PH Committee Hearing Transcript for 03/20/2013

SENATOR GERRATANA: We're good to go so I will open our hearing today, the Public Health Committee.

And the first person to testify is Jewel Mullen, commissioner of the Department of Public Health.

Welcome, Commissioner.

And for everyone that comes to testify, of course, we ask that you please state your name into the microphone so we know who is speaking.

Welcome, Commissioner, good morning.

COMMISSIONER JEWEL MULLEN: Good morning.

Good morning, Senator Gerratana and members of the Public Health Committee. I'm Dr. Jewel Mullen, commissioner of the Connecticut Department of Public Health.

The Department of Public Health supports House Bill 6644, AN ACT CONERNING VARIOUS REVISIONS TO THE PUBLIC HEALTH STATUTES.

I'd like to thank the Public Health Committee for raising the Department's bill.

Below is a description of each of the sections of the bill. Highlights of the Department's proposal include technical changes related to the Biomedical Research Fund, clarification of what is considered a volunteer in a long-term care facility, requiring that several Department-licensed professions conform to accepted standards of practice, clarification of the statute regarding continuing medical education for optometrists and dental hygienists, elimination of the Connecticut homeopathy board, and clarification of what data needs to be collected by the State's Tumor Registry.

You have pages of very technical language related to each of those sections, and I don't intend to read them to you, so instead I would, at this time, ask you whether or not you have questions.

SENATOR GERRATANA: Thank you, Commissioner.

Does anyone have any questions of the commissioner?

I do not have any questions, Commissioner. I did go over the bill, and it's your usual and customary that you present to us every year, and I thank you very much for coming today.

Next is Senator Michael McLachlan.

Welcome, Senator.

SENATOR MCLACHLAN: Thank you. Good morning, Senator, and members of the Public Health Committee. My name is Senator Michael McLachlan, and I'm here to oppose House Bill 6645, AN ACT CONCERNING COMPASSIONATE AID IN DYING FOR TERMINALLY ILL PATIENTS.

I urge this committee to reject this bill because I believe that this legislation promotes the culture of assisted suicide in Connecticut and tells citizens that suicide is an acceptable solution to life's hardships. I beg to differ. Suicide is not the answer. Suicide is the ultimate sin. Suicide is, God forbid, the wrong way to end one's life.

This morning we held a press conference -- actually, I attended a press conference that was hosted by Cathy Ludlum and members of the disability community in Connecticut. Cathy will testify before this committee later on today. And I hope that you'll listen attentively to what the disability community has to say about the pitfalls of assisted suicide in Connecticut.

Calling something "physician-assisted suicide" seems to be a misnomer completely. How could a physician participate in such an act? In the State of Oregon where suicide was passed many years ago, following the implementation of assisted suicide, suicide increased 42 percent in the State of Oregon. That's saying to the population that assisted suicide is wrong because it enables people to think that suicide is okay.

The Legislature shouldn't be making these decisions. These are not decisions for elected officials, clearly not decisions for elected officials to make. There are many ways for someone to -- to die with dignity, but it is not by taking one's own life.

I've submitted written testimony, and I'm very grateful for the opportunity to be here today and firmly urge you to oppose House Bill 6645.

SENATOR GERRATANA: Senator, thank you so much for coming and presenting your testimony. We appreciate that very much.

Does anyone have any questions?

If not, sir, thank you so much.

SENATOR MCLACHLAN: Thank you.

SENATOR GERRATANA: Next to testify is Representative Diana Urban.

Good morning.

REP. URBAN: It's so nice to see you, Senator. I miss you on the Children's Committee.

SENATOR GERRATANA: It's nice to see you, too, ma'am.

REP. URBAN: And it's very nice to see all the members of the committee here. I am here today to testify on House Bill 6591, which is an act requiring the euthanization of any cat or dog to be performed by a licensed veterinarian.

You do have my testimony in front of you, so I will summarize it because I know you guys have a long day ahead of you.

SENATOR GERRATANA: Thank you, madam.

REP. URBAN: You are most welcome.

What happened was there was a dog, a five-and a-half-year-old German shepherd whose owner could no longer take care of him, and he relinquished him to a rescue organization, and the dog got what they thought was a perfect home, a young woman where he'd be the only animal. And within 48 hours the dog was dead. And it turned out that someone shot him in the head, either the boyfriend or the girlfriend, and they were never able to ascertain exactly what happened because the body never showed up. The boyfriend blamed the girlfriend; the girlfriend blamed the boyfriend; one of them had a criminal record.

Anyway, to make a long story endless, Representative Camillo took this issue to heart and he has worked diligently on trying to get the law clarified that there would never be the opportunity for you to take your dog out in the backyard and shoot it; that if there is a problem and that that dog was either aggressive or whatever, that that would always be taken care by a veterinarian with humane euthanization. They did say that this dog bit someone, but there was no hospital record. There was no indication that the dog bit anyone and he had never bitten anyone in five and a half years so this bill is an answer to that situation.

Unfortunately, there was some meddling with the language of the bill, but I brought that to the attention of the chairs, and I really appreciate the fact that you were -- very quickly responded to that, and there is the real language of this bill which is from an amendment from last session, whereas time ran out and we couldn't actually get the bill done, but that language is there.

And, Madam Chair, this is really Representative Camillo's bill and he has testimony that you will have thereto. He is recovering from surgery and cancer and is very weak. And I said that I would be glad to say that how deeply he cares about getting this bill done. And I won't read you his testimony, again, because of time constraints, but just know that we're all sending our best wishes to him and that, you know, that you are listening attentively to what is taking place here. And I'm available for any questions.

SENATOR GERRATANA: Thank you, madam. Certainly, we all wish Representative Camillo a speedy, speedy recovery and great success as he goes through his trials.

I just wanted to ask you for the language that you discussed with me, because, unfortunately, I don't believe I have it in hand. So if you will, you can e-mail it to myself, Representative Johnson and Senator Welch and Representative Srinivasan, if you would please do that.

REP. URBAN: I believe it's attached to the testimony. It's just a question of scrolling down. And that is we, also --

SENATOR GERRATANA: Okay. Oh, I guess -- here it is. Okay, sorry.

REP. URBAN: I'm glad you said that because I cite LCO 5325 from 2012. It's actually LCO 5594, that was the fiscal, and there is no fiscal on it, but 5594 was the actual amendment.

SENATOR GERRATANA: And I made note of that. Thank you very much.

Are there any questions?

Representative Miller.

REP. MILLER: Thank you, Madam Chair.

And thank you, Representative, for your testimony. My question on the bill is, there's an exemption for the Connecticut Humane Society in this bill; is that correct?

REP. URBAN: In the language that is in front of you there is. In the amendment that we initially did last -- in 2012, that language was not included.

REP. MILLER: But -- so that will be -- will -- so it will be in the bill that there will be an exemption for them then?

REP. URBAN: Can I assume that you're asking me about the meddling part of this?

SENATOR GERRATANA: Well, madam, before we proceed there, I'm going to look at the recommendation you made, LCO 5594 from 2012, and is it -- and I hope the committee's understanding that the substitute language for this bill is section 1 new, it says, "language for House Bill 6591." Is that the language that you would like to substitute for the underlying bill?

REP. URBAN: Yes, Madam Chair.

SENATOR GERRATANA: Okay. Just so long as we are all on the page. Thank you -- same page, I should say.

REP. URBAN: And to respond to Representative Miller's question, what had happened, Representative Miller, was this was Representative Camillo's bill and Legislators for Animal Advocacy was supporting the bill, but, as you know, things get rushed around here, so Representative Camillo was following the bill, not me, and he was very sick, he had surgery at Sloan-Kettering and what happened was language was given to LCO through some conduit that I can talk to you about later, and the language was basically change to solidify Connecticut Humane's ability not to use a veterinarian when they euthanize animals. And as you know, I have always been a proponent of euthanizing any animal with a veterinarian, unless it's a farm animal because I grew up on a farm, and I know when you're in the north 40 and a cow has broken its leg or run through a barbed wire fence that oftentimes the farmer has to dispense humanely, really, because it's almost always, in my experience, done with a gun, and you just have to have that exemption. That's the only exemption that we're supporting.

REP. MILLER: Thank you for that clarification and thank you for your testimony.

And thank you, Madam Chair.

SENATOR GERRATANA: Thank you, Representative.

Representative Conroy -- oh, was the question -- okay.

I don't believe there are any more questions. I think we are clear now --

REP. URBAN: Thank you, Madam Chair.

SENATOR GERRATANA: -- and I thank you. Thank you very much, madam.

Next will be Senator Toni Boucher.

Good morning, Senator.

SENATOR BOUCHER: Good morning, Chairman Gerratana and other members of this distinguished committee. I am here today to present a constituent who is here to testify in support of Raised Bill 6645. The constituent is Mr. Bill Meyer from Westport. He is a gentleman that has had a long history in this community and was just recently honored by 400 of our residents for the 14 to 18 organizations that he has helped in so many ways, giving of himself for a very long time. And he has a deep experience with this issue, very deep experience, to the point where it catapulted him into national spotlight on national programs and went through a very difficult period and so I would think that there is no one better suited to address this very controversial issue than Mr. Bill Meyer.

Bill.

SENATOR GERRATANA: Thank you, Senator Boucher, for your comments.

We welcome you, Mr. Meyer, and just so you know because you are a member of the public, we do have to assign the three-minute limit to you for this, so please --

WILLIAM MEYER: Okay. Will you let me know when I got two minutes left?

SENATOR GERRATANA: The bell will go off. You will know.

WILLIAM MEYER: Thank you very much.

SENATOR GERRATANA: Thank you. Please identify yourself.

WILLIAM MEYER: Okay. Good morning, Senator Gerratana, Representative Johnson and esteemed members of the Public Health Committee. I'm William F. Meyer, the Third, Bill, from Westport. I'm here to testify in support of Raised Bill Number 6645.

My situation is this. In 1991, my father was 88 years old, five cancer operations, lived in West Hartford. And he came to me and said, look, I'm very emotionally disturbed over witnessing the lingering passages towards death of a number of contemporary loved ones and others. He said, I want you to help me take -- life.

In West Hartford he's gotten many awards. They made it Bill Meyer Day back in -- April 3, 1986, and I finally decided I want to talk to two people that would be the (inaudible). So I met my father's doctor, my father's doctor says, Bill, you've got about six months to live.

He said -- my father said, I'd like to take my life.

He says, Bill, I agree with you because you're such a person who loves life so much and has so much going for it that it would be miserable six months for you, I agree with you, I'll help you.

And then I -- I had my minister meet with him, from Westport, a famous UCC minister, he said to me, it's his life, it's his decision, and the best thing God gave is a brain.

So on July 23, 1981, I put a plastic bag over my father's head and this is the way Hemlock said to do it and held his hands back. The next morning the police came and declared it a suicide. I was not involved in any way, and then for three years, I went out am I spoke on this, speaking on behalf of Hemlock, for death with dignity. And the Connecticut Magazine wrote a four-page article on me. And at the end of the article, they said -- they told how I had held my father's hands when he died, I was arrested. And that was in September of 1994, and then had the most amazing three months imaginable. I was on the Today Show with Katie Couric. I was on 60 Minutes with Mike Wallace. Three hundred people in Westport wrote a letter backing me.

And one thing I learned through all of this was how many people have a miserable, terrible last part of their life. And that -- and 250 people in Westport wrote letters, seven doctors, five ministers and even 30 Catholics wrote letters back at me. And the front page New York Times -- I was on the front page of New York Times, and Mike Wallace saw it and he says I want you on 60 Minutes. So I spent -- I was the feature on 60 Minutes and Mike Wallace became a close friend. And then -- how much time do I got?

SENATOR BOUCHER: You're done.

WILLIAM MEYER: I'm done?

SENATOR BOUCHER: Yes, but go ahead just a --

SENATOR GERRATANA: It's okay, Mr. Meyer. Just summarize. Your testimony is so extraordinary, you know, I would please ask you to proceed and, perhaps, you can elaborate a little bit on your opinion. Thank you.

WILLIAM MEYER: Thank you very much. Yeah, and then because this article, I was -- there was a pretrial hearing in Hartford and two ministers spoke for me. I got accelerated rehabilitation.

So I did not go to trial because so many people had yet spoken for me, and I love Westport and they -- all these people vote for me and as Toni said -- I'm delighted because the last thing my father said to me was be a leader when you retire, and as Toni said, I'm the number one volunteer in Westport -- love it.

Love Toni, too.

SENATOR GERRATANA: Well, she is so wonderful to be here with you today.

WILLIAM MEYER: Well, I have so much respect for her.

SENATOR GERRATANA: That is wonderful. I'm not going to ask you any questions. I only want to say, I know I was there with my dad, too, when he passed away and he, you know, was terminally ill for over two years and I know that that moment in his life and in my life, of course, had such an impression, and I was grateful to be there when he did pass. But I am -- I'm sure you must have anguished over your decision to do what you did.

WILLIAM MEYER: Just one thing I'd like to -- I just wish my father could -- my father said when I retire, be a leader, like he was, and marry somebody like your mother, and I found a lovely lady in church. The church is the biggest thing in my life.

SENATOR GERRATANA: Oh, that's wonderful.

I will ask does anyone have any questions of Mr. Meyer?

Representative Srinivasan.

REP. SRINIVASAN: Thank you, Madam Chair.

Mr. Meyer, thank you for your testimony.

Senator Boucher, it's good to see you here again.

Mr. Meyer, could you share with us briefly your thoughts on if this were to pass, what do you think is going to be the percentage of people who once this has been prescribed, will make use of the tablet or whatever form that is being prescribed to them, in your opinion?

WILLIAM MEYER: No, I just -- you know, I just think it's for a few people. I think it's a choice issue. It's a choice issue, and I see how effective -- I've been out to Oregon and Washington, they had me out there to speak, when they went through it, and I saw how successful this is in Washington, in Oregon, and everybody is for it. No one's trying to repeal it. And I think, as my father's doctor said, he says, this is not for everybody. My father's doctor said, You love life so much, you're so active, you know, senior center in West Hartford it's for you. I think it's an individual choice issue, and I have just as much respect for people that don't want to do this.

REP. SRINIVASAN: Through you, Madam Chair.

So you think of this as a choice issue?

WILLIAM MEYER: Choice issue, yeah.

REP. SRINIVASAN: You firmly believe that the percentage of people that will make a (inaudible) will be relatively small?

WILLIAM MEYER: Yeah. Now in Oregon and Washington, because I've been out there on this, the people that get the medication, the pill, only 10 percent ever use it. You see there's a safety valve.

