 Good morning. This is the Vermont House Human Services Committee and it is Thursday, March 31st and this morning we are focusing on taking testimony on s 74 and act relating to modifications to Vermont's patient choice at end of life. Laws and we have three people before we take a break who are going to provide some testimony for us and we will begin with Dr Barnard Dr Barnard. Please go ahead. Thank you very much. I appreciate the opportunity to share my experience with the committee. Just to remind you of my qualifications for being here. As always, I'm most proud of being a lifelong Vermonter. I've also spent my entire medical career post training working with Vermonters in Vermont. I've been board certified in family medicine since 1994. And I also became board certified in hospice and palliative medicine in 2012. I have practiced medicine for 28 years now and the last 12 of those years have been focused exclusively on caring for patients living with serious illness. I was actively involved in the efforts to pass act 39 in Vermont. And since that time I've been on the patient choices Vermont board since its inception. And I am also on the American Clinicians Academy of Medical Aid and Dying Advisory Board since its inception in 2020. I regularly prescribe under the law and I also educate and support other doctors who are doing this work. Just to remind you of the numbers of the state of where our law is as some of you may know the Vermont Department of Health provides a report every other year on how the law is working and the last report came out in January of this year. And those numbers mirrored the experience of other states where medical aid and dying is legal. In the course of eight years now that our law has been legal, a total of 116 Vermonters have met the qualifications for participation in the law. As with other states the vast majority of those were living with cancer, and the next most common illnesses were ALS and other neurodegenerative illnesses. The numbers really show that our law is working largely as intended. There have been no documented cases of abuse. However, experience with the law has shown that there are some challenges and really that's what brings us before you today. And there are really three main issues that as 74 is addressing. Immunity and you're going to hear more from others on that but I would just say that Act 39 really focused unintentionally only on immunity for the prescribing physician. And we have now realized that pharmacists and other members of the health care team participating in the law who follow the law and use best medical practice really need and deserve that explicit immunity so we're asking to codify that. The, the second issue we're addressing is telemedicine. You know, medicine is always changing sometimes so fast and when we passed our law telemedicine was just not on our radar screen it was not being widely used in Vermont. So it was actually widely used in other systems for example the VA has been using telemedicine for years. And obviously as we all know, COVID has really opened our eyes to the importance and also the clinical usefulness of telemedicine and it's, it's, it has expanded, and we now want to include the process of medical aid and dying within that framework. So I thought it might be helpful to just sort of go through an example of what a telemedicine visit would entail, and I let's assume that it's a new patient to me. So, you know, first of course, before I even meet with the patient I would be reviewing their records so I would look at their physician notes, and their x-rays and labs and any other data, I would review what treatment they had for their illness, and any other data would give me a clue about their prognosis. After connecting via telemedicine we would engage in introductions, and I would start by introducing myself and then asking questions of the patient to help me learn really who they are and how they see the patients and how they've lived their lives and how they've managed their illness. And I would explore what supports they had if they had family or friends, whether or not they were on home health or depending on the situation perhaps hospice. I would be exploring what their most bothersome symptoms are, how they are suffering, whether it's physical or emotional, and explore that. And of course, while all of this is going on I'm continually listening to the patients. I'm listening for signs of advanced illness. I'm also listening to be sure that their thought content is clear, and that they can articulate what they are feeling and what their experience is with illness. I'm listening for a specific request about medical aid in dying and if that comes, that's when I then move into the details of exploring their ability to participate, whether or not they meet the criteria. And I'm especially focusing on if the request is voluntary and consistent with who they are, and if they are capable of understanding what they are asking for and if they have been well informed about their illness and the treatment options and to be sure that they have all of the supports that they need. And I could also be using my eyes to look and see what the patient looks like looking for signs of frailty. I'm looking for signs of advanced illness. I'm looking for signs that they're having trouble breathing if they're wearing oxygen or the respiratory rate is up. I'm looking for signs of weakness or weight loss and I could even ask the patient to get up and move around the room if I needed more information about their strength. I could even look for nonverbal signs of pain. And so really that visit provides me with the tools that I need in order to assure that this number one that the visit is working. And if there are any issues that the visit is not allowing me to do a comprehensive evaluation