Knowing when to choose hospice care is a challenge; that's highlighted by Rosalynn and Jimmy Carter's end-of-life journey

National Institute on Aging infographic

"The death of former first lady Rosalynn Carter on Sunday, and the survival of her husband, former president Jimmy Carter, have exposed one of the most achingly difficult questions faced by people with life-threatening illness: when to choose hospice care," Lenny Bernstein and Dan Keating report for The Washington Post.

Carter, who was 96, died two days after entering hospice. Jimmy Carter entered hospice in February at the age of 98, outlasting the six-month prediction of life that is typical of people when they enter hospice care. 

Rosalynn Carter (2005 Associated Press photo by Ric Feld)

Rosalynn Carter had a urinary-tract infection that was not responding to antibiotics when she entered hospice, which experts told the Post is among the many reasons people with dementia might switch to hospice care late in the course of the disease. 

Bernstein and Keating report that many people follow the same path. 

" About half of all people are in hospice at the end of their lives, but more than 25% of hospice patients enroll in the final week, according to 2021 data from the Medicare Payment Advisory Commission, which advises Congress on Medicare issues," they write. 

Others among the 1.7 million Medicare patients who used hospice that year used the service much longer, they report, with a median stay of 17 days and ab average stay of 92 days, "which shows that some patients were in hospice for many months."

Angela Novas, senior medical officer for the Hospice Foundation of America, a nonprofit organization, told the Post that Rosalynn Carter’s experience is not uncommon.

“When people are that age and have a chronic condition like dementia that is progressing, and progressing slowly, there comes a turning point where suddenly the symptoms accelerate exponentially,” Novas said.

Doctors also play a role in delays in enrolling because of "difficulty prognosticating" and patients often wait, hoping for a final experimental treatment to become available, Mamta Bhatnagar a University of Pittsburgh Medical Center physician who specializes in hospice and palliative care, told the Post.

The first U.S. hospice opened in Connecticut 49 years ago, but there is still considerable confusion about end-of-life care options, caregivers and experts told the Post. 

"People who choose hospice agree to give up therapeutic efforts to prolong their lives and focus on comfort and quality of life. Two physicians must attest that the patient has six months or less to live. The period can be extended, and patients can change their minds about being in hospice at any time," the writers report. "Hospice is most often provided at home, but “home” can be a nursing facility, a hospital or a free-standing hospice center, among others. The latter are increasingly run by for-profit companies but also are operated by nonprofits." 

In contrast, “palliative care” or "comfort care" aims to make patients more comfortable and ease stress but can be done while doctors are still seeking to cure a disease. 

Added to the confusion, the authors write that sometimes life-prolonging and palliative therapies can overlap, such as the use of diuretics for people with heart failure or radiation to relieve pain by shrinking a tumor. 

Myths and fears about hospice still abound, Joan Teno, a Brown University hospice physician and researcher, told the Post.

"Doctors and advocates said they still hear from patients that hospices are where patients are killed off, usually because of the use of morphine to relieve pain in end-of-life care. Others think that the hospice team will take over completely and that family can leave the responsibilities of caregiving to them," the authors write. 

“There’s very few people who say, ‘I wish I had started hospice later,’” Ben Marcantonio, interim CEO of the National Hospice and Palliative Care Organization, told the Post.

End-of-the-year holidays produce a surge in calls about hospice when families gather and physical and mental decline can become apparent, Novas told the Post. The Carters have provided a lesson in what to do next.

“The Carters are doing a fantastic job in continuing to educate us,” Novas said. “Throughout their lives, and now in their deaths, their legacy will be teaching us about mental health and how to live and how to die well.”

People seeking advice about hospice can contact the Hospice Foundation of America’s Ask an Expert service at https://hospicefoundation.org/Ask-HFA [hospicefoundation.org] or by calling 202-457-5811 or 800-854-3402. 

The Kentucky Association of Hospice and Palliative Care can be reached at 888-322-7317 or found online at kahpc.org. 

Most people have end-of-life wishes, but don't talk about it; planning for death is less likely in rural areas, study finds

St. David's Foundation graph; click on it to enlarge.

As America ages, more families face end-of-life decisions, and rural Americans are less likely to have their wishes known or followed by family members, reports Liz Carey of The Daily Yonder. "A new study found that while most people have end-of-life wishes, only a little over a third of them actually get them fulfilled. That is even more true with rural residents, researchers said."

Researchers from St. David's Foundation in Texas found that when it comes to end-of-life care, most Texans want to die at home (76%) and not be a burden to their families (77%). "But only one in three people surveyed said their loved one's wishes were honored," Carey writes. "Of those who are least likely to have their end-of-life wishes followed are rural residents, the study found. . . . Only 37% of the survey respondents said their loved ones died at home. Close to half of them (47%) said their loved one faced challenges related to their care – from problems with insurance coverage to facing cultural or language barriers."

Honoring a person's wishes begins with knowing what they are. Andrew Levack, senior program officer with St. David's Foundation, told Carey: "One of the interesting things the study found was how few conversations respondents had with their doctors around plans for end of life. I think people have an idea of what they would like, but it takes some active planning and advocacy to make that happen."

