one of our members requires these medications, we have to locate where the drug can be purchased. At present, there is only one pharmacy in the state of Vermont and one pharmacy in New Hampshire where we can procure these medications. So we believe that this may help make the medication a little bit more widely available and easier to get the person to make them. I don't believe that this alone is the issue, but I think it will help. So that is the reason we are supporting the bill, and we support all of our numbers health care choices. So happy to answer questions. Certainly. Carl. You said there's a manufacturing site or a pharmacy that this is available? Pharmacy. A pharmacy. In other words, it's not available in Vermont at all. There's one pharmacy in the state of Vermont that will build prescription. Yep. Are there other questions or is this anything else that you want to add? That was it. Thank you. Thank you. Thank you very much. Are you there? Yeah. Please go ahead and Julie, could you let, I know it's a bit earlier than you confirmed, but I thought if we have this and then we take a break, that that would be more appropriate. And Alan, please sit down. This is Alan Jewett McKay. And Alan McKay Jewett. Yep. Okay. Thank you. If you would wait 30 seconds, a fellow committee chair would like to be up here. Representative Brad would like to be up here. Oh, so we could. Yes, I'm sorry. You know some of us, but you don't know all of us. So let us introduce ourselves. I'm Julie Campion from St. Braugton. Yes. Tapper, could you introduce yourself? I'm Tapper McFlawn, and I represent Barrie Town. And I'm Jessica Branstad, and I represent Shelburney, St. George. I'm Dan Noyes, representing, we'll get Hyde Park, Johnson, and Belvedere. I'm James Grabber. I represent Fairfield, Fletcher, and Bikersfield. I'm Allison Allen, with the Montgomery, Buston, Stratton, New York, and Bendman. I'm Dane Whitham from Huntington. Nice to meet you. I'm Ray Glock, I'm a representative of this. Carl Rosenquist, represent the town of Georgia and Franklin County. Good morning. Taylor Small, representing Winniesky and Burlington. Taylor. Good morning, Ellen. Nice to meet you in person. Teresa Wood from Waterbury, and I also represent Fulton Field School in Huntington. Great to meet you all. Thank you so much for inviting me. Thank you for being here. We have just checked to represent the grad, and perhaps we'll wait a minute, and if not, we will go forward so that you know. Thank you. Thank you so much. Thank you. And for those of you on Topper and Sharon, just so you know, Sarah teach you how to just let so that you know who is in the room. Representative McFawn, you have your hand up. Yes, Madam Chair. Just a question. We're waiting for representative grad. Is she specifically interested in this witness's testimony? Yes. I think without, I believe that she would like to be here in person. But just this particular witness. Yes. There's other testimony. She is interested in all of the testimony. Okay. Former Representative Jewett was a longtime colleague and vice chair of House Judiciary. And as such, she wanted to be in the room if possible when his wife testified. Right. Okay. I'm sorry, Jim. Thank you. Since we're waiting, I asked Mr. Ingliter a question or one that he could possibly answer. Oh, absolutely. All right. I thank you for the reference that Taylor looked up for me about the prescription. I've thought all along that it was an injection or whatever reason. I don't know why I thought that, but I'm just letting it be known that I didn't realize it was a suspension and something would take my mouth. That even makes me question more my initial issue. But anyway, just saying. Was there something that led me to believe it was an injection or not? I'm trying to thank people. I can't say what might or may not be your mind, Representative. But it is a liquid. I think I made, I think I thought it is a liquid. As much as I would like to wait, I think it's hard for everybody. So please Ellen, please go ahead. Thanks. I'm Ellen Blackmore. I'm Jim McKay Jewett and I'm Willem Gudeau. And I really appreciate you guys inviting me today to talk about our family story. Many of you. Could you speak up both for this end of the table and for this thank you. Many of you knew my husband who worked with him here in the state house for many years and you knew that he was a strong advocate for Act 39 when it passed in 2013. I'm sure he never thought back then that he'd need to use it himself. But his diagnosis of a very aggressive new coastal melanoma in December of 2020 and the failure of immunotherapy, chemotherapy, radiation to control it, made medical aid in dying an option that gave him and us, his family, enormous peace of mind. We are extremely grateful that he had that option. You know that Willem was a fighter. He had more energy, determination, grit, and courage than anyone I've ever known. He wanted to live more than anything. We were making plans for adventures right up to the end. This was a man who was 100% committed to living. He loved his medical team at Dartmouth Hitchcock. His girls and I and countless friends supported him every step of the way through this sickness. He was all in with his treatment. But knowing that he had access to medical aid in dying, gave him and me and his brother and his daughters great comfort during his last few months when it became clear that there would be no cure. Willem hated using words like battling