if there are technical issues, if the patient has communication challenges that are present over technology. Or if I'm unable to clearly document that they are capable and well informed. If I found any of those challenges I would stop the visit and move to an in person visit and if the visit was adequate I would then schedule my next visit and and that would that would suffice. So, the last issue that this law is addressing is really the timeline of our process and I will just remind you that most patients want to live as long as possible. And if you are diagnosed with a serious potentially life limiting illness, all of your energy pretty much goes into treatment and people become all consumed with their appointments and their visits for testing and doing everything they can to control the disease and many people with the disease can go away. It's also true that most patients have very clear thoughts and wishes for how their life comes to an end, but they don't have the energy or the emotional capacity to focus on that early. And so it's often later in the illness when people have a high symptom burden and their disease is quite advanced and their energy is quite low. The timeline is quite short that suddenly plans for the end of life are needed. And in my experience, the vast majority of people interested in medical aid and dying have thought about it for a long time, but have not started the actual process because they've been hopeful, or providers have told them it's too early, or they've had trouble identifying a willing prescriber so there are many things that defer these conversations until late in the illness. And what's happened is unfortunately our safeguards having some ways become barriers. So just to remind you of the process that patients need to go through they need to make one oral request to the prescribing position, and then more than two weeks later they need to make a second request. It's really important to understand that between weekends and days off, more than 14 days is usually not 15 days but often many more. The patient also has to see a consulting position and they have to put their wishes in writing and have it signed by uninterested parties. So after all of those things have happened, which gives a lot of careful time to contemplate what's happening and assure that the process is voluntary and the right thing for this patient. There is an additional 48 hour waiting period after that. And what we have learned really is that that additional 48 hours offers absolutely no clinical benefit and it is becoming a barrier and a burden. And I actually want to end by sharing a story with you that illustrates actually all three of these issues I've been talking about. So this is a story of Lynn Ashay and her husband Tony specifically asked me to share her story in hopes that we could improve our law. So Lynn was a competitive athlete from Arlington. She was the first woman to bicycle to the top of Mount Washington, and the third woman to run to the top of Mount Washington. She was incredibly healthy and had no risk factors for cancer. She developed a nagging cough late in the winter of 2019 and eventually sought treatment. She was treated for pneumonia and then had a second treatment and then when her cough didn't go away. She underwent additional testing and by April of 2020. Unfortunately, her work up showed that she had evidence of widely metastatic lung disease lung cancer. In addition to being totally in shock Lynn immediately engaged in active treatment, because she was healthy and of course wanted to treat and hopefully beat the disease. At the same time she started talking with her husband, and her friends and her health care team about her worries about the end of her life. She had an experience with her father who had had a very difficult final days to short weeks of his life and really lingered in a condition that was traumatic for the family and Lynn absolutely did not want that for herself. Unfortunately, Lynn's illness was very aggressive, and despite active treatment her illness progressed rapidly over the last two months. According to the additional physician waiver that our current pharmacist asks us to sign Lynn could not find a willing prescriber in her area in Arlington. So when she contacted me I agreed to see her, but that unfortunately required two separate visits, an hour and 45 minutes each way to see me. And particularly during our second visit Tony called me from outside because he needed help getting her out of the car and when we went out to help her. I learned that Lynn had wanted him to use an ambulance because she didn't even know if she could sit up for the visit and poor Tony had reclined her passenger seat and stuffed a camping mattress in the car so that Lynn could be as comfortable as possible. And I just cannot tell you how hard it was to see her physically be so deconditioned. Despite being very physically conditioned she remained very clear and sharp in terms of her cognition. And during that visit I confirmed that she understood what she was asking for she was capable of moving forward, even in that condition. She was hoping for more quality of time but wanting to be prepared for the end. Because it was a Friday, we agreed that I would take care of the prescription first thing Monday. That would be the 48 hours plus a little bit and unfortunately in this situation on Sunday morning Lynn had a period of rapid decline and by Monday she lost the ability to be able to move forward with the use of the law. And unfortunately Lynn then had 11 more days as Tony heartbreakingly told me where she experienced the very kind of death that she desperately wanted to avoid with lingering symptoms and her husband having to care for her, and a prolonged period of dying. And in his intense grief, Tony was so frustrated