Study researchers noted a common thread of disconnection across the state -- people have end-of-life care desires, but don't voice them. "Most Texans, even older adults, are unprepared for decisions about end-of-life care. The vast majority believe it is important to have their wishes in writing, yet over half have not done so. Similarly, many say they would like to discuss end-of-life planning with their health care provider if they were faced with a serious illness, yet only 17% have had a provider initiate a conversation about it."

Geographical isolation and a lack of health care access make rural populations more likely to not have end-of-life plans or discussions. Dr. Kate Tindell, medical director for Austin Palliative Care and Hospice, told Carey: "People have really disjointed health care now. We've sort of lost that sense that there is a captain of the medical ship who is aware of all the moving parts and is giving the patient that guidance. I think that really causes people to not have the kind of relationship that would allow them to have that kind of conversation (about end-of-life wishes) the way they would if they had seen the same provider every single time for 10 years."

Medical cannabis bill passes Senate, awaits House vote March 30

By Melissa Patrick
Kentucky Health News

A bill that would make medical marijuana legal for some in Kentucky has passed the state Senate for the first time and awaits a vote in the House, which has passed two similar bills in previous legislative sessions.

Sen. Stephen West

"It is time for Kentucky to join the other 37 states in the United States that allow medical marijuana as an option for their citizens," said Sen. Stephen West, R-Paris, in presenting his bill to the Senate, adding later, "It is understood that this is a very complex issue and if passed, will be a work in progress." 

Senate Bill 47 passed late Thursday night on a 26-11 vote. The House gave the bill its first of three required readings the same night, which will allow enough time for it to pass out of the House when the lawmakers return March 29 and 30.

Last year, after a House-passed bill again got no hearing in the Senate, Gov. Andy Beshear used his pardon power to allow people with 21 specified medical conditions and a doctor's certificate to possess up to eight ounces of marijuana bought legally in another state. (Illinois is the only adjoining state where nonresidents can legally buy cannabis.) Beshear signaled Thursday that he would sign the bill.

West, who said he has worked on such legislation for about five or six years, told the Senate, “This is one of those issues where you take out the ledger and you list the pros and cons. It’s a long list on both sides, but for me personally, the pros outweigh the cons.”

The 124-page bill would not allow medical marijuana to be smoked, require users to be 18 or older or be a caretaker for a child, limit supply, and not take effect until Jan. 1, 2025.

The medical marijuana would be allowed for certain "qualifying medical conditions," including all cancers regardless of the stage; chronic, severe, intractable or debilitating pain; epilepsy or any other tractable seizure disorder; multiple sclerosis, muscle spasms or spasticity; chronic nausea or cyclical vomiting syndrome that has proven resistant to other conventional medical treatments; post-traumatic stress disorder; and any other medical condition or disease for which the new Kentucky Center for Cannabis Research at the University of Kentucky determines would benefit from medicinal marijuana.

West and other lawmakers praised the advocacy of Eric and Michelle Crawford, a quadriplegic who has long searched for another option to manage his pain. They also praised the ongoing work of advocate Jamie Montalvo, who suffers from multiple sclerosis, toward getting this bill passed. 

 Sen. Phillip Wheeler, R-Pikeville, said the Crawfords and Montalvo don't want to break the law: "These are people that are willing to work hard and make sacrifices to comply with the law. What they are looking for is a pathway forward to make sure that people can get a safe product." 

Sen. Stephen Meredith, R-Leitchfield, said it was important to show those who are suffering from  debilitating diseases  "just a little bit of mercy" and that was why he voted yes.   

“Will this be abused by some folks?  It certainly will," he said. "But again, if we can benefit just one person, one child, I think it’s worthwhile."

Only Republicans voted against the bill: Gary Boswell of Owensboro, Danny Carroll of Benton, Donald Douglas of Nicholasville, Rick Girdler of Somerset, President Pro Tem David Givens of Greensburg, Chris McDaniel of Ryland Heights, Robby Mills of Henderson, John Schickel of Union, President Robert Stivers of Manchester, Mike Wilson of Bowling Green, and Max Wise of Campbellsville. 

Marijuana is a "scourge of the earth," Boswell said. "I urge my colleagues to vote no. If you are going to violate federal law, at least tighten up the bill to include only the critically ill." 

Douglas, a physician, said, “With the different growing techniques and the increased concentration of these chemical compounds, I’m not really convinced that this drug is safe. But we do have some research going on out there, and I really want to thank the University of Kentucky. I hope we have some other institutions doing research who will give us good information.”

Quarles says that if elected governor, he would work with the General Assembly to legalize medical marijuana in Kentucky

Quarles spoke on the Capitol steps. (KL photo by McKenna Horsley)

By McKenna Horsley
Kentucky Lantern

Agriculture Commissioner Ryan Quarles told reporters Tuesday he would work with the General Assembly to legalize medical marijuana if he is elected governor.

“It needs to be dialogue between a doctor and their patient, and keep big government out of it,” Quarles said, adding that patients in end-of-life care could benefit from medical marijuana, and some are already self-medicating.