REP. SRINIVASAN: Thank you. And I --

WILLIAM MEYER: I'm might also -- I'm sorry.

REP. SRINIVASAN: I'm sorry. I thought you were done. Please proceed. Please continue.

WILLIAM MEYER: Okay. I also -- I also feel that this is such a big issue with people. When I was arrested what really impressed me was how many people wrote to me and said they had an experience in their life where a loved one died and they wished they had done what I did but they didn't have the courage. They had to live with watching someone go through a prolonged death for a long time, is something they live with all their life.

REP. SRINIVASAN: Thank you, Mr. Meyer. And my final question to you, are you concerned at all that people may go for this option a little too soon because it is available?

WILLIAM MEYER: No, I don't think so. Because they -- you have to have two doctors -- two doctors who will say it's right and there's a waiting period in between. It's a tough decision. I know that myself, my father only consulted two or three other people, and then he wrote a letter that was in the New York Times, you know, that was the front page of New York Times about why he did it. And I don't think so, because it's a waiting period. A psychiatrist has to say you're mentally competent.

REP. SRINIVASAN: Thank you, Mr. Meyer.

Thank you, Madam Chair.

SENATOR GERRATANA: Thank you, sir.

Are there any other questions?

Oh, Senator Welch.

I'm sorry.

Senator Welch.

SENATOR WELCH: Thank you, Madam Chair.

SENATOR GERRATANA: Oh, excuse me, ma'am. Excuse me. We're conducting a hearing here, and I recognized Senator Jason Welch.

SENATOR WELCH: Thank you, Madam Chair.

I guess I have two questions. One was just based on the statement you just made about a waiting period. And I guess my understanding, Madam Chair, through you, is that this bill didn't have a waiting period, and I had -- I don't know if --

WILLIAM MEYER: Yeah, there is one.

SENATOR WELCH: Yeah, well, let -- let -- I guess let me ask you this question. Whether or not the bill has a waiting period or not does that make a difference in your mind as to whether or not it's appropriate legislation?

Through you, Madam Chair.

WILLIAM MEYER: No -- Yes, there has to be a waiting period, yeah.

SENATOR WELCH: Okay. So I understand what --

WILLIAM MEYER: In Oregon or Washington show that people do change their mind, in all the studies out there. It's been very successful in those two states.

SENATOR WELCH: Okay.

SENATOR GERRATANA: But just to be clear, is it your preference, Mr. Meyer, to have a wait -- waiting period?

WILLIAM MEYER: Yeah, maybe three --

SENATOR GERRATANA: Is that your opinion?

WILLIAM MEYER: So you can change your mind. Well, you don't have to -- you don't have to use the medication. It's just there for a safety valve. So you don't -- it doesn't mean --

SENATOR GERRATANA: That is my understanding also.

WILLIAM MEYER: It doesn't mean when you qualify for this that you have to use it. It's just there as a safety valve.

SENATOR GERRATANA: I understand. Thank you, sir.

Are there any more question -- oh, Senator Welch has the floor.

SENATOR WELCH: And if I may, through you, Madam President, as I was reading an article about your experience in the past. It sounded like your father had attempted suicide prior to the time that you were with him. Is that a correct understanding or is that -- I'm just --

WILLIAM MEYER: No. He -- as the doctor said, he wouldn't recommend this for everybody. But my father liked life so much, he's so active, he got all these awards in West Hartford for things he'd done, that because of that nature of my father, it would be a very tough time for him. He had six -- seven months to live. He'd be in agony. No, he spent a long time thinking about this. He didn't just -- it wasn't a quick decision. And he -- all he said, he said the best thing God did for me is give me a brain. He was very active in his church.

SENATOR WELCH: I guess I'm a little confused as to the answer, and I probably wasn't clear. I -- and maybe this article reported it --

WILLIAM MEYER: Oh, yes -- yes.

SENATOR WELCH: He did.

WILLIAM MEYER: Yes.

SENATOR WELCH: Okay. Thank you.

SENATOR BOUCHER: If I may -- if I may, through you, Madam Chair, Bill has said that, yes, his father did think about ending his life or suicide before this actually occurred.

SENATOR WELCH: All right. I -- thank you.

SENATOR GERRATANA: Thank you, Senator.

Representative Betts.

REP. BETTS: Thank you, Madam Chair.

And thank you, Mr. Meyer.

In the situation, let's say somebody is diagnoses with, I believe it's Lou Gehrig's disease or they find out that they have terminal cancer, and rather than go through chemotherapy or some other treatment that might be prescribed to try and either slow down the process or slow down the pain, what would your view be or what would this bill do if that patient decided I don't want to go through this, I don't want my family members to watch me go through this. And under these circumstances, I just do not want to subject myself to any additional treatment, therefore, I would like to willingly and with a competent mind say, I'd like to take this pill and, you know, if the doctors are in agreement that I have a terminal illness, I'd rather forego the treatment and take this pill. Is this -- well, what would your view be on that kind of a scenario?

WILLIAM MEYER: Okay. I don't (inaudible) treatments. I don't understand what you mean by treatments, Senator.

SENATOR BOUCHER: Like cancer treatments.

WILLIAM MEYER: Oh, no, no. He had five cancer -- he had five different cancer treatments. The doctor told him it was creeping in his body. It was going to be five or six months to live, it would be very difficult. There's no hope at all, no hope at all. Just a --

SENATOR BOUCHER: What if someone didn't want the treatment?

WILLIAM MEYER: If somebody didn't want the treatments -- there's no treatments he could have had -- he was just too far along.

SENATOR WELCH: Through you, Madam Chair. And I appreciate that, but I'm thinking in the case, let's say somebody has Lou Gehrig's disease, and I understand that's a very debilitating painful slow way to -- to pass and that there's no cure. If somebody were told that they had that disease and were of sound mind and there is no cure, under that scenario, that person might turn around and say, you know what, I don't want my family to go through watching me suffer, I don't want to suffer, therefore, I think it's entirely appropriate, given the -- the inability to have any kind of cure, I'd like to take this pill. What would your reaction be to that scenario?

WILLIAM MEYER: Yes, yes, I would.

SENATOR WELCH: One of the problems -- and I could understand that kind of a situation, one of the problems I have with this is it's very difficult to write legislation and cover all circumstances, and there are a lot of different circumstances for this and a lot of this is subjective and I agree it should really be a personal decision. But I think we go down a very slippery slope in trying to put this into law and try and write what is acceptable or not acceptable. Do you agree that this is a very, very difficult and controversial way of -- of addressing people's personal illness?

WILLIAM MEYER: No. I don't think there's any slippery slope here. There are too many safeguards in this. Two doctors have to verify it. A psychiatrist has to say you're mentally competent, and -- and also the way it is in Oregon and Washington, it's limited to six months to live so that actual positive proof that person has six months to live, and that's the way most people with cancer -- my father had five cancer operations, and the doctor said, he's going to be a miserable six months for you, and he just said, he loved life too much, to the fact to go through that.

And he -- one thing he kept saying is the best thing God did for him, he gave me a brain. I mean, I was very impressed that my minister met with him and agreed with this. He's a very famous congregational minister. The doctor who he had known for 25 years, the doctor agreed, the doctor said, I wouldn't do that with many people, but Bill, yours -- a very unique situation.

SENATOR WELCH: Okay. Thank you very much.

Thank you, Madam Chair.

SENATOR GERRATANA: Thank you, Representative.

Are there any more questions?

If not -- I'm sorry. Who?

Representative Miller, I'm sorry.

REP. MILLER: Thank you, Madam Chair.

Thank you, Mr. Meyer. My question for you is, as you may know in the past several years as a legislature, we have had to make a number of decisions involving giving our physicians more latitude, perhaps, with this certain treatments and efficacies. My question to you is, as a native of Connecticut, you know our physicians, do you have any reservations that our physicians would in any way not handle this responsibly if this became law?

WILLIAM MEYER: No, I don't. I know socially, probably 10 or 12 different doctors. I certainly would trust them. I don't think so. I think that that's -- their code of ethics, I would think they'd be disbarred for this, if they did. They'd be the headlines in the paper. I think they'd be very cautious. I think they'd be very, very cautious because the controversy of this issue and saying somebody has six months or less to live. And I think they can tell -- the doctors I talked to say you can tell very easily if somebody -- mostly cancer patients, it's eating away at your body, you know. I think we have to trust doctors.

REP. MILLER: Okay. Thank you for your answer.

Thank you, Madam Chair.

SENATOR GERRATANA: Thank you, sir.

Senator Boucher, thank you very much for coming and bringing your constituent today, Mr. Meyer.

We appreciate very much your attendance here in giving your testimony and we wish you well.

SENATOR BOUCHER: Madam Chair.

SENATOR GERRATANA: Yes.

SENATOR BOUCHER: Madam Chair, may I just end with, as Bill has been undergoing some treatment himself the very next day, he got in his car and delivered his Meals on Wheels because they needed him. So he is, indeed, a very special person. Thank you very much.

SENATOR GERRATANA: I guess so.

WILLIAM MEYER: If somebody says have a good day and you like them, have a good life. Everybody have a good life in here.

SENATOR GERRATANA: To life, thank you, sir.

Next to testify -- oh, before I call the next person, I just wanted to remind, people here in the room that Room 2E, as in elephant, is also available for people to go to. They can follow along the hearing and urge you all, if you're going to to sign up to testify and before you do so please state your name into the microphone. And we also ask that the doorways be kept clear. This is a matter of safety, all of our safety. Thank you very much.

Next to testify is James McGaughey, Office of Protection and Advocacy.

I saw him in here earlier. We can come back to him if he's not here.

Next will be Deputy Speaker Elizabeth Ritter.

Is Representative Ritter here?

Okay. I see Representative Al Adinolfi is here, though. Sir, would you like to testify now?

And then we'll -- we'll go back to the other individuals.

Thank you.

REP. ADINOLFI: Thank you, Madam Chairman, co-chairs and ranking members.

I'm here to speak on two bills today, and I'm going to be brief.

First one I want to talk about is the 6590 about the licensing of tattoo technicians. I was never under the impression that a tattoo technician was not licensed, similar to a nurse who is licensed. They both put needles into your body and penetrate your skin. Tattoo technicians claim they don't need licensing because they have doctors overseeing them, well, so do nurses. And they have to -- and they have to be licensed, the nurses that is.

I had one constituent that told me her technician came forward with the tattoo materials ready to start the procedure. She asked him why everything was uncovered. He answered that he uncovered everything at the counter. She walked out, and I don't blame her.

This is one example of what can happen when an individual tattoo technician has not proven their qualifications in order to obtain a license. Please give moving this bill forward serious consideration.

If you have any questions for me on that one?

SENATOR GERRATANA: I don't know.

Does anyone have any questions of the Representative on licensing tattoo artists?

REP. ADINOLFI: I believe the way the bill worked on that it would be -- would be some initial cost for us to get it set up, but the licensing would be $250 for the first license and $200 every two years to keep your license going. So that's something to keep in --

SENATOR GERRATANA: Representative Al Adinolfi, I know you're an advocate of this and bringing it before the Public Health Committee is appropriate. I just want you to know that the Department of Public Health has a scope review, in other words, review of people's professions, if you will, and they testify -- the Commissioner in her written testimony asked that those who would be licensed to go through that review. I can work with you after the meeting and explain to you further what that means.

REP. ADINOLFI: Thank you very much.

The other bill I wanted to speak about was in opposition to Bill 6645, the basically was better known as the assisted suicide.

I am definitely opposed to assisted suicide. I spent four years as a trained hospice volunteer, and one of the first things we learned was that if family members were saying anything that might be offensive to the patient, remind them that although the patient was out of it, they hear and understand what they are talking about. I had heard families argue many times over how the assets would be handled -- how the assets would be handled. And my opinion is, many times it is evident that the family didn't give a hoot about the patient and were only concerned about what the benefits would be.

I, also, had patients that were in hospice care for long periods of time and then were declared better and removed from hospice. I had one patient that I read to for a couple of weeks and then she wound up reading to me. She was also removed from hospice. It's -- I was taught that a patient that seemed out of it and appeared unconscious felt no pain, no discomfort and nine times out of ten, they heard everything that was said and understood it.

One incident that I particularly remember was a young -- not a young man -- a gentleman that was in hospice and I visited him, and I knew he was an avid fisherman so even though he was out of it on the bed, I talked to him about fishing and a couple of minutes later, he put up his hand and slapped me five. That proved to me that people do hear you even though they're out of it.

Somebody mentioned before the safety valve. I'm going to have to research that more. What do they do, leave the pill on the table and it's up to you when you want to take it or not? If the individual has a conservator and wants to collect the estate, they might just give it to them. You don't know. You have to avoid all this. If this bill passes out of committee, I firmly believe that people we help to die against their will. Let nature and God prepare one for death. Please do not pass this bill out of committee.

And I'd be happy to answer any questions with -- about some of experience as a hospice volunteer.

SENATOR GERRATANA: Thank you, sir.

Does anyone have any questions?

If not, we thank you very much for giving your testimony today.

REP. ADINOLFI: Thank you very much. Thank you.

SENATOR GERRATANA: We'll go back to our list and next is Jim McGaughy.

JAMES MCGAUGHY: Good morning, Senator Gerratana, Representative --

SENATOR GERRATANA: Good morning.

JAMES MCGAUGHY: -- Johnson, members of the committee. My name is Jim McGaughy. I'm the executive director of the Office of Protection and Advocacy for Persons with Disabilities. I have submitted written testimony this morning regarding Raised Bill 6645, AN ACT CONCERNING COMPASSIONATE AID IN DYING FOR TERMINALLY ILL PATIENTS.

Basically, the bill would legalize what it terms, "aid in dying," but what is more often commonly referred to as physician-assisted suicide. And like many disability rights organizations, our office has consistently opposed proposals to legalize physician-assisted suicide and we oppose this bill, as well.

I won't read my testimony because I assume that you're all able to do that, but I will summarize a few things.

The other organizations that oppose it are mainstream national disability organizations. And they -- they, generally, have a very progressive view on social issues, and in fact, like most disability rights organization, they tend to promote respect for individual choice and personal autonomy as fundamental values of the disability rights movement. So if this proposal is all about personal choice, why are they opposed to it and why are -- and why is our office opposed to it?

Well, the reason is that -- is really rooted in -- in a couple of aspects of the disability experience. It is not uncommon for folks with disabilities to go through a very rough patch, particularly, if it's -- if they have significant disabilities, from time to time, or when they first -- when they first become disabled.