and fighting when talking about his condition. To him, it was more of a project. A project that he tried very hard to control. Karen Olschlager, another Ramonner who benefited from Act 39, put it well when she described her long illness. There can be a lot of pressure in our society to keep fighting, keep fighting, keep fighting, especially as a young cancer patient. I think that's what folks don't always, I think what folks don't always realize is sometimes keep fighting is really just a lot of prolonged physical suffering that gets worse and worse. Pointless suffering at the end of a terrible illness serves absolutely no purpose. Act 39 gave Willem control over the last chapter of his life. He thought about it for months and very clearly knew this was the route he wanted to take. He gathered us together in June of last year and told us this would be his plan if treatment did not work and we all supported his decision. He was a world-class athlete and he was good at listening to his body. It became very clear very quickly when his prognosis worsened. He knew when it was time. Willem got to the point where he could no longer get into the car and drive to Hanover for treatment. And for him that was the signal that he reached the end of the road. At that point he was very, very grateful to have the medical aid in dying description on hand. Five days before he died he reached out to patient choices Vermont and offered to lend his voice and firsthand experience to their advocacy to revise some of the bill's original wording. Some of that language made it incredibly difficult for dying Vermonters to jump through all the hoops necessary. Tell medicine visits for example rather than in-person visits would make their last few weeks much easier. Doctors can decide as they do with all other patient care if telemedicine is appropriate in each case. As Willem said let's not let the legislature get between patients and their doctors. At 39 gave Willem a peaceful and dignified death. It allowed all of us to be there with him in his last moments. While he was still the person we all knew and loved. He did not have to endure an increasingly medicated painful and drawn out death. We are so very grateful for that gift. Dr. Diana Barnard and Stephanie Stoddard our spectacular hospice nurse from Addison County Home Health and hospice were with us at home that day. While it was a blur of emotions for all of us what I remember most is the courage and humor that Willem was still able to share with all of us and the gratitude we felt that he was still in control of the most important decision of his life. It was a calm and peaceful and strangely happy death. None of us were happy that he was dying but all of us were happy that he was still calling the shots. I'd be happy to take any questions. I don't have any questions but I would say thank you for sharing your stories. It's very very powerful. This point and people need to understand that at the end of the day it's virtuous and it's not the beginning of life. It's not the I think Switzerland has a lot that's very we'll say liberal where you can just choose one day not to be there. This is dealing with absolute pain and if people nobody deserves to go. So I'd appreciate it. Thank you. Thank you for sharing a very personal story for the courage that you have in terms of sharing it. Like several of us in this building we knew well and we knew how much he loved life. I couldn't keep up with him walking up the stairs and he was feisty and his courage and the support of you and his family in his decisions and thank you. Thank you for sharing this. Is any sort of I don't know whether there's a place for questions or further comments to you or if there's anything else you would like to say? Well I just you know I mean it was such a short time before he died that he reached out and started you know that final push to help these changes go through. He believed in it you know 100% not only from a you know ethical and legislative point of view but from a personal point of view he was in it he was in it and he wanted to make sure that other people had a slight had had slightly fewer barriers to get through when it came to them and you know I'm just really happy that I can win my voice to help that stuff go forward because it's what he would have wanted and yeah. Sorry I'm not very loud with my mask on but thank you. I would just share that two years ago my mom died at home in a state where we did not occur this and it was horrible. It is a gift it is a gift that Vermonters had this option so they don't have to go through that awful and for the families for those of us who are left it I think I absolutely believe that it has enabled us to heal more thoroughly you don't have to go through that awful period of helplessness and fear and you know horror and for the survivors that makes a huge difference it makes a huge difference. Thank you. It was let's just it brings it back. Yes I am I'm so glad that I have an opportunity but you so thank you thank you for being here and committee what I would say is this is a good time for us to take a break and why don't we come back at quarter of 11 and when we come back at quarter of 11 let's talk about what we have heard if we have remaining questions for legislative council in terms of what the words mean and let's just talk amongst ourselves have a committee discussion about how we're moving forward so thank you very much and you're going to take a pause.