Quarles touted his experience running Kentucky’s hemp-licensing program in his seven-plus years leading the state Department of Agriculture. He criticized Democratic Gov. Andy Beshear’s executive order on medical marijuana, saying it “muddied the water on this issue” and failed to involve Kentucky agriculture.

 
He said provisions should be made to benefit production from Kentucky farmers, including those who already grow hemp, and medical marijuana should, like other medications, be exempt from sales tax.

Beshear has said that 90% of adult Kentuckians support legalizing medical cannabis. His executive order, which took effect Jan. 1, set criteria for Kentuckians with certain medical conditions to access medical cannabis in small amounts through legal out-of-state purchases.

Quarles said that because the General Assembly was bypassed in implementing the order, doctors and patients are confused.

“As a former legislator, I feel like I have the ability to work with the General Assembly and not sue them constantly like the current governor is doing,” he said. The legislature is controlled by fellow Republicans.

When asked how he plans to get legislation like this through the Senate — where bills to legalize medical marijuana have failed in recent years — Quarles said he’s worked to get other pieces of legislation passed and will approach it with the attitude of “consensus-driven” policy-making.

“I believe that over the course of the next year, we can find common ground that gets something that works for Kentucky and again is focused on that doctor-patient relationship,” Quarles said.

Bills to legalize medical marijuana have been filed in the current legislative session, such as Senate Bill 47 from Sen. Stephen West, R-Paris.

Asked about recreational marijuana, Quarles said Tuesday’s press conference would focus only on medical use. He said products with Delta-8 tetrahydrocannabinol — a psychoactive ingredient similar to delta-9 THC, the active ingredient specified by federal law — should be regulated. 

Quarles said none of the other candidates are “better positioned in this race to have a conversation about what the framework would be like to help pass a responsible medical marijuana bill through the General Assembly,” but in response to a question about how this issue sets him apart from the field, he said that he’s not focused on other campaigns, only his.

“Look, there’s 12 of us in this crowded primary,” he said. “All of them are my friends. They’re going to be my friends after May 16.”

The field includes Attorney General Daniel Cameron and former United Nations Ambassador Kelly Craft. Their campaigns have not responded to email questions from Kentucky Lantern about their positions on medical and recreational marijuana.

Somerset Mayor Alan Keck, another Republican running for governor, told the Bowling Green Daily News in January that medical marijuana is “a ‘common-sense solution’ for things like pain management, insomnia in veterans and children who suffer from seizures.”

Covid-19 update: 11 die at long-term care facilities; 55 residents, 22 staff test positive for coronavirus, other test results pending

The above video on how to properly wear a mask is from Sarasota Memorial Hospital nurse Jennifer Sorensen, via the Lexington Herald-Leader.

Kentucky Health News

Eleven people have died of covid-19 in long-term care facilities in Kentucky, several of them in the last day or so, Gov. Andy Beshear said Tuesday.

"These numbers have increased significantly even from yesterday," Beshear said at his daily briefing, adding that the state is working with health departments to make the numbers "as accurate as possible."

The day before, citing data from the Cabinet for Health and Family Services, the Louisville Courier Journal reported that there had been three deaths in nursing homes. Beshear spokeswoman Crystal Staley said Tuesday night that one death was in an assisted-living facility.

Beshear said 55 residents and 22 staff members, in 21 facilities, had tested positive for the coronavirus, and another 55 tests of residents and 41 tests of staffers are pending.

"This is a concern," Beshear said. "We’ve got to make sure we prevent the coronavirus from getting in as many of these facilities as possible, and that we react quickly."

He said the state has been encouraging the use of masks, eliminated congregate activities such as meals in dining rooms, suspended inspections and banned visitors except in end-of-life situations. The government is also "encouraging facilities to move sick residents away from those who have not been infected," the Courier Journal reported.

The newspaper said that as of Sunday evening, positive or potential cases had been reported at Signature Healthcare at Summit Manor in Columbia; The Heritage in Whitley County; Coldspring in Campbell County; Madonna Manorin Villa Hills, Rosedale Greenin Kenton County; Countryside Center for Rehabilitation and Nursing in Bardwell; Henderson Nursing and Rehab, Ridgewood Terrace in Henderson; Country Place in Hopkins County; River's Bend Retirement Community in Kuttawa, Parkview Nursing and Rehab in Paducah; Park Terrace in Lexington; Treyton Oak Towers in Louisville, and Masonic Home Louisville.

Beshear also voiced concern about the Green River Correctional Complex in Central City and Western State Hospital in Hopkinsville. At the prison, nine inmates and five staffers have tested positive; at the hospital, nine patients and four staff have. “I know the staff in all of these facilities are scared,” Beshear said, adding that the state appreciates their willingness to work.

"The hospital has stopped accepting new patients and is encouraging all current residents to wear masks," the Courier Journal reports.

The governor said he expects to announce new measures Wednesday to enforce his order banning mass gatherings, and said in response to a question that about two dozen churches were still having regular inside services despite his order., but some have decided to cancel services.