The history of disability rights movement is punctuated by stories of people who will tell you that at one point they just wanted to die. And so our concern is that if this -- if this measure goes forward, we will lose people, we will lose people who will -- who may have years of life in front of them but that -- that are going through a difficult period or, perhaps, feel that they are a burden to their families or that they -- they -- they're consuming resources that could otherwise be used, whatever -- whatever their feeling is.

And I know that they are -- there's a provision in the bill that says, you know, just having a disability doesn't qualify you for aid in dying. That, in fact, you have to be terminally ill and within six months of death in order to qualify. Well, the problem with that is that, first of all, it's not that precise of science to predict the life -- the life span of somebody with -- who's -- who is terminally ill. And secondly, there is a lot of confusion in the medical community about the distinction between disability and terminal illness, particularly, if it's a progressive disability. Disabilities like muscular dystrophy or multiple sclerosis or sometimes there are people who are born with very complex medical conditions that can shorten your life expectancy but don't always do -- don't always or genetic conditions that -- that may, in fact, predict a shorter life span but not always.

And you know, I just -- our office has been involved in a number of cases over the last 25 years where individuals were -- we were brought in because there was a claim that an individual was being inappropriately denied some kind of beneficial medical treatment. And most of these folks -- I want to -- I want to explain -- most of these folks are people who would not meet the competency requirements of this particular proposal, so these are people who had conservators or had -- had guardians appointed, and I -- I did not point that out in my -- in my written testimony, I should have done so. But nonetheless, the -- the lesson that I learned from this was that there were physicians who were willing to say that those individuals were in the end stages of a disease process or that they were terminally ill. In spite of the fact that once the -- once the treatment was obtained, they went on and lived for years, and in many cases -- in some of the cases they're still alive today, 20 years after we had -- we had done the original -- after we had been involved in the situation.

So I just want to caution that like to the extent that you're -- you're, sort of, like making a threshold judgment here on this business of a physician saying somebody's terminally ill. To the extent that you're dealing with somebody who has a progressive disability or is -- your -- or maybe somebody who is on life support equipment just as a matter of living, that -- that's turning over to a doctor who may not understand very much about disability authority to be -- to be casting that person as being terminally ill when, in fact, they may not -- they may not be. And I know that there's a provision that says there should be two physicians, but there's also a provision that says it's not always necessary. So, I mean, there's -- there's a lot of -- there's a lot of concern about that.

And the other area of concern that we have is basically that by involving doctors in this business of prescribing doses that -- lethal doses for people, you are -- you are invariably legitimizing a person taking their own life. And that's something that -- that is -- that will have all sorts of ramifications. It becomes, sort of, more socially acceptable. This is something that historically has been discouraged by society for thousands of years. And it can have an impact on the way people see their own prospects and their own -- their own responsibilities, I guess, to the extent that it becomes more common to do this, I think that more people -- you will find more people opting for it, not because they're concerned about dying in pain, that actually -- there are some statistics from Oregon that I cite in my written testimony. There -- Oregon keeps some records. It doesn't keep very many records, but it does keep some records -- that indicate that actually the things that motivate people to choose this option in Oregon are a concern about losing dignity and burdening other people much more so than dying in pain. That is not the -- that is not the primary concern that folks cite in Oregon who choose this option.

So I think that we are at risk of actually creating an option that people who would perceive themselves as being a burden or going through a rough patch or who may be vulnerable to some kind of undue influence from somebody who does stand to benefit from their demise that they -- that they might in combination with the doctor doesn't really understand that much about disability might also wind up having these prescriptions written for them.

And that's the essence of what I say in my written testimony, so I -- I know that from some of the other cases we've been involved with and some of my own personal experience with family members and friends that it is not the case that people always get what they need at the end of life. And I think it would just be better for us to put our -- to put our resources and our minds to trying to address that problem than to create something that is -- that really does fundamentally change the role of physicians and that's -- that's pretty much what I have to say so.

SENATOR GERRATANA: Thank you, sir. Thank you for your testimony.

Does anyone have any questions?

If not, thank you for coming today and giving -- we do have your written testimony.

JAMES MCGAUGHY: Thank you.

SENATOR GERRATANA: Next is Deputy Speaker Elizabeth Ritter.

Madam, welcome back.

REP. RITTER: Thank you. The table looks a little different from this chair.

Thank you very much.

Good morning, Senator Gerratana, Representative Johnson and members of the Public Health Committee.

My name is Betsy Ritter, and I'm the State Representative from the 38th District. And I am here today to support House Bill 6645, AN ACT CONCERNING COMPASSIONATE AID IN DYING FOR TERMINALLY ILL PATIENTS.

I first want to thank the committee for choosing to raise this bill. I'm particularly pleased to see that the discussion will be in the context of the public's health, and consequently it's here in this committee. In other years when this discussion has been had, it's been more in context of the issues in the judiciary and legal issues around that. And, perhaps, this is an opportunity to keep the discussion more patient centered and I appreciate that.

This bill offers a terminally ill patient an additional choice over how to conduct the end of their life, the choice to end their life themselves. It allows an adult patient that has been determined to be mentally and psychologically competent, terminally ill, and in full control of their decision-making abilities the right to make this choice by requesting a prescription from their physician that they may self administer at their will to bring about their death. It is strictly voluntary. Only the patient themself can make the decision to ask for or use this prescription, and no healthcare provider or facility has to participate in this aid in dying.

And those are all critical points in this discussion, and they are points that it is very easy to lose track of and have -- get confused as you face your difficult task of sifting through the details and, essentially, the requirements that might allow a patient to qualify.

The bill, essentially, establishes a procedure for a patient to be determined to be a qualified patient by reason of a diagnosis of a terminal illness with -- by their physician. As with hospice, that diagnosis must be of less than six months to live in order to qualify. And the patient must be able to make and communicate an informed medical decision and must be acting voluntary, also, important points as you look at some of the safeguards for patients.

The bill is modeled after laws that have been adopted in the states of Oregon, Washington and Montana; that first became law as long as 15 years ago in the state of Oregon. Since then in Oregon, 64 percent or 673 prescriptions that have been written have actually been taken. More importantly, over that period of time, the overseeing agency, the State of Oregon's Public Health Department, has found no cases of coercion -- excuse me, I'm already losing my voice -- of coercion, abuse or misuse of the law.

The experience in Washington is similar, over three years, where 62 percent of those prescriptions have actually been taken.

Medicine today is a tremendously powerful and advanced science. There's no doubt about that. Incredible measures can be taken to extend life in the face of equally incredible odds of survival, very often with marvelous success but sometimes the measures chosen to extend life do not work, and sometimes those measures themselves create suffering that is difficult to comprehend and impossible to manage even with our most powerful pain medications of today.

It's more likely today in Connecticut that lives will end after a longer, degenerative-type disease than -- than a sudden onset or accident, has been our experience in decades past.

This process requires patients to make many personal choices, how to treat their condition, where to stay, where to live, what kind of help to depend on, how long to pursue treatment, when to end treatment for a terminal condition. This bill would allow that terminally ill patient to make a decision to bring about the end of their life.

Thank you for your time and consideration. I know you have a lot of difficult discussion ahead of you as you look at this, and I encourage you to, perhaps, take your time in doing that. Thank you very much.

I'll take any questions.

SENATOR GERRATANA: Thank you, madam.

Are there any questions?

Representative Johnson followed by Representative Betts.

REP. JOHNSON: Thank you for your excellent testimony today, and I just wanted to have you speak to a couple of issues that were raised before. One was the example of somebody with ALS and once they -- the testimony was that they might decide to try and avail themselves of the -- of the doctor's assistance right after they got the diagnosis. Could you just explain how that probably would not be the case at all in terms of the way the bill is written right now?

REP. RITTER: Remember that the conditions are that in order to become a qualifying patient, then all of the conditions must be met, and the conditions are that the diagnosis must be a terminal diagnosis within a period of six months, that the patient must be fully competent and capable of making their own decision making and that -- there's another one that I've already forgotten -- and -- but in the case of a degenerative disease, like ALS, that terminal diagnosis would have to define a six-month period of time before an anticipated death. If a patient -- another point to think about is that a patient who might, perhaps, in that six-month period make the choice to avail themselves of the prescription is under no compunction ever to use it either if any of those conditions in their mind should change.

Does that help you?

REP. JOHNSON: Thank you. Thank you for the clarification.

Thank you, Madam Chair.

SENATOR GERRATANA: Thank you.

Representative Betts.

REP. BETTS: Thank you, Madam Chair.

Thank you, Representative Ritter. I was the one who had raised that question, and just elaborating on it a little bit more, anybody who has ever witnessed or knows anybody that's gone through ALS and knows that there is no cure could very likely come to the conclusion, I do not wish to have my family or myself put through this kind of misery, if you will, and they may determine its their wish to prematurely before you -- you get to those final six months, prematurely say, look, I do not wish to have my resources or my family go through this or myself. And I'm wondering how that would be affected by the bill before us today?

And the second question I would ask is, if you could respond to what was spoken about in testimony by the advocate for people who have disabilities because they're a great -- they're a great number of people who have concern over people who become disabled and become, if you will, an opportunity or a victim of, perhaps, premature death, as well.

REP. RITTER: Thank you, Representative Betts.

In answer to your first question, which I believe has to do with definition of terminal illness, and in the case of a degenerative type of disease, like ALS, when that might occur. The build itself provides a definition of terminal illness and clarifies that it would be in the final stage of an incurable and irreversible medical condition. The emphasis in that case would have to rely on that final stage determination, and only then would the qualification -- with the patient be allowed to qualify. So an early onset of a disease would not, under a medical definition, meet a final stage definition.

And your second -- I'm sorry. I've already forgotten your second question, if you could restate --

REP. BETTS: Yeah, thank you. Thank you for that answer. I just wanted to follow up. Maybe as you enter into the final stage of Lou Gehrig's disease, at that point, it may be determined that you're not medically -- I mean not medically -- not psychologically competent to reach that decision. I mean it's a very gray area and -- or somebody may become extremely depressed, for example. It's a -- it's a quite -- I mean these are all personal decisions, and I guess the bottom line comes -- comes down to is this something that should be put into law, or is this something that should be left to families and ministers, priests and doctors and then ensure that there is no liability if collectively they decide the best route to go is aiding them and aiding the patient in dying?

REP. RITTER: That might be question for another day. The bill, as currently written, is -- stipulates that only patients can make that decision and that -- and that the patient must, at that time, be mentally competent and fully capable of making their own decisions. And so I agree with your concern that there may be cases that by the time someone with a degenerative disease with a relatively known outcome -- although perhaps not a horizon on that outcome -- might at the same time not be mentally competent when they have a terminal diagnosis. They would not be a qualifying patient under the terms of the bill as written now.

REP. BETTS: And the second part of my first question was --

REP. RITTER: -- in my -- I should say, in my opinion.

REP. BETTS: Thank you.

The second part of my question had to do with the concerns expressed by people who have disabilities.

REP. RITTER: A person with a disability is a person under the terms of this bill and so the disability does not create a reason why the disability would give them a qualification should they be -- have a terminal diagnosis and, again, be able to meet the thresholds of the decision making that might indeed be the case but only under those circumstances.

REP. BETTS: Thank you.

SENATOR GERRATANA: Representative Srinivasan followed by Senator Welch.

REP. SRINIVASAN: Thank you, Madam Chair.

Thank you, Representative Ritter, for your testimony. I, too, am used to seeing you sitting on this side of me, and I find it unusual that you're there and I'm glad to -- to see you there.

A few questions I have, through you, Madam Chair, it was brought out in the previous testimony, and I just want to make it clarify to all of us in the committee that the -- it is not absolutely necessary that you need a second opinion or a second consultant to confirm that. Could you address that for us?

REP. RITTER: Under the -- let me just make sure I get it right because I'm still getting confused on this one -- if a patient who for all other reasons qualifies and their primary caregiver is capable of making that qualification, that would be the case; that is my understanding in the bill. Does that help you?

REP. SRINIVASAN: So, it does, thank you. So, if the -- if the physician in charge of the patient makes a determination that all criteria have been met, which have been outlined, in that case, the need, as I understand it, for a second opinion is not there.

REP. RITTER: That is my understanding, also.

REP. SRINIVASAN: Thank you.

And through you, Madam Chair, can I ask one more question?

The need for a psychiatric evaluation, you know, is once again required only if the consultant or both the consultants in this case feel that the -- the judgment may be impaired, there is a questionable factor and that is when a psychiatric evaluation is necessary. Is that how -- would you clarify on that?

REP. RITTER: That is also my understanding.

REP. SRINIVASAN: Thank you very much for that. I appreciate that.

Thank you, Madam Chair.

REP. RITTER: Thank you.

SENATOR GERRATANA: Senator Welch followed by Representative Cook.

SENATOR WELCH: Thank you, Madam Chair.

Deputy Speaker, it's good to see you. I don't know if you were here for Mr. Meyer's testimony. He's the gentleman who put a bag over his father's head and then held his father's hands to prevent the reflex from taking the bag off, but he -- he testified in supported the bill, but he was under the impression that there were two qualifications. One is a psychological determination as to the state of the person seeking to take advantage of this law and then, also, a waiting period.

Now as I read the bill, I don't see a waiting period, and I see that the psychological examination is only after the attending physician says we need to look into the psychology of -- of the patient. Is my understanding correct or is his understanding correct?

REP. RITTER: That is also my understanding. I believe you are correct.

SENATOR WELCH: Okay. And then, if I may, through you Madam Chair, the next question I have has to do with the question of competency. And as I read the bill, competency is something that can be determined by any number of individuals: The first being the patient's attending physician; the second being a consulting physician and a psychiatrist, a psychologist or a court makes that -- that determination. And I guess in a case where you have an attending physician and a consulting physician whose primary purpose is to look at whether the patient is terminally ill or not terminally ill and they, say, agree as to the terminal illness but disagree as to the competency and it's not required that the consulting physician make a determination of the competency, it's only required that one of them make a determination of competency. What -- what happens? Is there a mechanism in here that then says, all right, we need -- now need to -- we've got a disagreement as to competency, we, you know, we need an arbitrator to decide that. How does that -- that work?

Through you, Madam Chair.

REP. RITTER: That's -- Senator, that's a very interesting point and a point of disagreement, and I'm not sure I can answer that. I might leave that -- that note for the committee to take note and clarify the language around those circumstances, specifically.

I will state that one of the issues around the psychological determination, as you alluded to, is that the attending physician or the primary caregiver may not feel they are the person in best position to render that opinion, and you can see how that often may happen depending on the circumstances of the patient and so then it would indeed be necessary to get another opinion. But I think maybe that's something that the committee might want to take a close look at and clarify.