and distraught and desperate to make things better that he wrote to me and the hospice team, and to blue cross through shield. And many of you might even have heard from him because he wants her story to serve as a very poignant example of why we need to update our law and make it better so that others don't go through what landed. I think I will stop there and I'm happy to take questions if you have some. Thank you. Thank you very much. Dr Barnard and let me look around the room. Representative McFawn has a question. Thank you madam chair. You just described a situation that leads me to the question that I had. If you during the telehealth visit if you sense that there was a problem of any kind, then you would move to an in person visit. If a person with say, ALS who, and I've dealt with this I've carried the person out of the bed into the car and up to the hospital and all that. How could you do that how could you move from telehealth to in person. Is there a way that you could figure you know, I mean, I'm just trying to, that would be a barrier as far as I'm concerned. You know, I think with our law, our law is is an important balance of safeguards, which in some instances become barriers, and it's important to have the right balance and the truth is, there are certain situations in which people would not be able to access the law, and we are engaging in constant quality improvement that's why we are before you to try to maintain that balance. You know, I've worked with ALS patients and when I've had the time, I would make that an in person visit by going to their home. I have to assess each situation and each prescribing physician has to determine what they are able to do. And in the setting of advanced illness we need a lot of flexibility, I wish that I had had the flexibility to go see Lynn, but the request came so late in her course that my schedule was such that I did not have the time. And if I had the time, I would do that visit in person in their home so that they wouldn't have to make that. Does that make sense or answer your question? It does. I just feel that we still have a barrier that we've got to figure out how to get over. So medically denying is still a relatively new process and I think we are all continuing to explore how to meet patients needs. And again, always with the right balance of safeguards. Yeah. Thank you. We have a question from representative Rosenquist. Thank you madam chair. Yes, thank you for coming this morning. I'm wondering, can both those request visits, if you will, in other words the ones that have to be so many days apart or whatever. And both of those be done by telemedicine or does one have to be physically present. I was curious about that. I didn't hear you say that they both could be telemedicine. They both, they both could be telemedicine. You know, it's, it's interesting in my work as a palliative care physician in the work that I do with evaluating suffering and symptoms and exploring end of life wishes. I might be surprised to hear that most of my interaction with the patient and my assessment comes from my eyes and my ears. And just like in the hospice realm, I do not. I very rarely have to lay hands on the patient to know what's going on and offer the evaluation of suffering in the process. It's just not something that's, that's often needed in some cases it might be. And if that was ever the case for any reason, doing one of those visits in person would be appropriate. And there are other situations where a thorough evaluation can happen over telemedicine. Thank you. Dr. Barnard. In the situation you were describing there was a different attending physician who didn't participate in, in this service. And so I'm just curious, would you as a matter of course, be consulting with that physician about the patients situation, given that they would be new to you and if somebody's just seeking you out for this particular assistance in their dying. Yes, I'm, you know, I'm often reaching out to consultants by looking at records and almost always I'm calling people to because there are parts of the story that you get from there. So, in Lin's case she was even working actively with another palliative care physician that I was regularly in touch with because he was doing most of her symptom management, though he was not able to participate in the law, because of the waiver. Okay, thank you. I just have follow up now that you said that. So, do you do you feel in your experience in working with other physicians who are uneasy because of the waiver situation. Do you feel like this would improve access for people closer to their home. I definitely worked specifically with several physicians who would have considered prescribing, but we're not comfortable signing that waiver and you know it's a small world in Vermont this. We're in regular touch with each other and I'm confident that this move will help increase access. Thank you. In the specific example that you shared, you mentioned that the attending physician was not participating. Is it up to the individual then to seek out a physician that does or does the attending physician have any responsibility to maybe provide a referral or any other physician to help them find someone who can assist them basically or is it up to the patient to do all that research. Yeah, every situation is unique and of course we know and it's important to honor that the process is voluntary so that no patient or provider is mandated to participate. Physicians do have a duty and responsibility to inform people of their options and we have other legal precedent to assure that I in my in my experience there are many ways that that unfolds sometimes the physician might not want to prescribe but might be willing to consult. Sometimes there's a referral even within the own office or to another provider