"Where people are intentionally putting people in harm's way, we're gonna start taking action," Beshear said, adding later, "My faith is one of the things that compels me to do that; my faith tells me that we protect one another." He thanked "faith leaders" who are cooperating and asked them to "please spread the encouragement."

Here's other covid-19 news in Kentucky:

• Beshear reported seven deaths, many of which appeared to be at long-term-care facilities. He said a death reported yesterday in Louisville was of an Indiana resident, so the new total is 65. The deaths were four men in Jefferson County, aged 42, 60, 70 and 85; two women from Lyon County, 72 and 94; and an 83-year-old woman in Adair County.
• The governor reported 147 new covid-19 cases, the most in one day, but said some were probably delayed from Sunday and Monday. He said the three-day average of about 80 was less than the previous three days, and "I'm not sure many places in America can say that right now." The total number of officially recorded cases is 1,149.
• The Lexington-Fayette County Health Department released the first demographic information on cases in the city, and it revealed that African Americans were much more likely to be hospitalized for covid-19. They accounted for 52 percent of hospitalizations for the disease, while whites were only 32%, the Lexington Herald-Leader reports. The virus "appears to be infecting and killing black Americans at a disproportionately high rate," The Washington Post reports. "Counties that are majority-black have three times the rate of infections and almost six times the rate of deaths as counties where white residents are in the majority." The state is still compiling data for a report.
• Of the 170 covid-19 cases found in Lexington through Monday, 17 have been at the Miles Point school-bus garage, local Health Commissioner Kraig Humbaugh said. That illustrates the difficulty in thwarting the coronavirus, he said: “Persons with relatively mild illness or perhaps no symptoms at all can unknowingly spread the virus to others who are at higher risk of severe illness and complications.” One employee has died and others have been hospitalized, the Herald-Leader reports.
• Beshear continued to voice his frustration at the lack of personal protective equipment. "We are trying everything," he said. "Virtually nobody has orders that are coming in, and it’s concerning. . . . It’s the wild West right now." He said the state is getting shorted partly because "We are doing a better job flattening our curve … but my job is to fight for as much of it as we can get. Many days I feel like Charlie Brown trying to kick the football."
• "A nurse at Norton Women’s and Children’s Hospital said she was suspended for insubordination for refusing to treat covid-19 patients when the hospital would not supply her with a protective respirator, the Courier Journal reports. "She said in an interview Monday that supervisors would only give her a surgical mask, a loose-fitting disposable device that isn’t sealed around the nose and mouth." Norton Healthcare said it follows guidelines from the Centers for Disease Control and Prevention, which last month said N95 respirator masks should be reserved for the riskiest situations, "such as intubations and respiratory treatments, and that looser-fitting surgical masks be used for routine care," the CJ reports. "Nursing unions strongly opposed the relaxed guidelines."
• Health Commissioner Steven Stack, asked what he thought of the anti-malaria medications President Trump has promoted as treatments for covid-19, said "All of these things are experimental," without the scientific confidence needed to recommend them. "Those things have not yet been proven to be beneficial."
• Stack said the state's arrangement with Northern Kentucky lab Gravity Diagnostics to provide up to 2,000 daily virus tests will be done through 32 hospitals. The tests will initially be limited to high-risk people, health-care workers and first responders; if supplies meet demand, people with chronic medical problems will qualify, he said, with the hospitals making the decisions. “I support the hospitals in their decision-making,” he said.
• Stack said may types of tests are available, and he cautioned against getting tested without the involvement of a “properly qualified health-care professional who understand what those tests are useful for.”
• Beshear said the state's pilot drive-through testing facility in Frankfort is "on pause" because of a shortage of supplies.
• Walgreens said it will put drive-through virus-testing sites in Kentucky and six other states for people who meet CDC criteria. "It is not clear how many of those 15 sites will be in Kentucky," the Courier Journal says, but the sites "are planned for places with escalating rates of covid-19 cases, according to a news release. The sites will be activated later this week and, in total, will test 3,000 people per day."

• 

  David Pitman

  "A Southern Kentucky man is getting considerable attention for a somber video he posted minutes after the decision to end life support for his father," David Pitman, Bill Estep reports for the Herald-Leader. "Dustin Pitman went on Facebook live early on April 2 to describe how his father, David Pitman, quickly deteriorated because of the covid-19 respiratory illness. David Pitman, 62, had survived colon cancer, but the illness caused by the coronavirus overwhelmed him. Doctors gave him little chance of survival, Dustin Pitman said."
• Florence Mayor Diane Whalen "has told a hotel that it could not rent rooms to more than 40 homeless people because it was a public health hazard and a possible zoning violation," Beth Musgrave of the Herald-Leader reports in a detailed story.
• Barbourville Mayor David Thompson "and half of the city’s police officers have been ordered to quarantine after they were exposed to the coronavirus" through a department employee, the Herald-Leader reports, citing the assistant police chief. "None of the officers nor the mayor have shown any symptoms of coronavirus . . . The department has 11 officers."
• A Louisville physician has been placed on leave "over his role in a confrontation" about social distancing "in Louisville's upper-class Norton Commons neighborhood," the Courier Journal reports. He "approached the group because the nine people who were there – all older teens – were not engaged in social distancing." A video shows him "shoving three young women and grabbing the neck of another."
• University of Kentucky basketball coach John Calipari has started a weekly show focused on the pandemic. "The show — titled 'Coffee with Cal' — will be a Facebook Live broadcast on the John Calipari Basketball Fantasy Experience Facebook page," the Herald Leader reports. "It will air the next 20 Mondays beginning next week." Calipari said, “I want to do something that’s uplifting and creates hope, and gives people an idea of what to do.”
• Senate Majority Leader Mitch McConnell said he would try to take the unusual step of appropriating money by unanimous consent or voice vote when the Senate next meets, on Thursday, to put more money into the Paycheck Protection Program for small businesses and their workers. The New York Times reports the Treasury Department is preparing to ask for at least $200 billion.
• Sen. Rand Paul, who has delayed emergency spending bills in the past and missed the vote on the last one because he was quarantined. said he is now free of the coronavirus and is volunteering at an unnamed hospital in Bowling Green.
  