SENATOR WELCH: And then if I may, Madam Chair, follow up to the first question, I think Mr. Meyer's impression of the bill might have come from other states' bills which actually have those. And I'm curious as to why, in this bill, there isn't a mandatory waiting period or a mandatory determination of competency based on a biased psychiatrist or psychologist?

Through you, Madam Chair.

REP. RITTER: In terms of the waiting period, there -- and I think there are, perhaps, other models or other laws out there that would address a waiting period. Some of the difficulty about weighing the waiting period -- waiting period, and the reason that I might have a problem with that is that you have to understand the circumstances that we're talking about here, don't allow a lot of period of time to wait in many cases for these patients and, in fact, the imposition of the waiting period could deny them the opportunity or to what I might advocate for could be their ability to make this decision in a time where it could help them and that would be my concern with the waiting period.

It's not a situation -- the bill offers, I believe, ample opportunity for the patient to consult and to receive all the information from either their physicians or other healthcare providers before choosing to make this decision themselves and as would be appropriate, so in terms of any hesitation on the part of the patient to think things over, all of that is preserved and remains their right. So I think I would advocate that a waiting period only takes away, perhaps, the potential benefit of the bill.

SENATOR WELCH: And then the second part of that was with respect to having a psychologist or psychiatrist make a determination mandatory as opposed to upon referral.

REP. RITTER: I think the issue and, again, I think the -- certainly, the committee might want to take a look at the language there, if they don't feel that it's clear enough. One problem with that is that if a -- that determination is not necessary and it's -- there is a time element involved there that, also, I think, would be an issue of concern.

SENATOR WELCH: That's it. Thank you.

Thank you, Madam Chair.

SENATOR GERRATANA: Senator Welch, I know we have a lot of questions to say the least.

Representative Cook followed by Representative Ziobron.

REP. COOK: Thank you, Madam Chair.

Nice to see you, Deputy Speaker. Nice to have you there.

We, obviously, get a ton of e-mails weighing on both sides of a topic and this one, obviously, a very hot topic, if you will. The conversation that's been thrown out there is assisted suicide versus taking one's life. I mean, a variety of different ways to express what we're talking about right here.

I think I have a clear understanding of what this bill is proposing -- could you -- for I think the public who is listening or sitting in the room, please explain what you believe, if you can, the difference between an assisted suicide and the right to die?

REP. RITTER: The bill, I believe, gives an individual patient and only that patient the ability to make their decision to end their life in advance of what has been determined to be the end of a terminal illness.

It does not empower somebody -- it does not demand that somebody assist them to do that other than the fact that they request a prescription from their physician, but only the patient takes it and they take it voluntarily, knowing all of those circumstances.

I think the discussion about -- I'll say this a little differently -- as opposed to what many people think of as suicide or assisted suicide when it is, perhaps, either an act taken without premeditation, an act taken when someone is not fully in -- does not have full competency over decision making or a full understanding of the scientific facts behind their situation.

And the reason that that's important is the safeguards in the bill require an independent judgment that that person is in full command of their own decision making and are fully competent and able to do that and to weigh those factors that would be the difference.

REP. COOK: Thank you for that answer.

And one more, through you, Madam Chair, following up to that, then, if you take a patient -- I have an aunt that's in hospice right this very minute and will probably not, you know, she dealt with Alzheimer's -- and I appreciate the Senator's question about competency, I think that's extremely important -- but if that decision was made to end of life and then took a terrible turn rather quickly, and we know that some things do change rather quickly, and I had already made the decision, but at that point I could not administer the medication, is that decision now not an option at that point? Are you understanding what I'm asking you?

REP. RITTER: I might ask you a question -- you might want to understand that the person who makes the decision has to be a patient. So I cannot make that decision for my mother if my mother is not mentally competent and able to exercise her own decision making. I can't do that for her.

REP. COOK: Correct, right.

REP. RITTER: So, that also must be accompanied by a diagnosis of -- end stage, perhaps, of Alzheimer's, and so in the -- so I guess what I'm trying to say is that there are many diseases, sadly, degenerative diseases that take people's minds, that are this -- those patients are most likely not going to be able to qualify for this unless they happen to have the circumstance of it being accompanied by a medical condition that results in a terminal diagnosis. That is the case.

REP. COOK: I think, to maybe clarify my situation, is if that person that was at one point able to make that decision and then between the time of the decision making and the prescription, if you will, had a stroke and could not now make that change -- that they were not able at that point, but they had already been approved for what we're talking about. Are they still -- is there still a family member that can follow through with that if something changed within that instant? That's what I'm asking.

REP. RITTER: I believe the answer to that is, no.

REP. COOK: Thank you.

That's what I was -- I just wanted clarification. I think it's important for everybody to understand the difference and the clarifications because, obviously, different pieces of legislation that we deal with have a lot of interpretations. And if you have -- if you've seen people at the end, it's -- it's very hard to deal with.

REP. RITTER: That is -- that is correct and I think I might say that this is, actually, quite narrowly prescribed here, a narrow set of circumstances and understanding that, you know, in the world today, there is innumerable circumstances, all of which we cannot capture. And this, by no means, attempts to do that. It's extremely narrow.

REP. COOK: Thank you very much for everything that you do and your answers.

Thank you, Madam Chair.

SENATOR GERRATANA: Thank you, Representative Cook.

Representative Ritter, I just want to be clear here that we are talking about an individual who may have this choice and only he or she would administer the dose, no one else.

REP. RITTER: That is correct.

SENATOR GERRATANA: Thank you, madam.

Senator Kane.

SENATOR KANE: Thank you, Madam Chair.

I'm glad to see the good representative made her way into the -- on the other side of the table here. Oh, wait, look, we're being surrounded.

SENATOR GERRATANA: Yes, you have two -- two -- two more members.

SENATOR KANE: It's not enough that you control the House and the Senate, now you want to control each committee room, too.

In response to Senator Welch's question about the mental health professional being involved in the counseling, I think your answer was that we -- time won't allow a patient to wait. Can you explain that? Is that not your answer, did I hear that wrong?

REP. RITTER: Let me rephrase Senator Welch's question first to make sure we're talking about the correct question because he had several. I believe Senator Welch was asking if -- was suggesting that in every circumstance a full psychological evaluation would be required. Is that -- are we talking about the correct question?

SENATOR KANE: Yes.

REP. RITTER: And my answer to that was that I'm not -- I'm not sure -- well, that's not a requirement of the bill that in absolutely every case a full psychological examination be conducted first. One of the reasons --

SENATOR KANE: Then, if I may, then how do we measure the competence of the patient?

REP. RITTER: Because it -- there's a difference between a full psychological evaluation and a medical -- your -- your doctor's opinion that you are, indeed, in full competency and able to make your own decisions.

A full psychological evaluation would involve a psychiatrist, a specialty would be required to do that.

And you're getting me on -- you're getting me on thinner ice defining that, I will tell you that, so I know that Representative Srinivasan can also respond to this a little bit, too, but in terms of -- and, perhaps, we're talking definition in here and, again, I would put that back on the committee, if you feel that these definitions are not sufficiently clear.

SENATOR KANE: In lines 73 through 76, it talks about a psychiatrist and a psychologist. What is the reason for that to be in the bill if your decision is being made between you and your doctor and not through a psychologist or a psychiatrist? Am I not reading the bill correctly?

REP. RITTER: A, there is no -- a -- let me get it right. I don't want to insult any medical practitioners here.

SENATOR KANE: There is only one, don't worry about it.

SENATOR GERRATANA: Excuse me, what line is that, Senator Kane?

SENATOR KANE: 73, I believe.

SENATOR GERRATANA: Thank you.

SENATOR KANE: It defines a psychiatrist, and the 75 defines a psychologist as if they were partaking in the process.

REP. RITTER: Yes, it does. And that indeed may be necessary if in the opinion of the attending, the doctor, the primary care provider, they are not able to make that determination, then that determination could be made by a psychiatrist or a psychologist, remembering that a psychiatrist or psychologist would not be the doctor that would be making the diagnosis of the terminal illness.

SENATOR KANE: Correct. And that's -- that's fine.

REP. RITTER: But in some cases, that person -- that physician may be competent and capable of making the diagnosis that a person is competent.

SENATOR KANE: But I would argue the psychologist or the psychiatrist has a much better ability to reason the competence of the patients.

REP. RITTER: My concern was only that if that is not necessary or not needed, it indeed could be a timed issue and a delaying factor and --

SENATOR KANE: But wouldn't it be needed because this individual has to be of -- of sound mind and to make this determination, I mean, we're talking about ending their own life so it's, you know, I think it's not just a medical thing but there's a mental health aspect to this, as well.

REP. RITTER: Yes, there is. And that doctor -- that medical doctor must be confident in their ability to make that diagnosis and that determination.

SENATOR KANE: And you believe the doctor has that ability versus the mental health professional that the person would also be possibly talking to?

REP. RITTER: I believe in many cases a physician is capable of making that determination and in many cases they're not. It's circumstantial to the patient and their condition, but nobody else knows that condition better than their doctor.

SENATOR KANE: And then, going back to your answer of the time, why wouldn't the time allow?

REP. RITTER: I think -- it's my opinion and certainly from much of the work we do around here that it can be a time consuming process to obtain that full psychiatric evaluation. It's not a next day kind of thing in today's world. Understanding, that these are patients, by definition that are looking at, perhaps, limited remaining life.

SENATOR KANE: And then, lastly, Madam Chair, if I may, the bill says self-administer. So what if the patient is inable or unable to self-administer, then they don't qualify for the bill?

REP. RITTER: I believe there is language precisely as to how they would ingest or take the medication and are (inaudible) --

SENATOR GERRATANA: Actually, Madam, on line 81, there is the definition of self-administer means a qualified patient's act of ingesting medications so we do have a definition.

SENATOR KANE: So, if they are --

REP. RITTER: Thank you.

SENATOR KANE: -- unable to self-administer, then they do not qualify for this bill. Correct?

SENATOR GERRATANA: That would -- that would be --

SENATOR KANE: Whoever wants to answer?

REP. RITTER: -- my understanding --

SENATOR GERRATANA: -- if they cannot self-administer, and I made that point before, they would not qualify. Correct.

SENATOR KANE: Thank you, Madam Chair.

Thank you, Representative.

REP. RITTER: Sure.

SENATOR GERRATANA: Is there anyone else?

Yes, Representative Maroney.

REP. MARONEY: Thank you very much, Madam Chair.

And thank you, Representative Ritter, for your testimony.

I just have a question about attending physician. It seems that the attending physician would just be the primary care doctor and there is no requirement that the specialist who usually -- it's my assumption the specialist -- if it's in the case of cancer, terminal illness, the oncologist would make the prognosis. So is there any requirement to consult with the specialist? I know it says the consulting physician, attending physician, but I guess one of the concerns is if someone is just shopping around for someone, you know, to sign off on this, so to speak, if you could address that concern, please.

Thank you.

REP. RITTER: Thank you for that concern. And I had heard discussion about shopping around. So I want to talk -- and I'm not perhaps the best qualified person in the room to talk specifically about the -- the training or the competencies or the responsibilities of the profession of physicians. But under this definition, it must be the physician who has primary responsibility for the medical care of the patient and treatment of that patient's terminal illness. Indicating, obviously, the primary responsibility would -- is the responsibility that would be complete as to the patient's condition.

Physicians are bound by their oath and profession to exercise responsibility for their patients and so -- can I tell you that there is no physician that might treat that differently? No, I can't tell you that, but I can tell you that with the full force of the law and as well as their professional ethics, it would be a physician that has the full and complete knowledge of the patient and indeed is responsible for their care. Does that help?

REP. MARONEY: Thank you.

REP. RITTER: Thank you.

SENATOR GERRATANA: Thank you, Representative.

Senator Kane has a follow-up question.

Please proceed, sir.

SENATOR KANE: I'm sorry, Madam Chair. Sometimes I'm slow to learn.

SENATOR GERRATANA: Quite alright.

SENATOR KANE: Line 22 says, “counseling means one or more consultations as necessary between a psychiatrist or a psychologist.” So I'm confused, I thought earlier you said, that's not necessary, the physician will make the determination but, yet, the language in the bill says that we need one or more consultations with a psychiatrist or a psychologist.

REP. RITTER: If that determination has not been clearly made.

SENATOR KANE: Where does it say that in the bill?

REP. RITTER: Oh, boy. I'll probably have to read the entire bill.

SENATOR KANE: That's okay. I won't (inaudible).

REP. RITTER: That's okay, and I -- and I will tell you that -- and Senator Welch had some questions about this, too, that, indeed, I would hope that the committee would take seriously the need where they find necessary to clarify the language around some of those points.

SENATOR KANE: Thank you. I appreciate that.

REP. RITTER: Absolutely.

SENATOR KANE: Thank you.

Thank you, Madam Chair, I won't hold up the committee any longer.

REP. RITTER: No -- thank you, Senator Kane.

SENATOR GERRATANA: Thank you, Senator Kane.

I know, I've been reading the bill also. If this bill does go forward, here in the committee, I have concerns about much of the language, as well as the definition of "attending physician" and the term that is used. I mean, there is -- there are many questions that I have also.

Are there any others from committee members?

If not, madam, thank you very much for -- oh, I'm sorry. Representative Sayers.

REP. SAYERS: Thank you.

And I -- you know, the first -- the scenario that you talked about early on about ALS, chances are that that particular patient probably would not have the ability to self-administer medications towards the end, so that even if they'd made that decision that would not be possible under this legislation. Would there be a requirement that anybody under this legislation have already, at least, had advanced directives in place?

REP. RITTER: I don't believe this bill sets that requirement, but there is no reason that the advanced directives could not already be in place.

REP. SAYERS: Because it certainly would make sense that they, at least, had looked at all those options and, at least, made those early decisions about advanced directives prior to making a decision about assisted suicide.

The other thing is is there anything in this legislation that would require them to be informed about other alternative options, such as hospice and palliative care?

REP. RITTER: Yes, there is, and I cannot at this exact moment give you the line numbers, but that also was a concern of mine, and it's here somewhere. And if it's not, Representative Sayers, I know you will talk to the committee chairman to make sure that it is because I agree with that concern. If this is being presented as a choice, then all choices should be presented as choices, absolutely.

REP. SAYERS: And I'm not so sure it should be presented as a choice. Certainly, if I was a nurse going out to do -- a visiting nurse and -- from a hospice agency, I certainly would not offer that option as a choice to somebody. And it's certainly not part of the hospice philosophy at all and so one of my concerns is if the person is involved in hospice or palliative care and they are reading -- receiving, say, home care services, that -- how would that fit into the scheme of assisted suicides because that is not really part of the hospice philosophy?