of the same specialty say oncology or neurology. And sometimes, if the patient is working with a home health agency or has a social worker that can make some of those calls, and sometimes the patient ends up making those calls themselves. And that of course can be challenging. Yes, follow up question from representative would. Dr Barney that just made me think about represent Garfano's question. So, to what extent, our physicians do do they get continuing education regarding changes in laws that happen. You know, over time, like, you know, we're familiar with there's a judge university, you know, they get updated every year on the new laws and we've just have heard stories here in our committee and personally around physicians who don't seem to be as up to date on some of the changes in the laws that have happened and what kind of opportunities do physicians have to get that updated information. That's a really important question and, you know, as I said before medicine is constantly changing and it is a challenge for physicians to stay up to date on these things and oftentimes your desire to seek updated information comes in the moment. You know when you, excuse me, when you get a request or have an ill patient. In Vermont, you know the Vermont Medical Society does ongoing education at the University of Vermont there are grand rounds routinely for family medicine and internal medicine, which cover topics that sometimes include serious illness and end of life care. I just gave a talk at the family medicine grand rounds about medical aid and dying and the updates including this law. We have patient choices Vermont has a volunteer nurse who takes calls from people needing information and we have a network of when those calls come to myself or Dr. Clow and other physicians I work with. And we now have the Academy in California which has a very wonderful robust website and offers regular education. And so there are resources out there to turn people to once they reach out with the request. And, and we, I consider it part of my job in supporting this law to offer those kind of educational sessions on a regular basis. Thank you for your service and doing that. Dr. Barnard I'd like to sort of follow up a question from representative Rosenquist when he was asking about the, the two visits and that the two visits could be both could be through telemedicine. The diagnosis of within six months of life. Is that made by someone else, or in one of the two visits, can that be made. The responsibility of the prescribing position to make that prognosis. And if they had questions about that, you might look to all sorts of information and the information from the medical records about other specialists and the tests and and a phone call to a oncologist about their, their belief in the prognosis. Of course, many patients that I see are already enrolled in hospice and so they have already had a formal referral and been given a six month prognosis, but it is my responsibility or the prescribing providers responsibility to independently make their own assessment to confirm that. Thank you. Thank you for clarifying that. Representative Rosenquist. This is not specifically about this amendment. Okay, that's okay. Absolutely go ahead. And just out of curiosity, somebody has pretty serious kidney disease and is on dialysis and the prognosis says they won't come up dialysis. Would you which means that would terminate their lives by not continuing dialysis. I know such a case. Somebody I know up in Maine, they decided they didn't want to continue dialysis so they stopped and first probably within a week they were, they were dead. Would you still allow a person like that, the opportunity to terminate their life through this mechanism, other than just terminating dialysis or not. They wanted to come to you as a physician and they said I want to avail myself of this process. But they already have a process that they could use I was just curious what you would do. Yeah this this you know that's a that's an interesting question and it reminds me that you know I cannot emphasize enough how every situation every patient and every clinical patient is unique. And there is no one right answer for any situation so I would not use words like always or never having what I call parallel planning and exploring different options is always important. So with a patient on dialysis in meeting with them, I would do what I normally do which is explore what they're worried about and what they're hoping for. And I would talk about different pathways in different ways in which they could bring about a peaceful end to their life. And, and that's something that I do all the time. And if that person were to stop dialysis their prognosis would definitely be less than six months. And if they wanted to, and we had an appropriate window because that window would be pretty narrow but there could be circumstances in which that would be appropriate. And there could be circumstances in which there are other things going on. And part of my job is to help support the patient's wishes but also be clear when it isn't best to use medical aid and dying and we're instead going to use other measures to meet their needs and assure them a peaceful death. It's a very nuanced and subtle and important clinical evaluation that happens in those situations. Thank you very much. Are there. Before I say thank you to Dr Barnard for the time that she has given to us and are there any further questions. Thank you. Thank you for your work in this area. It is clear that this is something that you think about a lot and that you are providing a important service for those individuals who choose and want it. And thank you for talking with us today. Appreciate it. Yes, you're welcome I will mute myself but I am hoping to stay on in case of our