Kentucky Health News is an independent news service of the Institute for Rural Journalism and Community Issues, based in the School of Journalism and Media at the University of Kentucky, with support from the Foundation for a Healthy Kentucky.

Kentucky pastor uses his experience to offer advice to caregivers

Paul Prather
(Photo from the Herald-Leader)

As a minister for more than three decades, Paul Prather has sat with more than his fair share of people who are sick or dying.

But the pastor of Bethesda Church near Mount Sterling says nothing prepared him for the experience of taking care of his wife Renee as she struggled with cancer from 2000 to 2005.

"Caregiving is the hardest thing I’ve ever done. Nothing else comes close. Unless you’ve held that job, you have no idea how you’d fare," Prather wrote in his Sunday column in the Lexington Herald-Leader.

About 40 million Americans are caregivers, most of them unpaid, Prather notes. An American Association of Retired Persons study from 2015 estimates the economic impact of caregivers' work at $470 billion annually.

Prather used his own experiences, as well as a New York Times article by Dr. Dhruv Khullar and a Herald-Leader column by Robin Hamon, to offer advice to caregivers:

"You are not the only one. ... You’re one of 40 million." Whatever you're feeling is normal. He notes insight that a counselor once gave him: Emotions are neither good nor bad; they just are. Sometimes emotions jump from rage to fear to grief to numbness and everything in between, and that's OK, he says.

Don't beat yourself up. "You must be pretty decent or you wouldn’t be sacrificing your life for someone else," Prather writes. "Quit berating yourself for your shortcomings. Be merciful to yourself. Do your best on any given day, and leave it at that."

Remember to take care of yourself. Prather encourages caregivers to arrange for a sitter once or twice a week in order to have some time away. He also encourages healthy eating and exercise.

Ask for help. He suggests asking doctors for tips and seeking out information from books and websites.

Vent your frustrations. "You might not be able to talk candidly to the person you’re taking care of. But you might have a trusted sibling, friend, minister or adult child to whom you can speak honestly and safely," Prather writes.

Keep it in perspective. It's important to remember that this tough situation won't last forever, he says.

Prather also offers advice to those who know someone who is caring for a loved one:

"Look for the cracks," he notes. "When the sick person isn't within earshot, ask the caregiver is she's struggling."

Ask specifically what help is needed, but don't impose your agenda. Prather says most caregivers don't want to impose and will likely say, "Nothing," when asked what they need. Be specific with your questions, such as, "Would it help if I brought you a meal?" He warns, however, not to push what you think is needed onto the caregiver. Don't simply announce your plans to bring over a meal without asking.

Also, withhold judgment. "Never judge a caregiver for how she’s handling the situation," Prather writes. "Is she surly? Has she lost her faith? Is she praying that Mama will just go on and flipping die, like, today? Don’t delude yourself that you’d do better. God might let you find out."
Be a source of encouragement. Prather says that caregivers need to hear that they are doing a good job and that their work is noticed. Offer support and reassurance; it just might help him or her get through a rough day.

Caregivers can find additional resources through AARP here.

New health-related laws deal with heroin, dating violence, end-of-life care, prescriptions, colon-cancer and newborn screening

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. – The Kentucky General Assembly passed several health-related bills this session, including high-profile measures on heroin and dating violence. It did not pass many others, including one that would have a great influence on the state's health: a statewide smoking ban, which passed the House for the first time ever, but never got out of an unfavorable committee in the Senate. Here's a roundup:

Heroin: Kentucky's heroin-overdose epidemic was caused partly by a 2012 legislative crackdown on prescription painkillers, which steered users to the illegal drug. Last year's bill died because of deadlock over sentences for traffickers and needle-exchange programs for addicts, and Gov. Steve Beshear and legislators gave this year's bill top priority. It was not finally negotiated until a few hours before passage, but Beshear signed Senate Bill 192 into law less than 12 hours after it passed so that its emergency clause could put it into effect immediately.