REP. RITTER: The bill clarifies that no healthcare provider or institution must comply with the patient's wish and that the patient advances what they intend to do, has the right to request all of the necessary information and help to find a healthcare provider or a situation where that would not be the case. So nobody is forced or required by law to partake in any of this unless they choose to also do so.

REP. SAYERS: So, that would get back to Representative Maroney's question about doctor shopping, and we know that that happens sometimes in cases, like, if someone's looking for pain medication, their -- they might find out who -- what doctors were more likely to give them a scrip without asking a lot of questions and hope that those are the doctors that end up losing their license, but we know that that happens in some cases. And so that is a fear that they would have -- they would doctor shop until they found a doctor that would be agreeable to this even if it wasn't.

And I will tell you one other thing with hospice. When Medicare came out with their hospice regulations, the regulations required that you only receive six months in -- of care, and the idea was that you had six months to die or else, and the federal government found that they had to change those regulations because what happened is hospice is a very specialized care, and it recognizes that people can no longer improve from their chronic conditions and lots of times what happens, as a result of the type of comfort measures that people receive from hospice, they actually improve to the point where they no longer need that hospice care, and they might have another period of time to live. So -- and do well -- so that they -- there is even regulations that allow for an extension of hospice.

But this, to me, sounds, like, so hopeless. You have to make a decision by yourself, all alone, with no one there to comfort you or offer you any help versus hospice where someone is there to hold your hand and when you do die -- and make sure that you have comfort -- and when you do die, they are there to support your family, as well, because hospice provides bereavement services for families up to a year afterwards. I mean, to me, this sounds like the worst possible thing you could do for a patient versus so many very good alternatives, and I really have a problem with it.

Thank you.

SENATOR GERRATANA: Thank you, madam.

I think we have finished asking questions? I ask that with a question mark and thank you for coming today and giving your testimony. We appreciate that very much.

At this point, we are going to --

REP SAYERS: Thank you, Madam Chair.

SENATOR GERRATANA: -- thank you -- we are going to go to the public, and then we'll get to you, Senator Meyer, I know you're waiting on deck there.

But first we will go to, I think it's Myra Rochow -- and I apologize, it's the handwriting here, I may not be reading clearly. This is on House Bill 6590, Myra Rochow. Mrs. Rochow may be in Room 2E, where we have overflow -- nope, she's here. Myra -- Ms. Rochow, am I saying that correctly?

MYRA ROCHOW: Rochow.

SENATOR GERRATANA: Well, I'll have you say it into the record. Thank you, madam.

MYRA ROCHOW: Okay. My name is Myra Rochow, and I am support of Bill 6590 because as a commissioner of the Quinnipiac Valley Health District, I was surprised to learn that the tattoo artists and all of the premises are not licensed by the State of Connecticut.

In going over information that I have read recently, I have found out that the State of Connecticut, also, has no guidelines for technicians to follow. In checking other States, such as Florida and California, et cetera, they have strict licensing guidelines for tattoo artists.

It does surprise me that I see so many young people today with tattoos and with all the different diseases that they could possibly get from tattooing, I cannot believe that our state does not consider protecting its citizens from the many diseases.

Please consider this important bill, Number 6590, to help protect our citizens. Thank you.

SENATOR GERRATANA: Thank you very much for your testimony, also.

Are there any questions?

If not, thank you for coming today.

MYRA ROCHOW: Thank you very much for hearing my (inaudible).

SENATOR GERRATANA: You're welcome.

Senator Meyer -- Meyer. Senator Meyer.

SENATOR MEYER: Thank you distinguished Chairs and members of the committee. I am here today in support of the compassionate aid and dying bill. I am a sponsor of it, and I wanted to tell you why I am sponsoring it.

This is a bill that's intended to have a great deal of safeguards, as Representative Ritter so well described. It is a bill that must have safeguards in order to be effective. Life is not to be taken without great determination and care. And this bill has many, many safeguards, as Representative Ritter described, to ensure that the decision that's being made by the patient is competent and informed. And indeed, the bill has a very strict definition of competent that I'm going to -- want to share with you. It says competent means in the opinion of the patient's attending physician, consulting physician, psychiatrist, psychologist or a court that the patient has the capacity to understand and acknowledge the nature and consequences of healthcare decisions including the benefits and disadvantages of treatment to make an informed decision.

It also says that the patient must make an informed decision and that is defined to mean an understanding and acknowledgment of the relevant facts after being fully informed by the attending physician of the patient's medical diagnosis and prognosis, the potential risks associated with self-administering the medication, and the probable result of taking the medication and the feasible alternatives and healthcare options available, including but not limited to palliative care.

So, when -- when I heard one of the witnesses this morning talk about patients being out of it and another witness talking about patients who are -- who are under the care of a conservator or a guardian, that's not this bill. That's not what this bill is about.

This -- this bill really applies to people who are fully competent and well informed as the definitions carefully do say. I think that as you consider this bill, you could never, you know, this is the first time this bill has been actually had a public hearing in Connecticut -- do consider further safeguards. Some of your questions indicate that you all are really well informed about this bill. There should be a waiting period, probably. We should add a waiting period in there.

The absence of having to have a consulting physician applies, the bill says, to a situation where the -- the disease is so advanced that -- that the attending physician doesn't feel that there really is time to bring in a consulting physician. I think that could be changed, as well. I think -- we could add the additional safeguard of always having a consulting physician, as well as the attending physician to be certifying to the fact that this person is mentally competent, making an informed decision and is terminally ill.

Those kind of safeguards make -- make a lot of sense. We've come a long way in the United States with respect to dignity in dying, you know. When most of us were younger, we didn't have healthcare proxies. We didn't have options that said no resuscitation, no special measures. You know, my wife just -- we talked about this just last night at dinner, she was reminding me, don't use any special measures if I am out of it, okay?

We are -- we have progressed in the United States and in Connecticut with respect to death by -- with dignity. And this bill is intended to be in that careful tradition so, thank you very much, and I wish you well.

SENATOR GERRATANA: Thank you, Senator.

Representative Sayers.

REP. SAYERS: Thank you.

Senator Meyer, instead of going to a doctor to get approved for this, what's the difference between going out and taking a whole bottle of Tylenol and maybe a little Jameson's and taking care of the job that way? Why do you need to involve someone else?

SENATOR MEYER: Because I don't think that most people understand how they can die in a merciful way. With Tylenol and Jameson's, I didn't know that until you just mentioned it.

REP. SAYERS: Tylenol is not an innocuous drug. I would not recommend more than 4 grams in 24 hours for anybody. And believe me, you will have problems as a result. Many people don't realize that and think of it as a very innocuous drug. And many times people that have an illness, any kind of a chronic illness,; are on multiple medications, any one of which could do the job without them ever getting a special prescription.

SENATOR MEYER: Well, this -- this bill is intended to bring about death with dignity in a very scientific medical professional manner. And, you know, not something that's self-prescribed you hope works and half works and you're in worse shape than you were when you went in -- when you took it.

REP. SAYERS: I guess my thing is that it's not dignified to be so hopeless, so hopeless and feeling that -- so uncaring situation that you need to take something to die. To me, that's not very dignified.

SENATOR MEYER: You know, the New Haven Register did an editorial recently, and the last sentence of that editorial is as follows: A death with dignity statute would be a gift for those who suffer terribly in Connecticut and want a humane way out." This bill does that.

REP. SAYERS: Senator, do you -- do you believe everything you read in the newspaper?

SENATOR GERRATANA: Are there any other questions?

Representative Srinivasan followed by Senator Welch.

REP. SRINIVASAN: Thank you, Madam Chair.

Thank you, Senator, and good afternoon to you.

SENATOR MEYER: Good evening, Doctor.

REP. SRINIVASAN: You know, you began by, to some extent, squelching some of our concerns that we had with the previous people that gave us the testimony. I'm glad you mentioned that -- that additional safeguards can be added because that I'm sure you have heard since we began discussing this bill what concerns that all of us had, you know, the waiting period, the need for the second opinion and never saying that one opinion is adequate. Those are all very important safeguards to make sure that no error ever happens.

But what is -- may be confusing to me and may be to some of my colleagues for my -- from the previous questions was around -- if you look at around line 11 and going forward, looking at "competent," it means in the opinion of the patient's physician, consulting physician, psychiatrist, and so on and so forth, but somehow -- and if you'd be kind enough to clarify for the -- this for us, we have -- we get the impression, at least, that the patient does not need to see all these people and if one physician says that you are competent and you are making this decision because you're competent and you're informed and that is enough. But somehow the language does not say that.

So I just want to get your feel as to who all should say that this person is competent enough to make this extremely, extremely important decision in their life?

SENATOR MEYER: Okay. Well, Representative, the decision, first, has to be made by the attending physician and the attending physician is described in the bill not as the primary care physician but as the physician primarily responsible for treatment of the illness -- of the terminal illness. So that would be -- that would be one person. The second is the consulting physician and, again, that's defined in the bill not -- not as someone who just has no particular knowledge of that terminal illness, but he has to have to have a specialty of knowledge and treatment of that kind of illness. The psychologist and psychiatrist comes into effect if one of those two physicians decides that -- that this patient is either depressed or has impaired judgment or has some kind of psychological or psychiatric condition as the bill describes it and, therefore, says, hey, this may not be a well-informed and competent decision by this patient, I want a psychiatric examination.

And that's why there's a -- I'm mentioning this -- in this particular definition of a psychiatrist or a psychologist because that kind of examination would be required if there's any question about the voluntary quality of the decision or whether or not the patient has impaired judgment.

REP. SRINIVASAN: Thank you, Senator.

And if I may, I have one more follow-up question, Madam Chair.

What I -- what I couldn't comprehend was when a second opinion is needed or the need for a psychologist or psychiatrist is needed and that at times can be circumvented because this patient is so ill, so terminally ill, that he or she does not have time. And I didn't understand this concept of not having time because if they did not have the time, they would not need this anyway because unfortunately, time would have taken care of in a natural way. So, I didn't understand this not have time to get this second opinion or the necessary safeguards.

SENATOR MEYER: What the bill says in section 7, paragraph (b), a patient may be found to be a qualified patient without examination confirmation by a consulting physician when the patient's attending physician reasonably determines that the patient's terminal illness is sufficiently advanced that confirmation is not necessary. I would strike that if you're going to work with this bill, and I would always bring in a second physician. Every safeguard is really important in this decision to end life. And, you know, we are stewards of our constituents, and I would favor always having that second opinion by an expert.

REP. SRINIVASAN: Thank you very much, Senator.

Thank you, Madam Chair.

SENATOR GERRATANA: Thank you, Senator Welch.

-- and followed by Senator Kane.

SENATOR WELCH: Thank you, Madam Chair.

I think -- Senator Meyer, first of all, very nice to see you.

You can tell I think that there's a bit of consternation about the term "competent" and what exactly that means. And as I read the bill, it almost sounds like competent means someone's competent when one of these individuals says he or she is competent and that's kind of where the definition ends so, I guess my first question to you would be what does it mean to be competent?

SENATOR MEYERS: Competent has got a long legal history, and it -- it starts off with meaning -- knowing well the difference between right and wrong. It then talks about court decisions defining competence; talk about your ability to analyze an issue; see both -- all sides of an issue and make a reasoned and responsible decision.

One of the references in the definition of competent is to a court. And that's because, ultimately, if -- if I was a dying patient and I wanted to have medication to end my life; and the doctor, one of these two doctors said, You're not competent to make that decision. I would have the opportunity under the law in Connecticut to take that to a court, and the court would make a finding that I was legally competent or legally incompetent.

SENATOR WELCH: So I -- I mean, I understand -- I understand the term "competent" in a legal setting. And unfortunately, I think if we're talking about this in a legal setting unless a doctor has went and gone through a court, we're actually now Monday morning quarterbacking a doctor's determination of competency, and -- which raises a whole host of issues, I think.

One of the -- one of the -- well, and I'm often surprised at knowing and understanding and appreciating the legal definition of competency, the people that are often deemed competent to stand trial or to make whatever decision they have to make so I still have great concern about what that means.

But even as I read the definition we have in here further, we talk about making an informed decision -- and I appreciate that informed decision is defined, albeit it's defined to a narrow universe as an understanding with respect to just this decision that they're making -- but it talks about communicating that decision, as well. And in the very end -- and we're talking about line 17, 18 right now -- the communication of the decision can be done by that patient, including communication through a person familiar with the patient's manner of communicating, which now, in my mind, creates a whole host of other questions, and if I may, through you, Madam Chair, just ask you, Senator Meyer, what does -- what does that mean, what is intended there?

I thought I heard Representative Ritter talk about, you know, kind of the assurances of somebody's capabilities when -- when they're making a decision and now we're talking about maybe somebody who has great difficulty communicating decisions and allowing somebody else to be that -- that proxy and interpret a communication.

Through you, Madam Chair.

SENATOR MEYER: Did that -- those words dealing with communicating through a person familiar with a patient's manner of communicating is taken directly from the Oregon statute. And I would just give it the plain meaning of the words and that is that someone's got to be communicating with the patient who speaks this patient's language. If the language is not English, whatever the other language is. Someone should be communicating with the patient who knows the -- knows the patient's sense of humor, if the patient is kidding about something, is serious about other things. You know, I think those are the kinds of things without hearing exactly what happened in Oregon when they -- when they drafted this and passed this, that those -- that's the plain meaning of the words.

SENATOR WELCH: Okay. Thank you.

Thank you, Madam Chair.

SENATOR GERRATANA: Senator Kane.

SENATOR KANE: Thank you, Madam Chair.

Thank you, Senator Meyer.

SENATOR MEYER: Thank you, Senator.

SENATOR KANE: Listen, no one gets my sense of humor so I'm in big trouble.

I just want to follow up on Representative Sayers' question about the necessity of the bill. And she, you know, made the reference of the Jameson and the Tylenol, and you said, well, this is, you know, we don't want to take a chance and have a person in worse shape than they were, if that's possible. But what is the drug that we're talking about in use of this bill?

SENATOR MEYER: I don't know what the drug is. I've been told it's potassium, in part, potassium, but I -- I don't know what the drug is.

SENATOR KANE: And is it 100 percent effective?

SENATOR MEYER: 100 percent effective.

SENATOR KANE: And the way it's written to be self-administered, is that because he physicians did not want to do this?

SENATOR MEYER: That was to ensure that a physician would not be ever accused of facilitating or aiding and abetting a murder.