questions later. I think we have more than welcome to. Next we have Betsy Walker men who is president of patient choices Vermont and Betsy is in the room. It's so great to actually be here in person. Good morning and thank you, Madam chair and members of the committee for the opportunity to testify on Senate bill 74. My name is Betsy Walker men. I'm a lawyer. I live in under hill and I am president of patient choices Vermont. I've actually been working on end of life choice and all of these issues for about 20 years since 2002. That's when my parents who some of you may have known Dick and Jenny Walters suggested that we launched the effort to get a medical aid and dying law passed in Vermont. And it was a long process but in 2013 that's that's what happened to back 39. And I want to say that in our work since one of the most consistent themes is gratitude from Vermonters and that gratitude really shouldn't be coming to me it should be coming to the legislature over and over we get those kinds of calls and expressions of appreciation. So after the law was passed in 2013 we established patient choices Vermont as an educational organization. And as Dr Barnard alluded to, we have, we're largely volunteer driven, and we have a help line where we get in the range of five to 10 calls per month from doctors and patients. And from people who from students from people who are looking to learn about medical aid and dying. We connect doctors with others with colleagues who are knowledgeable about the process and can help them learn about how to have these conversations whether it's about medical aid and dying or whether it's about end of life. In general, we've trained, at least a couple thousand people across Vermont, this runs the gamut from grand rounds that Dr Barnard and Dr cloud have chaired to sessions at the medical school sessions at hospice organizations workshops with community organizations senior centers conferences and so on. We maintain an extensive website with resources on medical aid and dying, including videos of Vermonters and a lot of pictures of people. And I want to say that I also have personal experience with late and dying my father, Dick Walters used medical aid and dying in 2015 when he was dying from it was his birthday yesterday so excuse me. When he was dying from lung cancer, and it was an amazing experience. And I'll just take a minute to relate that experience. He, like some of the situations you've heard about this morning. He was declining very quickly. He knew the end was very soon. He went through the process, and not everybody does this but he picked a date when he was planning to take his medication. And that created a window of time for the family to gather one of my daughters was living in Africa. She came in. So the whole family could be there. He spent a week talking to absolutely everybody he knew and many, many people visited including some of the representatives who've been involved in act 39. And his the day he took his medication he was totally in charge and joyful actually to be able to have that kind of clarity at the end of his life. And it was a really peaceful and beautiful experience. So my dad was 90, but one of the things that is important to know is that people who choose medical aid and dying or of all ages so many of you knew Willem do it, former representative from Addison County. I was fortunate to have the opportunity to speak with him in early January about a week before he died he was 58. And I went to go with cancer, and I want to share. We had an extensive conversation but I want to share one of some of his words if that's okay. He was referring to the process of passing act 39 and he said at the end of the day that patient needs to really have control. I'm proud of this one. Yeah, and then it was the next week and I believe you'll be hearing from some people who are connected with Willem. Karen Olschlager is another patient who came to us about a year and a half ago as Betsy could you speak up. Yes, I can. Thank you. Yeah, I know these masks. Karen Olschlager was a young cancer patient she was 33 when she was diagnosed with stomach cancer, and she was 37 when she died, and her experience is very relevant to Senate bill 74. Here's what she said about the process. She said it is hard when you are dying hospitalized and grieving from this major loss to go through the logistics of the act 39 process. It felt like a really, really, really long time to get through that process. By the time I was talking to the actual physician, I had thought about it for literally years. So as we know, when act 39 was passed legislators want to make sure that the law was properly used and so there's a whole list of qualification requirements and this process. So five qualification requirements and an eight step process. And I'm not going to go through the details you've heard about some of it but you do have for reference on your, in your document list. One page flow chart, which has all the procedures. And so do two doctors have to determine that the patient has a terminal illness for six months or less to live that they are capable of making their own decisions, and that they are able to self administer the medication. We now have doctors across the state hospice nurses and an excellent pharmacy who all have experience with, with helping patients through the act 39 process. It's interesting to see also that hospice use during the period from 2013 has also increased 26%. And almost half of people dying in Vermont are using hospice services. Medical aid and dying is a lot more established across the country and Kim Kalin and who will speak more to that. So I just want to address the specifics of act of Senate bill 74. More in the context of the personal stories you've heard about the mechanics, but when we look at the three provisions