SB 192 includes both a needle-exchange program and harsher penalties against traffickers, the main points of contention between the House and Senate, but requires local governments to approve needle exchanges and allows judges to be lenient in sentencing addicts, to help them get treatment. It allocates money for drug-treatment programs, allows increased access to Naloxone, a drug that reverses the effects of an overdose, and allows jailers to provide medically assisted treatment for inmates with opiate addiction.

Dating violence: After 10 years of lobbying and debate, the dating violence bill will allow dating partners to get interpersonal protective orders from a judge if they have been the victim of dating violence, sexual abuse or stalking. This year's bill largely dissolved social conservatives' opposition by creating a new chapter in the law for dating violence, with the same protections as the domestic-violence law. Kentucky is the last state to offer protection to dating-violence victims. House Bill 8 was sponsored by Rep. John Tilley, D-Hopkinsville, who also sponsored the House heroin bill.

Beshear has signed these bills into law:

Prescription synchronization: SB 44, sponsored by Sen. Julie Raque Adams,R -Louisville, will allow patients with multiple prescriptions, in consultation with their health-care provider and their pharmacist, to synchronize prescriptions so that they may be picked up at the same time.

Medical order scope of treatment: SB 77, sponsored by Sen. Tom Buford, R-Nicholasville. will create a medical order scope of treatment (MOST) form that specifically directs the type of treatment a patient would like to have, and how much intervention he or she would like to have, during end-of-life care.

Colorectal cancer screening: SB 61, sponsored by Sen. Ralph Alvarado, R-Winchester, will require that a fecal test to screen for colon cancer, and any follow-up colonoscopy, be considered preventive measures that health insurance is required to cover without imposing additional deductible or co-insurance cost. The governor also signed a similar measure, HB 69, sponsored by Rep. Tom Burch, D-Louisville, which contains an amendment by Sen. Julian Carroll, D-Frankfort, for a Medicaid savings study.

Newborn screenings for fatal disease: SB 75, sponsored by Sen. Alice Forgy Kerr, R-Lexington, will require all newborns to be tested for Krabbe disease, a neurological disorder that destroys the protective coating of nerve and brain cells and is fatal once symptoms occur.

Spina bifida: SB 159, sponsored by Adams, will require medical providers to supply written, up-to-date, accurate information to parents when their unborn child is diagnosed with spina bifida so they can make informed decisions on treatment.

Emergency care for strokes: SB 10, sponsored by Sens. Stan Humphries, R-Cadiz, and David Givens, R-Greensburg, requires that local emergency services have access to a list of stroke-ready hospitals, comprehensive stroke centers and primary stroke centers in Kentucky. Emergency medical providers will set their own protocols for assessment, treatment and transport of stroke patients.

Alcohol and drug counselors: HB 92, sponsored by Rep. Leslie Combs, D-Pikeville, creates an enhanced licensing program to recognize three levels of certified alcohol and drug counselors, with different levels of education. The goal is to increase the number of counselors in the state.

UK cancer research center: HB 298, sponsored by Rep. Rick Rand, D-Bedford, revises the state budget to authorize $132.5 million, half of the cost, for a new medical research center at the University of Kentucky. The university says it will raise money to cover the other half.

These health bills awaited the governor's signature Monday morning:

Physician assistants: HB 258, sponsored by Rep. Denver Butler, D-Louisville, to allow physicians to supervise up to four physicians at the same time, rather than two.

In-home care: HB 144, sponsored by Burch, to establish a 60-day, hospital-to-home transition program through an approval waiver from the Department for Medicaid Services.

Pharmacist-practitioner collaboration: HB 377, sponsored by Rep. Dean Schamore, D-Hardinsburg, to allow collaboration between pharmacist and practitioners to manage patients' drug-related health needs.

Tax refund donations: SB 82, sponsored by Sen. Max Wise, R-Campbellsville, to put an income tax check-off box on tax forms to allow people the option of donating a portion of their tax refund to support pediatric cancer research, rape crisis centers or the Special Olympics.

Health related bills that were left hanging:

The smoking ban, HB 145, sponsored by Rep. Susan Westrom, D-Lexington, never got a hearing in the Senate Veterans, Military Affairs and Public Protection Committee, and neither did the Senate companion bill, SB 189, sponsored by Adams.

Three bills challenged Medicaid managed-care companies. SB 120, sponsored by Alvarado, would have created a process for health-care providers to appeal the companies' decisions to the state passed the Senate, but not the House.  And the following two bills that never got out of the Senate: SB 88, also sponsored by Alvarado, which challenged the $50 "triage fees" MCOs pay for emergency-room visits that they conclude were not emergencies, and would have required them to pay contracted fees instead and SB 31, sponsored by Buford, which would limited the amount of co-payments. Also not getting House action was Alvarado's SB 6 would have created review panels for lawsuits seeking damages from health-care providers.

As session nears end, bills on heroin, dating-violence orders, managed-care appeals and lawsuit review panels are hanging fire

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. – The General Assembly has sent Gov. Steve Beshear four health-related bills, and several more could reach his desk in the legislative session that ends Wednesday. Legislators will return briefly after 10 days to reconsider any bills Beshear vetoes; they could also pass more bills, but would not be able to override any vetoes.