SENATOR KANE: And the simplistic view of this for a second is -- is there, also, an insurance benefit for this at all?

SENATOR MEYER: No. The bill has a specific provision that insurance will not be a factor -- it cannot be a factor with respect to the implementation of this law.

SENATOR KANE: Thank you.

Thank you, Madam Chair.

SENATOR MEYER: It also has a provision -- I hope you all noticed that this is warning about safeguards -- that if somebody coerces the patient in deciding to take his or her life or uses undue influence, this bill says that person is guilty of murder. Okay. So this is a -- this is a tough bill, and we can make it even tougher. I'm just urging you to -- you have enormous responsibility with respect to this, and I -- I hope you will give it very careful consideration, make such amendments, and move it along so that both houses can -- can debate it.

SENATOR GERRATANA: Thank you, Senator Meyer. I'm sure we're --

SENATOR MEYER: Thank you, Senator Gerratana.

SENATOR GERRATANA: -- all -- all thinking about it.

SENATOR MEYER: Well, you're -- you're a remarkable committee. I don't think I've ever testified before you're -- you're what lawyers would call a hot bench so nice to be before you.

Thanks.

SENATOR GERRATANA: Thank you, sir.

From time to time, we do have people who request to go out of line to testify. Usually, it's people who have come into the state and have transportation needs or other needs so at this time, I'm going to recognize Mary-Ann Langton.

MARY-ANN LANGTON: Good afternoon.

SENATOR GERRATANA: Good afternoon, Mary-Ann.

MARY-ANN LANGTON: (Inaudible.)

TY LEWIS: She is going to have her assistant read what she wrote. Thank you.

SENATOR GERRATANA: Okay. Can you state her name into the record? Thank you -- and then your name also.

TY LEWIS: Okay. Hi, my name is -- (inaudible).

SENATOR GERRATANA: Yes, please sit down, be comfortable.

TY LEWIS: Okay. My name is Ty Lewis, and I'm a personal care assistant for Mary-Ann Langton. I will be reading her testimony today.

SENATOR GERRATANA: Thank you. Thank you.

TY LEWIS: No problem.

My name is Mary-Ann Langton, and I'm speaking on behalf of many friends with disabilities. I am very opposed to Bill 6645 because many people in the medical profession do not view people with disabilities as human beings. There is a notion from the medical field that we will be better off dead. When, in fact, people with disabilities have many abilities.

Some people with disabilities are able to work, live in a community and be active members of society. In addition, people who are elderly may see this bill as an easy way out when they are very capable of living when they -- but may need to change their lifestyles.

Please vote no to House Bill 6645. Thank you.

SENATOR GERRATANA: And thank you very much. Thank you.

Next is Meg McDermott.

Good afternoon. Are you Meg?

MEG MCDERMOTT: Yes, I am.

SENATOR GERRATANA: Okay, just let us know that.

MEG MCDERMOTT: (Inaudible.)

SENATOR GERRATANA: We really can't.

Maybe you could direct the microphone in her direction. Oh, thank you. Thank you.

MEG MCDERMOTT: Does that help?

SENATOR GERRATANA: Yes.

MEG MCDERMOTT: Okay, good. My name is Meg McDermott, and I am speaking today on behalf of the disability community, as well as the Developmental Disabilities Council.

Please do not support Bill Number 6645, AN ACT CONCERNING PHYSICIAN-ASSISTED SUICIDE.

I oppose this bill and live in Unionville, Connecticut, at 14 Bliss Road, and my phone number for -- my phone number for comments to you is -- is 860-404-2584.

Individuals with verbal, mental or physical disabilities should not have death forced upon them by doctors or family members. We all should be advised by a lawyer to have documentation written before our death that states refusal -- refusal of treatment and final desires because most people can make a choice regarding how their life ends.

A person who does not have the ability to make decisions for themselves should have someone assigned in writing to do so before their death. The use of these measures could and would eliminate physician-assisted suicide. Everyone can make choices with support. What we choose to do can be decided early. So, again, we all ask that you not support physician-assisted suicide. Thank you.

SENATOR GERRATANA: Thank you, ma'am.

Are there any questions?

If not, thank you for coming today and giving your testimony.

MEG MCDERMOTT: Thank you.

SENATOR GERRATANA: You're welcome.

Next is John Kelly followed by Representative Roberta Willis.

JOHN KELLY: Hi.

SENATOR GERRATANA: Hi. Hi, John. Just state your name for the record.

JOHN KELLY: My name is John Kelly.

SENATOR GERRATANA: John Kelly. Thank you.

JOHN KELLY: John Kelly, and I -- thank you very much for the opportunity to testify. My name is John Kelly. I am the director of Massachusetts Second Thoughts, people with disabilities opposing the legalization of assisted suicide. I also represent Not Dead Yet, the national disability rights group that has long opposed euthanasia and assisted suicide.

We were the progressive voice in Massachusetts that last November defeated the assisted-suicide ballot question that once had support as high has 68 percent. Our opposition is based in the universal principles of social justice that apply to everyone, whether disabled or not.

The name Second Thoughts comes from our finding that the more people learned about assisted suicide, the more they oppose it. And that's what happened in Massachusetts. We asked people to look deeper into HB 6645 and the real world -- real-world threats it, and all assisted suicide, legislation poses. It draws on bad science to create bad public health policy. This bill amounts to a government recommendation that sometimes death is the best treatment.

Innocent people will lose their lives as a result of this bill. First, because, as we all know, doctors make mistakes. Under this bill, a diagnosis can become deadly.

In a letter to the Boston Globe, Oregonian, Jeanette Hall wrote that she voted for assisted suicide and when she received her own terminal diagnosis asked for a suicide prescription. I didn't want to suffer, she wrote. Her doctor persuaded her to try more treatments. Now, more than 12 years later, she writes letters urging people not to make Oregon's mistake, that she is so happy to be alive.

Underlying the effort to pass this bill is an unwarranted faith in the accuracy of terminal diagnoses. Proponents use the word, "dying," with a gerund, to emphasize the imminent certainty of death, but many people with a terminal diagnosis are not yet dying. And doctors admit that they cannot predict when an individual will die. The disability community is full of people who have outlived their diagnoses by years. And then there is the example of longtime proponent of universal healthcare, Senator Ted Kennedy, who was diagnosed with aggressive brain cancer in 2008. His cancer certainly would qualify under this bill as sufficiently advanced such that a second opinion would not be necessary. His widow, Victoria, described his story in a powerful opinion piece that many believed sealed defeat for the Massachusetts' referendum.

When my husband was first diagnosed with cancer, she wrote, he was told that he only had two to four months to live, that he would never get back to the U.S. Senate, that he should get his affairs in order, kiss his wife, love his family and get ready to die. It's that prognosis, like so many prognoses, was wrong. Teddy lived 15 more productive months.

Under this bill, someone in Connecticut receiving a similar diagnosis could be dead within days, based on the tragically mistaken, but government-endorsed belief that death was agonizingly imminent. Legalized assisted suicide, Vicki Kennedy wrote, turns Kennedy's vision of health care for all of us on its head by asking us to endorse patient suicide, not patient care, as our public policy for dealing with pain and the financial burdens at the end of life.

In this age of induced austerity, the media is full of stories of the expense of people's last year of medical care, while hospitals lose money and try to reorganize.

SENATOR GERRATANA: Thank you, Mr. Kelly. Could you summarize for us please.

JOHN KELLY: Sure.

People in Oregon were denied treatment but offered assisted suicide. People with depression and a history of suicide attempts are easily able to get the medication prescription. Out in Oregon, almost no one is referred for a psychiatric consultation. Doctors are not able to judge competence, depression, and they also cannot tell what kinds of influences are being exerted upon the person. And then, worst of all, this bill because it has no witness requirement when the death takes place, the stipulation that a person self administer is merely a recommendation. There were 3800 cases of elder abuse reported a few years ago in Connecticut. This bill is a ticket for murder. And because of the falsification of the death certificate, it will be impossible to investigate. There's no reporting; there's no gathering of information; nothing is heard from doctors who say no; people will be able to doctor shop. This is a terrible idea, bad social policy.

Please protect the vulnerable people in the State of Connecticut.

SENATOR GERRATANA: Thank you, Mr. Kelly. We appreciate your testimony.

Does anyone have any questions of Mr. Kelly?

Please hold your applause. Thank you.

Senator Welch.

SENATOR WELCH: Excuse me, Mr. Kelly.

SENATOR GERRATANA: Mr. Kelly, Senator Welch has a question for you, if you please.

SENATOR WELCH: I know they were clapping for you but it was a bit premature because I had my question.

SENATOR GERRATANA: That's why I asked people not to do that. Thank you.

SENATOR WELCH: I believe, Mr. Kelly, you probably heard some testimony earlier today that persons with -- with disabilities often, kind of, come in and out of terminal diagnoses and also often have ups and downs emotionally, kind of, coming in and out of depressions at times. And just with your experience in the community, I'm wondering if you -- other than the Senator Kennedy story that you told -- if you have actual examples of that or could maybe help us understand a little bit what are the diagnoses that they're coming in and out of?

JOHN KELLY: Well, one of the members in Massachusetts, John Morton, he received a diagnosis of ALS and was given a terminal diagnosis at the age of 19, and he said that were assisted suicide legal, there would have been no doubt that he would have taken advantage of it, and he's alive 55 years later. And I know quite a few people who have been given terminal diagnoses and still are alive. There are advances in health care that can change things, and doctors really just cannot predict.

And when people with disabilities come into the healthcare system, we get very nervous because doctors and hospitals are always trying to make sure that we have a DNR and encourage us to refuse treatment, and it's already a system where value judgments are being made. Adding this bill is like gasoline to a fire.

SENATOR GERRATANA: Thank you, sir. I think you can go now. Thank you, Mr. Kelly.

Next is Representative Roberta Willis, and she will be followed by Leslie Balch.

REP. WILLIS: Good afternoon. Nice to see all of you.

SENATOR GERRATANA: Good afternoon, madam.

REP. WILLIS: You are certainly taking on some difficult issues, tough decisions to make, but I really do applaud you for having this conversation on this issue.

I'm here to speak on a different matter so you can catch your breath a little bit.

Senator Gerratana, Representative Johnson, Representative Welch and Representative Srinivasan, thank you for considering House Bill 6391, AN ACT CONCERING THE PRACTICE OF ADVANCED PRACTICE REGISTERED NURSES.

For the record, I'm State Representative Roberta Willis. I represent the 64th District.

Connecticut residents already have experience difficulty in gaining access to care. In Torrington, we have lost ten primary care physicians in the last six years. The Affordable Care Act will also -- will provide access to approximately 400,000 additional Connecticut residents. Our state has been in the forefront of preparation for this influx.

As chair of the Higher Education Employment Advancement Committee, our committee is keenly aware of the challenge we face in Connecticut in finding a workforce to care for all these newly insured patients, particularly, primary care physicians. APRNs are well trained to provide such level of care to meet patients' primary care needs. Over the past several years, our committee has tried to address the shortage of primary care doctors through loan forgiveness programs, for medical students' training to be primary care -- that's -- the problem has been funding, that we lack the funding for those incentive programs that certainly would be worthy of funding if we could do it.

Studies have found fiscal benefits to nurse practitioner care and significant savings for state budgets in states that use nurse practitioners to their fullest potential. In 2010, the Florida legislature publish a report by the Office of Program Policy Analysis and Government Accountability, with the estimates of potential cost savings from using APRNs and PAs scope of practice range from saving from 7 million to 44 million annually for Medicaid. And that increases amounts also with state employees' health insurance and 400 million in Florida alone, across the healthcare system.

Recently the Federal Trade Commission provided comments on the impact of this bill, House Bill 6391. Their comments were, in part, of an ongoing effort to promote competition in the healthcare sector which benefits through lower cost and better care. According to the FTC, by eliminating the requirements that APRNs have agreements with physicians in order to practice independently, it could benefit healthcare consumers by expanding their choices, containing costs and improving access to primary healthcare services.

I want to thank you for considering this bill, and I look forward to working with you, and I also want to acknowledge Theresa Conway who's really taken quite a leadership role in this so thank you very much.

SENATOR GERRATANA: Thank you, Representative Willis. Thank you for testifying here today on this bill.

Does anyone -- Senator Welch.

SENATOR WELCH: Thank you, Madam Chair.

I get a little confused about the information that's out, Representative Willis. And I don't know, you might not be the right person to ask -- okay. Then I'll probably save my questions for somebody else on this (inaudible).

REP. WILLIS: Okay. Certainly, someone in the field because that's the technical scope of practice that is above my scope of practice.

SENATOR WELCH: Right.

REP. WILLIS: Thank you.

SENATOR GERRATANA: Thank you.

Representative Srinivasan.

Hold on.

REP. SRINIVASAN: Thank you, Madam Chair.

Thank you, Representative Willis, for being here and testifying in front of us today. We appreciate that.

It is my understanding that we have given this -- to the Department of Public Health in the scope of practice and that was -- it was under the purview to review the relationship of a practice between a physician and an APRN and then get back to us as to what their recommendations are.

Did that scope of practice happen and is that their recommendation that this collaboration is not needed? Could you enlighten this committee?

REP. WILLIS: I can't speak to what the Department is doing, and I was not aware of their investigation of this issue, so thank you for alerting me to it, but I don't have the answer to your question.

REP. SRINIVASAN: And if I can have a follow-up question, as -- I'm not sure as you said earlier that you're not technical person to answer this and maybe we should wait, but in case you're aware of this, I would appreciate an answer, if possible, this collaboration that exists between the physician and the APRNs -- and I support you 100 percent, APRNs are phenomenal people in delivering care because they give excellent care to our patients, and it is a team, it is a team, physicians, APRNs, PAs and everybody else that make sure that we have a healthier Connecticut, and I could not agree with you more on that.

But having said, the -- the APRNs in this collaborative agreement that they have with the -- with the physician, are they encountering difficulties in maintaining that relationship, this collaborative treatment, that something else needs to be done or if things are working between the two of them -- which is my understanding it is -- I'm not sure the need to separate out that collaborative agreement. As I said in case you were aware of this or maybe we should save it for somebody else.