I think the story that illustrates the need for telemedicine. So very clearly is Karen Olschlager story she's the young cancer patient I mentioned her video is on our website. I have a quote from her. I had to physically go and get myself in front of this doctor which is rough when you were dying. I'm not going to go into the details of what rough meant in her case it was pretty graphic removal of that requirement to be in the doctors physical presence would be a huge relief. So that Vermont is the only state which requires or currently requires that the request be made in the physical presence of the doctor in all the other states that now have medical aid and dying laws. Those requests can be made by telemedicine. Another of the documents that you have in your records is a chart that we did. That takes the provisions of s dot 74 and and compares them to all the other states. So if you want to verify how it happens in other states you can be the second provision of s dot 74 would fix what I think is probably an insight in act 39 and provide explicit legal immunity to all of those who are involved in the process and we firmly believe that this would enable more pharmacists and more doctors to participate and help help their patients with whatever range of options the patient might want to consider. Another part of s dot 74 course relates to the timeline and the final 48 hour delay in the process. This 48 hours may not seem like much, but to a severely ill patient. It can make all the difference. We have one of the longest timelines among the states that have medical aid and dying laws. Now we were early in the process. Well we were the third state to adopt a medical aid and dying law so it's not that surprising that there have been some evolution since Vermont's law was adopted. We recorded the story of D Allen. Some of you may know D Allen. She was resolutions clerk here at the state house for many years. She declined very quickly from a neurodegenerative disease and in connection with the 48 hours. Here's what her son Duncan explained and I'm quoting. That last 48 hours was a nightmare. After six weeks working through the process in that last 48 hours there were any number of things that could have rendered my mother ineligible to use this procedure. That was the most dread and anxiety and fragility that I've ever seen on my mother, who was the strongest person I've ever met. The share emotional toll that it took on her when she was just waiting for what felt like arbitrary reasons, even though everybody had signed off. So with the changes that are in Senate Bill 74, I think we could all serve Vermonters who are facing their end of life decisions end of life care. Better we could help reduce suffering while maintaining a strong and effective process for medical aid and dying. I'm happy to answer questions and appreciate your consideration. Thank you. We do represent frozen quest. Yes, thank you. I just to verify something you said that 48 hours is from the time that the doctor is prescribing the medicine to the pharmacy or after 48 hours after the patient has received the medication. So, the patient goes through all the processes the two requests the second opinion and so on when all those formal parts are finished, the doctor has to wait another 48 hours before they can write the prescription. Then this prescription has to go to the pharmacy. And then, so it's often not 48 hours is often more in practice. Representative McFawn. Thank you, Madam Chair. Thanks for coming in today. Because I can't remember. We did provide immunity to the person. If there was an individual in the room with the person didn't we, in the original. Did we not. I don't, I don't remember doing it. I'm just wondering. I'm going to, could you repeat your question, Tapper. I didn't. Go ahead. The person that sometimes there's an individual that is in the room with the person. When in fact, they, and there may be more than one person in the room. In the original. Bill that we passed. I don't recall providing immunity to those people. I'm wondering if we did or not. I, because I couldn't remember. Representative McFawn, I'm going to ask legislative council. Who is. Trying to signal to me the answer. And rather than me. Figuring it out. I don't know. I don't know. Jennifer. Legislative council. So there is a provision in the existing law that says. That nobody would be, can be subject to civil or criminal liability. Solely for being present. When a patient with a terminal condition self administers the medication. Or for not acting to prevent the patient from self administering. I think that was. The language you put into, to try to address exactly that situation. I think that's a good question there to address that situation. What I am understanding. From the addition. And in this proposal from the Senate. Is to, is to, for it. The pharmacist, for example, is not covered under that general language. And that's really about who's present in the room when the patient takes the medication. And I think that's a good question. I think that's a good question. And the bill is looking at. So who are broadly the liability for. Participating for acting and just get compliance. This is for. People who deliver health care services, including pharmacists. So the language in the existing law is, is a bit. I'm clear. It doesn't specify it as clearly as. As 74 does that community for the health care professionals. Thank you. Thank you for the question. I'm looking around to see if there are other. Questions right now. Thank you very much. And you did reference. You have provided us with a couple of documents. On our webpage, one is you showed us. Whatever it is. Thank you. The words, the flow chart. The other is some links. And the other is the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the stories