Here are some of the health-related bills that were pending on Monday; bills with two readings are ready for floor action.

Heroin: tougher penalties and needle exchanges?

Both the Senate and the House have heroin bills and both remain in committee in the other chamber, but hope remains high in both chambers that a compromise can be reached so that a heroin bill will pass this session. Senate Bill 5 is sponsored by Sen. Christian McDaniel, R-Latonia; House Bill 213 is sponsored by Rep. John Tilley. The main differences are how traffickers would be punished and whether to start needle-exchange programs for addicts. The Senate's penalties are tougher and it has opposed needle exchanges, which advocates say prevent disease and death from dirty needles and can lead addicts to treatment.

Now the Senate is moving toward accepting needle exchanges, James Pilcher reports for The Cincinnati Enquirer. Rep. Dennis Keene, D-Wilder, and Sen. Wil Schroder, R-Wilder, said exchanges "are much more likely to be included than when the session started," Pilcher writes. Schroeder told him, "I think there is a real possibility that we could include needle exchanges and then get our tougher penalties." Pilcher reports, "The possible legislative position shift comes as health officials throughout the Tristate have expressed deep concerns about the spread of diseases that can be contracted using dirty needles."

Protective orders for dating violence

House Bill 8, sponsored by Rep. John Tilley, D-Hopkinsville, has received its second reading and is awaiting passage in the Senate. This bill would allow dating partners to petition for interpersonal protective orders if they have been the victim of domestic violence, sexual abuse or stalking. Such orders are now available only to those who are married, live together or have lived together, or an unmarried couple with a child in common.

Kentucky is the only state that offers no protection for such victims. Legislation to do that has stalled in the Senate in earlier sessions, but a Senate committee substitute addresses a key objection, by creating a new chapter in the statutes for the bill, separate from the existing domestic-violence chapter.

Advocates say domestic violence is a health issue not just because of the physical injuries it causes. They say victims are more likely to be depressed, have unplanned and premature pregnancies, go to fewer prenatal visits, and to miss more well-child visits with their children.

Prescription synchronization, managed-care appeals

Senate Bill 44, sponsored by Sen. Julie Raque Adams, R-Louisville, has had its second reading in the House. This bill would allow patients with multiple prescriptions, in consultation with their health-care provider and their pharmacist, to synchronize prescriptions so that they may be picked up at the same time.

House Majority Caucus Chair Johnny Bell, D-Glasgow, has filed a floor amendment on an unrelated issue, to create a state appeals process for health-care providers to appeal decisions of Medicaid managed-care companies. It is the same as or similar to Senate Bill 120, sponsored by Sen. Ralph Alvarado, which has given it a first reading without assigning it to a committee. The Cabinet for Health and Family Services opposes a state appeals process, saying it would have a conflict of interest (successful appeals would cost the state money) and providers have the courts available to them to resolve contractual issues. UPDATE: Bell withdrew his floor amendment to Senate Bill 44 March 9. 

Review panels for suits against health-care providers: Senate Bill 6, filed by Alvarado, remains in the House Judiciary Committee, but a discharge petition was filed March 4 to bring it to the floor, bypassing leaders of the House's Democratic majority. This bill would establish panels of three medical experts, two chosen by each side and the third chosen by the other two, to review suits against health-care providers to determine if the case has merit before the lawsuit can proceed. Panel findings would be admissible in court, but not legally binding. Opponents say that Kentucky already has laws to punish attorneys for filing frivolous cases and that this just adds another barrier for patients seeking justice.

Newborn screenings for fatal disease: Senate Bill 75, sponsored by Sen. Alice Forgy Kerr, R-Lexington, has had two readings. It would require all newborns to be tested for Krabbe disease, a neurological disorder that destroys the protective coating of nerve and brain cells and is fatal once symptoms occur. Treatment with stem cells from an umbilical cord blood transplant is sometimes successful it the infant is treated early enough. The cabinet opposes the bill, saying the screening will cost half a million dollars a year at a time when local health departments are suffering budget cuts.

Spina bifida: Senate Bill 159, sponsored by Sen. Julie Raque Adams, R-Louisville, is in the House and the three-day posting rule has been waived. This bill would require medical providers to supply written, up to date, accurate information to parents when their unborn child is diagnosed with spina bifida so parents can make informed decisions on treatment

Physician assistants: House Bill 258, sponsored by Rep. Denver Butler, D-Louisville, is awaiting Senate passage. This bill allows a physician to supervise up to four physician assistants at the same time, rather than two.

In-home care: House Bill 144, sponsored by Rep. Tom Burch, D-Louisville, is awaiting Senate passage. It would establish a 60-day, hospital-to-home transition program through an approval waiver from the Department for Medicaid Services. The daily cost would have to be less than the average daily nursing home payment allowed by Medicaid. The bill would also provide non-medical support services to the applicant as needed.