REP. WILLIS: Well, I think someone else could probably answer better but I -- I certainly can speak to the issue of -- in places that have, you know, we're talking about -- and again, going back to my role as chair of Higher Education, we know that we have a shortage of primary care physicians today. And it's only going to become more acute, and what I was trying to point out is although we've been looking at remedies on our committee, we have not been able to find one that wouldn't be costly to the state of Connecticut to implement. That being said, I am aware in other places that have gone this way that they've been able to -- APRNs set up their own practices and deliver health care more readily to a greater number of people. Doctor practices -- and you probably could speak to this more than I could -- my impression is that they maybe take on one or two in a practice but they don't have a full complement of staff. And I know there are young people in the state of Connecticut who are APRNs that would probably be interested in establishing their own business and expanding it, so I -- I think it's a wonderful opportunity.

Again, the other issue I would point to is in Torrington, for instance, we have an FQHC, a federally qualified health center, we need, you know, getting a primary doc in there has been a challenge, and we really could use APRNs in there functioning independently. So that's my own personal experience with it, and I really don't -- can't speak to anything beyond that.

REP. SRINIVASAN: Thank you, Representative. I appreciate those answers.

Thank you, Madam Chair.

SENATOR GERRATANA: Certainly.

Anyone else have a question?

Representation Sayers.

REP. SAYERS: Thank you. Thank you, Representative.

REP. WILLIS: This is not fair. You get all these experts on this committee.

REP. SAYERS: One of the points that Dr. Srinivasan made and I think needs clarification is that he talked about PAs and APRNs, and the statutes really differentiate in that PAs practice under the direct supervision -- under direct supervision from the physician, and they have to be in communication with that physician at all times, whether it be by telephone or within the office building, next door, that they cannot ever be out there on their own.

But the collaborative practice is an agreement and there is no supervision. It does not require any supervision of the APRN and so that's a very different -- and a couple times when people spoke about this legislation they talked about them both as if they were equal and that's not true. We're talking seven years worth of education versus two. So I think that it's important that be clarified so I'm not going to put you on the spot.

REP. WILLIS: No, no, I realize that and, actually, I have a child who's a -- daughter who is an APRN so I'm aware of the seven years. Thank you.

SENATOR GERRATANA: Roberta, I'm sorry, Representative Willis, we will not let you go. You have to sit in that chair.

REP. WILLIS: I have that effect on people where they don't want me to leave (inaudible).

SENATOR GERRATANA: I think, was it just you, Representative Srinivasan, who had a question for her again?

REP. SRINIVASAN: Right.

SENATOR GERRATANA: Okay. Please proceed.

REP. SRINIVASAN: Thank you, Madam Chair.

Thank you, Representative. I do appreciate Representative Sayers', you know, clarification, which is very important, very critical for us -- all of us to know that the difference in terms of training and who needs to be under the umbrella of a healthcare giver on a constant -- consistence basis as opposed to someone else who can be a standalone and then have a collaborative agreement. I do appreciate the clarification.

What I was doing, perhaps, misinterpreted to an extent, was thanking all the caregivers in a -- from PAs to physicians to APRNs for the excellent, excellent care that they take of all of our -- our people in Connecticut so that we have a healthier Connecticut. I was thanking them and not combining all of them, you know, thinking that they all had the same training. I just wanted to clarify that to you. Thank you.

REP. WILLIS: Thank you and good luck with your deliberations.

SENATOR GERRATANA: I think you can go now.

Thank you, Representative.

Next is Leslie Balch, followed by Vicki Veltri.

LESLIE BALCH: Madam Chair, members of the committee, good afternoon. My name is Leslie Balch, and I'm the director of health for the Quinnipiac Valley Health District, serving Bethany, Hamden, North Haven and Woodbridge. And I am here to support Raised Bill 6590, AN ACT CONCERNING LICENSING OF TATTOO TECHINICIANS.

The popularity and frequency of tattooing has grown significantly over the years. According to a 2012 Harris Poll, about one in every five adults has a tattoo. That's a 7 percent increase since 2008. With this popularity and with this increase, there's a greater chance of seeing more infection and more disease.

Body art is now sought by every age, every occupation and every social class. It's no longer the backroom or the back alley or only in prisons. My own daughter flirted with the idea of getting a tattoo but became very hesitant and concerned when I told her, in Connecticut, the artists are not licensed and, in fact, there is no standardized oversight for the establishment, practice or the operations. The only guidance I had to give her was, carefully choose based on what you see.

The procedure of tattooing involves multiple skin pricks with an intra-dermal injection of a non-FDA approved coloring agent. This poses the health risk of transmission of viruses and blood-borne pathogens, such as HIV, hepatitis B, hepatitis C. It also poses the -- excuse me -- the potential transmission of bacterial infections of the skin, perhaps, of MRSA. We all heard about MRSA, and also the potential of allergies, which oftentimes would require emergency response in the establishment. Such risks carry an economic burden, not only for those affected, not only for those with pain and suffering, but society as a whole.

The cost associated with disease investigation, disease containment and treatment also has to be considered as a cost. The reason --

SENATOR GERRATANA: Ms. Balch, could you summarize for us, please.

LESLIE BALCH: Sure.

The education awareness for tattooing, which is addressed in this bill, has the potential to make the business safer, disease and the cost of disease less and the peace of mind for customers. I support this bill. Myself and my local colleagues will be more than happy to help the State Department of Health come up with the standards based on things that are there because we do believe that prevention saves money.

SENATOR GERRATANA: Thank you.

The Department of Public Health did testify in writing on this bill, and they believe it needs to go through -- if we're going to license tattoo artists -- at least it's their suggestion -- that it goes through the scope of practice review. So I would urge you and your colleagues to put a request into the Department. The process starts in August, and you can go to their web site and see what the procedure is.

LESLIE BALCH: Thank you.

SENATOR GERRATANA: So I appreciate that, just wanted to let people know who are testifying on this that they did request that. Thank you, ma'am.

Any questions? Senator Welch.

SENATOR WELCH: Thank you, Madam Chair.

A simple question, as a health district, do you have any authority whatsoever to either inspect or go in or have any say with respect to any of these?

LESLIE BALCH: Actually, at the present time, the current laws do not exclude it. And at my health district, we do have three shops. We do go in, we do inspect. That's how I became aware of the fact that we were dealing with other than sanitary issues and medical issues that have -- my environmental health professional staff did not have the qualifications to review.

SENATOR WELCH: And, if I may, through you, Madam President, if you could just quickly describe, you know, what is entailed with that kind of inspection and then, you know, what remedies you feel are currently available to you if somebody is out of spec?

LESLIE BALCH: I -- well, first of all, there are very little remedies. It is very inconsistent across the state. We can't pull a license. We -- which we wouldn't because we don't have that medical knowledge. We can tell them that they can't get our certificate, but there's really no law that can tells me I can close them. What that inspection entails, from my point of view at this point, is the sanitary inspection. Do they have the right autoclave equipment for sterilization? Is it clean? Are the surfaces cleanable? We don't deal with the blood-borne pathogens or OSHA standards. We do not deal with, are they causing infection. We don't deal with the equipment and how deep does the -- does the needle go deeper than the intra-dermal? Are they doing scarring? We don't have that knowledge.

I'm more than willing to educate my staff in order to protect our community. But if I feel if I need to educate my staff to be -- excuse me -- to be tattoo artists, all but the artist part, because that I can't teach, that we should have education awareness for the artists themselves.

REP. JOHNSON: Are there -- Representative Srinivasan.

REP. SRINIVASAN: Thank you, Madam Chair.

Thank you very much for your testimony.

Could you enlighten us as to this is needed or required in how many states in our country?

LESLIE BALCH: I think that's a very interesting question, and I wish I could give you a number. What I do know from reviewing the literature is that recently Florida has done it, New York had done it, DC is looking at it. There are some Midwestern states that have certification, which is another word for licensure, different categories. I do know that California has it; Hawaii has it. It's new. Since we've seen this increase, it's just happening.

I've also had the opportunity to review the national organizations of the tattoo artists and they are not opposed to it if it's not totally crippling and restricting because those that are good and reputable want to keep others reputable. So I can't give you a number, but I know there's more and more every day. And it's been increasing. Interestingly, I think Virginia and a couple of Midwestern states were far ahead of the two coasts, for a change.

REP. SRINIVASAN: Thank you. Appreciate it.

LESLIE BALCH: Thank you.

REP. SRINIVASAN: Thank you, Madam Chair.

REP. JOHNSON: Thank you.

Are there any additional questions?

Thank you so much for taking the time and for your testimony today.

LESLIE BALCH: Thank you.

REP. JOHNSON: The next person on my list is Vicki Veltri.

Welcome, and please state your name for the record and please proceed.

VICKI VELTRI: Thank you. I'm Vicki Veltri. I'm the State Healthcare Advocate. I'm very happy to be here today, and I'm also here to testify on a different bill. I'm here to comment on HB 6588, which is an Act Concerning Expiration of Certain Healthcare Provider Contracts.

The requirement that consumers receive notice of impending contract termination between hospital organizations and insurers really does enhance consumer protections. You know, it provides timely notice that the treating providers may no longer be in an insurer's network once the contract expires.

Right now Connecticut law requires that insurers notify consumers at least 30 days prior to the termination of a contract between an insurer and an in-network provider. However, nearly 60 percent of our state's residents are insured by plans that are not regulated by the State of Connecticut. They're covered by plans that are regulated by the federal government or otherwise in other plans that the state cannot reach through its current law. The variation in the notice requirements can leave consumers really struggling to find alternate in-network services and, essentially, be stuck paying while they wait for appointments with new in-network providers.

So what we ask for or what we hope would be in this bill is really a requirement that the hospitals who treat these patients that are, let's say, patients of an out-of-state insurance plan that contracts with an in-state insurance plan to administer the plan, notify the patient of (inaudible) that they've treated in that hospital, which they can identify of the expiration of a contract.

And I'll give you an example of why it's important, in the last few years, as you know there have been more and more disputes between hospitals and carriers about their contracts. And it's not always certain that a contract will resolve itself when the parties are trying to negotiate. In one scenario last year, providers -- or a hospital and a health insurance organization here in Connecticut were out of contract for about three to four months, and many of the people that were affected by that contract dispute had insurance plans that were, let's say, BlueCross-BlueShield of Minnesota or BlueCross-BlueShield of Georgia, and they're not state-regulated plans, but they were administered by the home plan here in Connecticut, and those people never had notice that they were no longer in-network. And so suddenly they were frantically running around trying to provide or find an in-network care provider. So that's one part of this bill.

The other part of this bill would require the carriers to, essentially, recertify their network as being adequate if that hospital now is removed from the network. And the reason that is important, from our perspective, is there are more and more hospitals that exist, many of them have provider organizations tied to them, and if the hospital goes out of contract, the providers are also out of contract. And now that there are more hospital systems that have bought up other hospitals, the impact to a consumer can be really drastic. So what we think should happen is that a carrier should have to, essentially, say to verify to the insurance commissioner, again, that their network is indeed adequate if this provider network leaves the system.

We think that's an important consumer protection, and, frankly, every carrier who has a contract with the consumers, part of the contract is that your network is adequate. So, what we would suggest is some substitute language for the bill because the bill as written actually puts a requirement on hospitals and the hospitals really should not bear and really can't bear. So, we have suggested some language in our testimony, but the bottom line is we would like to see some more protection for the consumers when these disputes take place.

REP. JOHNSON: Thank you so much for analyzing the situation and providing the committee with this testimony.

Just going back to your example, with the out-of-state insurer having an in-state insurer that they're working through, is there a way for us to regulate that relationship?

VICKI VELTRI: No. We can't -- we can't regulate the insurance relationship or the health plan relationship in the state. And the reason for that is that those -- the governing law is a federal law called ERISA law and that preempts the state's ability to regulate those kind of plans. The state, however, obviously, has jurisdiction over the hospital side in terms of just providing notices to their patients. Many hospitals do, not everybody does, but there is no notice requirement currently in law, so we just think it's a fair thing to ask the providers to do.

REP. JOHNSON: So the out-of-state plans are only ERISA plans?

VICKI VELTRI: Most of the plans are ERISA plans, yes.

So -- and what often happens is they -- they're not always, but most of the time they're ERISA plans and if they are out-of-state plans that the State does not regulate, then the State has no jurisdiction anyway. But what often happens is you'll have -- you could have a large employer, for instance, or a -- that is self-insured, we can't reach those, period, because those are regulated by ERISA.

You may also have an employer that has a plan that's an out-of-state plan, but they just agree because carriers often act as administrators, they agreed to use the carrier in state to help them out. But if the carrier in state goes out of contract, then the people that would use that network are also now out of contract.

REP. JOHNSON: Very good.

Are there any questions?

Senator Welch and then followed by Representative Srinivasan.

SENATOR WELCH: Thank you, Madam Chair.

Thank you, Ms. Veltri, for your testimony. I -- I'm doing this a little bit on the fly because I wasn't aware of the alternative language that you're proposing but -- so, right now under my personal healthcare situation, if my health -- my insurance company is about to run out of time on a contract with a provider, they typically send me a letter. So, in my understanding that not every insurance is -- is doing that and that is really the genesis of the problem?

VICKI VELTRI: That is correct. That is correct.

SENATOR WELCH: Okay. And, the original bill would then have put a burden on hospitals to send letters to their patients that their insurance contracts about -- with the hospital is about to end, but you're suggesting that that is not the appropriate remedy?

VICKI VELTRI: Well, what we're suggesting is an in-between remedy which would be -- yeah, the hospitals would send a notice because they -- they do know their patients and they know their patients plans, and we know that from our work with the hospitals on some of these disputes. What they should not be doing and they cannot do is provide particular information about a member's insurance options where they could otherwise get in-network care. And the problem with the bill, as worded, was it would put a burden on the hospitals that if you really could not assume practically speaking. That burden really belongs to the carrier and the carriers do have already that burden in state law for the state plans.

SENATOR WELCH: And -- and so does the carrier -- excuse me -- who then in this bill -- let me back up even further, so that's great if you're a patient of a hospital, but you might be a past patient or never have been a patient. How is that individual then notified? Does this legislation address that at all?

VICKI VELTRI: This legislation, no. It would not get -- reach that far. What we tried to do was reach -- do the best we could. With the alternative language we're proposing is to reach as many people as we think we can. Of -- it will not affect a person who has not gone to that hospital except for a person who is covered by a state-regulated plan, because even if you've never gone to that hospital, you should get a notice from the carrier for a plan that's regulated by the State of Connecticut.

SENATOR WELCH: So then I guess and there's, obviously, I am sure a reason for that. I'm curious as to what it is. My mind says to me that if out-of-state plans have in-state surrogates for the administration of in-state care, ought not those in-state surrogates be subject to state regulation, and then ought not we just say to the in-state surrogates, it's your burden, it's your duty to get this information out?