and. That. So I would encourage people interested in this to look. To those as well. Thank you. Thank you very much. And our. Our last witness in this segment of the testimony. I would like to thank the president and CEO of compassion and choices. I want to say nationally. Thank you so much for having me here today. I don't know if I can get screen sharing permission, but I had a couple of slides. I'd love to show if I can. If not, I can just talk through them. You can get. I'm looking to my right hand. And you should. You should have it now. Yes. So thank you so much for being here today. My name is Kim. For having me here today. My name is Kim. And I'm the president. Excuse me, Kim. I'm going to it. Looks okay. It looked like for a while. Chat or something was being. Oh, I see. That's gone now. That's got it. Okay. Okay. Let me, how do I share the, you can see the slide show. Okay. Yeah. Yeah. Yes. It's fine now. Great. So I'm Kim Callan and I'm the president and CEO of compassion and choices. And we are a national organization. I have the pleasure and the benefit of working across the country and both helping to pass the laws and implement the laws. And we are. It's important to remember that. Terminally ill people are able to access the law while still protecting vulnerable populations. We worked in partnership with patient choices, Vermont, both on the passage of this law. And also on the implementation, always making sure we're taking our cues from the local state about what is most appropriate in their state. But I do have the perspective of laws across the country and happens here in Vermont. So as Betsy mentioned in her testimony, Vermont was an early state to authorize medical aid in dying. You were actually the first state to pass this law through the legislature. Oregon and Washington first passed by ballot initiative in Montana through the courts. And so that, first of all, my profound thanks to you from all of the other states that followed you, California, DC, Hawaii, New Jersey, Maine, New Mexico are all state legislatures that followed in your footsteps. And so you guys should feel, I think, very proud of setting the way for so many other states to bring this option to their residents as well. But I think it does mean, because you were the first, that you put some provisions in the law that were designed to be safeguards that we're now seeing are roadblocks. Right now, one in five adults across the country has access to this option in their states. There are 10 states in Washington, DC, that have all authorized the option. When you look at how many people use the law across all the authorized states, and it's been in practice first in Oregon for nearly 25 years now, there have been just over 5,000 people adults who have died after ingesting the prescription. So it'll be a very small number of people, as Dr. Barnard mentioned, 116 people in Vermont have accessed the law over the time it's been in effect there. So we know that it's gonna be a small number of people who choose to use the law, but it provides profound peace of mind to those who do use it. And we also know from the data that it results in improvements to hospice care, palliative care, better conversations between doctors and patients. And so it ends up having an impact on far more people than the few that choose to use it. In terms of who uses the law, about three quarters are 65 or older, with the median age being about in their mid-70s. Most are dying of cancer or another neurodegenerative disease. Most are already on hospice care. So about 80, 85% of people who choose to use the law are on hospice care and they're able to die at home, which we know from data is where the vast majority of people want to die. Those who are not on hospice care, what we hear most often is that they don't wanna have to forego their treatment options to go on to hospice care. So they want the option of medical aid and dying often they'll have cancer. There is some very aggressive final treatment that they can try, but their body is shutting down and the treatments themselves are causing so much pain that they want the option of medical aid and dying should that treatment result in even more devastation to their body. They wanna know that they haven't out, but the vast majority of people are already on hospice care. And it really brings families together. There've been some studies that show that when people go through the process of medical aid and dying, it helps in the grieving process because people are having those conversations in advance. They're saying goodbye to their loved ones. They're getting the communication and the closure that often doesn't happen at the time of death. Most people who choose to use the law have a range of reasons that they wanted. For some, it's loss of autonomy, reduced quality of life, fear of pain and suffering. So it's really not any one reason. It's a whole host of sort of what happens to a person when they're at the very end of life is why people choose the option. And you'll see equal percentages of male and female who use the option. So that is it in terms of the share. And then I was gonna talk just a little bit about the provisions in the law and what we know is kind of taking place in other states. So really the small modifications to the law, there's really three elements to them. The first is around telehealth. And as has already been mentioned, this is an option that is in use in every other authorized state. Removing the requirements is really just giving physicians the ability to practice medicine in a manner that's consistent with how medicine is being practiced today. And as Dr. Barnard mentioned, if there was any uncertainty, that physician would institute an in-person visit. However, it does take away that barrier for the vast majority of patients. In