BILLS SENT TO THE GOVERNOR

Colorectal cancer screening: Senate Bill 61, sponsored by Sen. Ralph Alvarado, R-Winchester, received final passage in the House March 4. This bill requires that a fecal test to screen for colon cancer, and any follow-up colonoscopy, be considered preventive measures that health insurance is required to cover without imposing additional deductible or co-insurance cost. The bill would apply to health plans issued or renewed on or after Jan. 1, 2016, if it becomes law. A similar measure, House Bill 69, sponsored by Rep. Tom Burch, D-Louisville, is awaiting passage in the Senate with a committee substitute by Sen. Julian Carroll, D-Frankfort, calling for a Medicaid savings study.

Medical order scope of  treatment (MOST) form: Senate Bill 77, sponsored by Sen. Tom Buford, R-Nicholasville, received final passage in the House March 3. This bill creates a medical order scope of treatment (MOST) form that specifically directs the type of treatment a patient would like to have, and how much intervention he or she would like to have, during end-of-life care. It is considered a physician's order, travels with the patient between health care facilities, and must be reviewed annually. The bill clearly defines the order of controlling documents for end-of-life care: the living will first, the MOST form second and the health-care surrogate, which is chosen by the patient and listed on the form, third. The MOST form is already used in 32 states.

Emergency care for strokes: Senate Bill 10, sponsored by Sens. Stan Humphries, R-Cadiz, and David Givens, R-Greensburg, received final passage in the House March 4. The bill requires that a list of all acute stroke-ready hospitals, comprehensive stroke centers and primary stroke centers in Kentucky be posted to the cabinet's website and be made available to all emergency medical services providers, who are required to set their own internal protocols toward assessment, treatment and transport of stroke patients.

Funding for UK cancer research center: House Bill 298, sponsored by Rep. Rick Rand, D-Bedford, received final passage in the Senate March 4. This bill authorizes the state to appropriate $132.5 million, half of the cost, for construction of a new medical research center at the University of Kentucky. The university will raise money to cover the other half. The facility will target prevalent diseases in Kentucky, including cancer, diabetes and cardiovascular disease. The bill required a 60 percent vote in each chamber because it affects the state budget and the legislature is in a non-budget session; it passed the House 83-9 and the Senate 36-1 (Sen. John Schickel, R-Union).

Panel OKs new medical-order form that would clearly define a person's end-of-life wishes on nutrition, hydration, medication

A bill to create a medical order form that details a person's wishes for end-of-life care passed the Senate Health and Welfare Committee Feb. 4 and seems headed for passage in the full Senate.

Advocates say that while many physicians discuss end-of-life care with their patients and families and document it, this information is often buried deep in the chart and is not easily accessible in an emergency situation.

"This issue comes to play on a daily basis," Christian Furman, vice-chair of geriatric medicine at the University of Louisville and medical director of two nursing homes in Louisville, told the committee.

Sen. Tom Buford

Senate Bill 77, sponsored by Sen. Tom Buford, R-Nicholasville, would creates a new Medical Order for Scope of Treatment form to specifically direct the type of treatment a patient would like to have and how much medical intervention they would like to have during end-of-life care. The MOST form is used in 32 states, Furman said.

The form is more detailed than a living will because it addresses not only the question of resuscitation, but specifies which life-saving measures, such as nutrition, hydration and medication, that a person wants to receive and under what circumstances.

The form must be reviewed annually. It allows for information sharing between providers and is part of the patient's electronic health record.

Furman said the order of controlling documents for end-of-life care is clearly defined in the bill: the living will first, the MOST form second, and the health-care surrogate, which is chosen by the patient and listed on the form, third.

Sen. Ralph Alvarado, R-Winchester, who is a physician, told his fellow committee members that the MOST form will not only assure a person's personal wishes are honored, but will also save an "immense" amount of money "just in terms of doing unnecessary treatments for folks."

"Five percent of Medicare beneficiaries die each year and their end-of-life care accounts for about 30 percent of total Medicare spending with as much as one-third spent in the last month of life," Bill First writes for Morning Consult, citing an article from the peer-reviewed journal Health Affairs.

Sen. Reggie Thomas, D-Lexington, a lawyer, said the medical community and patients need to be made aware that such forms exist. Buford said he trusted this would happen.

House passes bill creating new type of order for end-of-life care, to be signed by patient and physician

An end-of-life order known as “medical order for scope of treatment” would be allowed in Kentucky under a bill that passed the Kentucky House on an 86-7 vote Thursday, March 6.

Unlike advance directives, such orders spell out a patient’s wishes for end-of-life care are also signed by the patient’s physician. A standard form for the orders would be developed by the Kentucky Board of Medical Licensure for use statewide.

“As a physician, I want to help people live and have a quality of life as long as they can,” said Rep. David Watkins, D-Henderson, the sponsor of House Bill 145. “But I sure don’t want to prolong suffering and agony … It’s our duty to make sure we keep our people in the final hours and final days of their life as comfortable as possible, and also to follow their wishes as close to the letter of the law as we can.”

The House defeated, 18-69, an amendment by Rep. Joe Fischer, R-Fort Thomas, that would have prohibited such orders from allowing food and water to be withheld from a patient unless death was “inevitable and imminent.” The bill now goes to the Senate.