terms of the 48 hour timeframe, the law already has a 15 day waiting period and it plus an additional 48 hour time period. And so all this provision is doing is removing the 48 hour timeframe that 15 days is still in effect. There are other, the largest timeframe that's in place, which is the 17 days, really it's only two states that have such a lengthy timeframe, Hawaii and Vermont. And hope the Hawaii legislature is also considering a reduction in their timeframe as well. All of the other authorized states, the 48 hours is happening at the same time as the 15 days. And three other states, Oregon, New Mexico and California have even reduced that 15 day timeframe down to a much lower amount. So you will still have one of the longer timeframes in place, but it will be far more manageable for terminally ill people. And then the last one in terms of extending immunities, all, but I think one other state has immunities extended to everybody, including pharmacists. And I do suspect Betsy's kind of guess that it was just an omission in the original laws, right? Pharmacists, just like providers and nurses all would want immunities under the law. So that is consistent with what is currently taking place across all the other authorized states. So in closing, I just like to stress that none of the changes that are being proposed here are really large. They're simply trying to take your original law, keep those core safeguards in place while helping to make terminally ill eligible people in Vermont able to access the law just a little bit easier. So thank you so much for your consideration. I'd be happy to answer any questions. Kimberly, thank you. Thank you very much. I've not looked, are those three slides that you showed us? Do we have them? And if not, could you please email them to- Yeah, I think they were in my written testimony, so you should have them. Okay, good, thank you. I wanna look around the room. Go ahead. Am I able to ask a question, Dr. Barnard, after we wrap up? Okay, let me first, before we move to another question to Dr. Barnard, let me see if there are questions for Kim Kellenan. Thank you, thank you. At this point, we don't have any further questions. You were quite clear. And we do, Dr. Barnard, have a question for you from Representative Wood. First, thank you, Kimberly. And actually my question is resulting from the testimony that you just gave. So Dr. Barnard, I'm just curious your thoughts about the 15-day time period and hearing that there are other states where that is either being considered to be reduced already is less. And your thoughts about that in Vermont? Well, I would reiterate my appreciation and thoughts for the process of trying to balance safeguards and being able to access. And as Kim said, we were early in the process and now we've identified these, what we feel are relatively small fixes that we can do. And because it's still a relatively new process, I think we're gonna learn more going forward. Some of the states have recognized, as I alluded to in my testimony, that the truth is while there are some fears of people racing out and considering hastening their death at the moment of a terminal diagnosis, that in reality, the experience is very different and that people wait till very late in the process. And there are people who wait so late that their prognosis is so short that even when they start, they will not live long enough to be able to complete that waiting period. Thank you, Dr. Barnard. Do you have another question? No, that's good, thank you. Representative Rosenquist. Thank you. I was just curious if there are any statistics on how many people who have been diagnosed with a terminal situation do not die of that terminal situation. Do we have any statistics on that or not? I am seeing a silence. I think the question was to anyone, but I think the question is, Representative Rosenquist is wondering, I guess if people have a terminal diagnosis, how many people don't die of the terminal? Right, that's essentially what the question was. I mean, we know, obviously, doctor gives their best prognosis that they can, but sometimes it may not be correct. So do we have any statistics on that? I don't believe we have such statistics, although when someone completes a death certificate, the death certificate includes the cause of death as well as other significant contributing factors. So that information exists, but I don't know how easy it would be to catalog it. I think the main issue is thinking about it. Many people now live with several life limiting illnesses. People live a lot longer with advanced illness. Those are all wonderful things and people still die and some of those people wanna have a say in how they die and some people, even with expressed wishes, their lives will come to an end through other means. Yeah, I will just add, the data does show that people hold on to the prescription till the very end. So they're not getting a terminal diagnosis and then taking the prescription right away. They really are holding onto it until their symptoms are really bad and they no longer have quality of life. And it really shortens the dying process by maybe two weeks. It's not that people are taking it six months and they would have a lot more of life left. Thank you. I wanna looking around the room to see if there are any final questions. I really, I wanna thank the three of you for your testimony today and both the personal stories to put a face on it and the data and information to balance those out. Thank you very much. Committee, we now have a 15 minute break and when we return, we will continue our discussion, our testimony on S74 based on people's questions. We have Charity Clark who is Chief of Staff on the Attorney General's Office and we have Theo Kennedy who is representing the Vermont Retail Drugists Association.