VICKI VELTRI: Yeah. And I think the -- the problem with that is -- and I hear you completely -- but I think part of the problem is the ERISA preemption. And there is preemption around anything that relates to the benefit plan.

We have limited jurisdiction over third-party administrator here in Connecticut. I know there -- I think the -- there was some discussion with the Insurance Department, I have -- I would have to go back and talk to the Insurance Department about that, but I suspect that we can't reach those people, and that was one of the reasons for this option. It's that we can't reach -- we can't reach the out-of-state employers, obviously, we have no jurisdiction over them, but also that we -- we can't get inside of the benefit plan and how it works because of ERISA.

SENATOR WELCH: And if I may, through you, Madam Chair, just a request, if you could chase that down for me that would be very helpful.

VICKI VELTRI: Yes, happy to do that.

SENATOR WELCH: Thank you.

REP. JOHNSON: Thank you.

Representative Srinivasan.

REP. SRINIVASAN: Thank you, Madam Chair.

Thank you very much for your testimony this afternoon, and thank you for all that you do on behalf of patient advocacy. I know you're the voice. You represent them and we are very, very appreciative of all your hard work.

VICKI VELTRI: Thank you so much.

REP. SRINIVASAN: Expanding on what Senator Welch just asked of you, if you could just clarify my mind. If the person has not been to the hospital at all and, therefore, is not on their roster on their list, this termination of an agreement would then apply to the hospital services only, may not apply to outpatient services because that contract for the individual provider has a physician in an outpatient setting may still be in place; is that a scenario that can happen?

VICKI VELTRI: Yes, theoretically. So, there -- there are, obviously, providers who terminate their contracts, let's say, with a carrier. There are requirements on those providers to give notice, too. The reason I think the bill goes to hospitals is because, obviously, the volume is a lot larger and there are many, many hospitals now who have provider organizations tied to them. So the provider isn't independently practicing anymore. They're now an employee of the hospital. So -- so it reaches those groups. It would not reach the single provider out there on their own.

REP. SRINIVASAN: Thank you. And you're so right. A single provider pretty soon is going to be a thing of the past and -- and we will only see hospital providers. You're very, very right on the target there.

And, through you, Madam Chair, just for clarification, if the -- when the negotiations break down between a provider, I mean, between the insurance company, obviously, out-of-state, in this case, and the hospital, and in the interim period where they don't have adequate depth in terms of the various specialties and subspecialties that they need to cover, how would that be addressed through -- through this particular bill or through other -- some other format?

VICKI VELTRI: So one of -- one of the things this bill would do under our suggested language is to require a carrier to recertify or to prove that without that hospital that its network is indeed adequate.

So what happens now is, under our state law, a carrier has to -- its network adequacy is proven by its accreditation through NCQA or URAP, which are two accrediting organizations that are used quite often, nationally here in Connecticut. What -- what that accreditation essentially means is that you've developed standards to determine your network adequacy. So you have geographic distance to providers, time -- a time limit on how long a person must wait to get access to care. What it does not do is go into the network and ensure that the network is adequately functioning as it's supposed to. So, what happens in reality is if one of these situations happens, you are arguing to the carrier. What we did on behalf of a lot of people is, look, you can't -- it's not reasonable to make somebody drive 75 miles every day to get their child care. That's just not adequate. But I don't -- without seeing their network adequacy standards, it's hard to determine whether those -- they are meeting their standards or not.

I will tell you when the exchange rolls out in 2014, Access Health Connecticut, the Health Insurance Exchange, the carriers will have to disclose those network adequacy standards, so those are what you use, kind of, to make your argument about whether the network is still adequate. So, I would say -- so whatever hospital it is is now out of contract. The nearest provider looks like it's 30 miles away, your adequacy standards say that a provider must be within 15 miles; therefore, it's unreasonable and you must pay the provider here as if in-network. You can't make somebody pay out-of-network rates. So that's kind of how it would work in practice.

REP. SRINIVASAN: Thank you very much. You definitely clarified a lot of things, especially in contract, out of contract, when those negotiations, you know, are -- don't continue and then, you know, the patients, unfortunately, are left in a limbo because, as you said, the waiting time increases or the travel time increases enormously.

Thank you, thank you very much.

Thank you, Madam Chair.

REP. JOHNSON: Thank you.

Are there any additional questions?

Thank you so much for your testimony and your good work.

VICKI VELTRI: Thank you.

REP. JOHNSON: Thank you.

The next person I have on the list is Walter Rochow.

Welcome and please state your name for the record and then proceed.

WALTER ROCHOW: Yes, my name is Walter Rochow, and it's spelled R-o-c-h-o-w. You heard it earlier from my wife, Myra -- and I live in the snow capital of the state, Hamden. I want to support Bill Number 6590, the tattooing bill and I'll be very brief.

They are using needles to puncture the skin, something, heretofore, reserved for licensed professionals, such as physicians, nurses, and others in the medical field such as phlebotomists. Licenses are issued for occupations as benign as barbers, glass installers, court reporters -- which I am a licensed court reporter in Connecticut -- and interior designers. My wife has a license through the state so you don't get a green carpet instead of a red one.

The failure of a tattoo artist to be scrupulously sanitary -- and I want to emphasize those two words -- scrupulous sanitary, can have devastating effects on the person who has been tattooed. And you heard about that from Dr. Balch.

The other thing that I feel is important is we require people in any occupation where food is served to thoroughly wash their hands after using a bathroom facility because we are aware that deadly infections can occur if that is not complied with.

I believe a bill such as this should be passed because of the many reasons that you have heard.

And I want to thank the representatives and senators for their time here this morning on a bill that I, as a layman, think is very important to be passed to have some control over what is going on in the tattooing field today.

REP. JOHNSON: Thank you for your time and well-timed remarks.

Are there any questions?

Thank you so much for taking the time.

WALTER ROCHOW: Thank you for your courtesy.

REP. JOHNSON: The next person on my list is Andy Condon. Andy Condon here? From the Department of Labor.

Okay. Moving along, Barbara Wolf followed by Abby Beale on House Bill 6592.

Welcome and please state your name for the record and then proceed.

BARBARA WOLF: Good morning, Representative Johnson, members of the committee. I'm Barbara Wolf, I'm from Farmington, Connecticut. And I am here today to represent Homeopathy for Connecticut. It's a diverse group of people who are asking you to improve access to homeopathy by allowing nationally certified classical homeopaths, those who have achieved the highest standard of homeopathic education and training, to practice in Connecticut.

Homeopathy for Connecticut supports House Bill 6592, and we thank you for raising the bill. However, we respectfully request a language change. We believe that the good intent of this legislation will be best achieved through statutory recognition of the profession rather than state certification. Our goal is to provide recognition of professional homeopaths, who are certified by the national Council for Homeopathic Certification, allowing them to practice in the state.

A required disclosure statement to clients will make clear that certified classical homeopaths are not doctors. They do not practice medicine, and a physician should be consulted for medical evaluations and check-ups. Proposed substitute language is attached to my testimony.

The practice of homeopathy is restricted in Connecticut. Ours is only one of three states -- the others being Arizona and Nevada -- that require a license to practice homeopathy, and only medical doctors may apply for this license. This is a result of a law enacted in 1893, which is 120 years ago, and no longer reflects contemporary practice.

In contrast, the vast majority of homeopaths in the United States are not medical doctors. The remaining 47 states, homeopaths are not regulated and consumers may freely consult with both certified and uncertified practitioners. The issue here is that well trained and nationally certified professional homeopaths are not allowed to practice in Connecticut.

Currently there are only nine licensed homeopathic medical doctors in the state and most practice homeopathy on a limited basis, if at all. As a result, homeopathic care is often sought in our neighboring states and certified classical homeopaths leave the state to practice their profession.

Homeopathy is a very safe system of natural health care that gently stimulates the body's innate ability to heal itself. Homeopathic remedies, regulated by the FDA, are sold over the counter and anyone is free to purchase and use them. The national Council for Homeopathic Certification sets proficiency standards and certifies professional homeopaths in the U.S. and it's a rigorous process and we have attached those to our -- our testimony, as well.

So we urge you to support Raised Bill 6592 with our proposed substitute language. This is also a no-cost proposal for the state. Thank you.

REP. JOHNSON: Thank you.

Thank you for your testimony.

Are there any questions?

Yes, yes, Representative Demicco.

REP. DEMICCO: Just -- yes. Thank you -- thank you, Madam Chair.

I just wanted to say to my constituent, Barbara, welcome.

BARBARA WOLF: Thank you.

REP. DEMICCO: Thank you for your testimony, and I -- I was just wondering if you would like to take the opportunity to expand a little bit on the reason for the language change that you've proposed in order to educate me a little more and also the members of the committee.

BARBARA WOLF: The -- well, first of all, the language change -- the bill, as written, seemed to be both a recognition bill and a certification bill. And so to clarify that, we were proposing a recognition bill. And one of the reasons why we feel that recognition is a good way to go is that homeopathy is not a medical practice. It is very, very safe. In fact, you'll -- you'll be hearing Raised Bill 6644 from the Department of Public Health, and in section 44 there they -- they are proposing that the Medical Examining Board for physicians -- homeopathic physicians be eliminated, and that's because there's really no claims that go before them in. I don't know maybe ten years, more years, and as far as I know there have been no claims of harm before them.

Homeopathy is a very, very safe healthcare modality. And -- and -- so, I'll stop that with that.

REP. DEMICCO: Thank you, very much.

REP. JOHNSON: Representative Srinivasan followed by Representative Klarides.

REP. SRINIVASAN: Thank you, Madam Chair.

Thank you very much for your testimony. If I understood you clearly, there are nine people in our state who are -- who are practicing homeopathy with a license. Is that what you say about the nine -- are those -- are those nine each and every one of them an MD, as well?

BARBARA WOLF: Connecticut licenses homeopathic physicians, and you have to have a prerequisite is you have to have a MD license and then you -- then you have to qualify as a homeopath, as well.

REP. SRINIVASAN: Sorry for interrupting, but they need to have what?

BARBARA WOLF: To be a homeopathic physician, the prerequisite is to be an MD, and then you have to then have the qualifications to be a homeopath, as well, and so, this is, you know, 120 years of law passed, and there are nine practicing in the state, and most -- most of them are either practicing, sort of, tangentially or not at all. The -- the other people practicing homeopathy in Connecticut -- naturopaths and their scope of practice may do it, not many do, but they may and they may not call themselves homeopaths. So, you have a few practices, very, very limited.

And, you know -- and if I could also say that physician homeopaths are required only to have 120 hours of education and training. And a classical homeopath, certified classical homeopath, is required to have almost 1000.

REP. SRINIVASAN: Thank you for that clarification. So the -- so the -- the request is that the people who also have, obviously, more than adequate training in homeopathy be listed by the state so that people -- patients can have access to them and these providers do not have necessarily be MDs?

BARBARA WOLF: Correct. And -- and if only -- it's confusing in Connecticut because we have this licensing law. Really, in most other states, they aren't even regulated and if we did not have this licensing law from so long ago, it would not be an issue. So people who have gotten board certification, which is really the highest standard of this profession, we are -- we are in Connecticut proposing a very high bar, higher really than most states because we are saying "certified." But it gets lost in the -- in the fact that because we license physicians to do this that people think that you need a medical license to do this.

REP. SRINIVASAN: And finally, Madam Chair, so if I understand it in our neighboring states or other states where the homeopath can practice, what they have is a certificate from the -- from the Council for Homeopathic Certification and that --

BARBARA WOLF: -- or not.

REP. SRINIVASAN: I'm sorry?

BARBARA WOLF: Or not.

REP. SRINIVASAN: Or in neighboring states, they don't even need that?

BARBARA WOLF: Correct.

REP. SRINIVASAN: Okay. And then that is enough for them to open up their -- their business for people who are interested in -- in that form of medicine?

BARBARA WOLF: Correct. They are unregulated, so they may, you know, people may see people without -- they're unlicensed or unregulated and -- and that's sort of the -- and that has been sort of the standard.

REP. SRINIVASAN: Thank you. Thank you for that clarification.

Thank you, Madam Chair.

REP. JOHNSON: Thank you.

Representative Klarides

REP. KLARIDES: Thank you.

That was very good today. I just can't take it anymore.

Thank you, ma'am, for coming today. I know you explained this before. I'm just a little bit confused. So can you just explain the difference between a classical homeopath and what would you call somebody who wasn't a classical homeopath?

BARBARA WOLF: People are trained to be homeopaths. And -- but if -- but there is a certification organization in the United States that says if you want to reach the highest standard and you want people to know that you've achieved this standard, you may meet our education and training requirements, pass our exams and maintain our continuing education so that when somebody wants to see a homeopath, they can see somebody that's recommended to them or they could say who's certified close to me, I want -- I want that level -- I want that assurance. So, it's really just, it's not a required thing. It is a way to distinguish yourself as a professional.

REP. KLARIDES: And you explained before the difference is more education, more training to become a classical -- certified classical homeopath?

BARBARA WOLF: It's more -- if you're not certified, it doesn't, yeah, the people who are uncertified might have really great educational training but they have not gone through the certification process to verify it. So --

REP. KLARIDES: So can you be a noncertified classical homeopath?

BARBARA WOLF: Can one be -- yes, yes, absolutely.

REP. KLARIDES: So you can be a classical homeopath and not be certified?

BARBARA WOLF: Correct, correct. What -- what the difference you were making here is that, in Connecticut, physicians are licensed to be homeopaths. They're called homeopathic physicians. And so, in contrast, we are saying we'd like to open it up to -- to the larger profession who is well qualified.

REP. KLARIDES: And what's the difference between a homeopath and a naturopath?

BARBARA WOLF: A naturopath is a licensed physician, kind of, physician in Connecticut who is trained to do a range of holistic modalities. Homeopathy is one of them. But, homeopathy is a field to itself, and someone who is practicing homeopathy is specializing just in that. So you can't be a naturopathic physician if you're just a homeopath, but if you, you know, but if you're a naturopathic physician, it's one of the things in your scope of practice.

REP. KLARIDES: Okay. So if you, as a naturopathic physician, and as you mentioned, they -- one of the things they practice is homeopathy. How do we -- how do we classify them -- insofar as the homeopathy part of their practice?

BARBARA WOLF: They would you call themselves naturopathic physicians and offer homeopathic remedies.

REP. KLARIDES: But they can't differentiate themselves like -- like you want to differentiate yourself.

BARBARA WOLF: Right. And there naturopaths who get certification in homeopathy, they do both.

REP. KLARIDES: Okay, thank you.

REP. JOHNSON: Thank you.

Are there any other questions?

Thanks so much for your testimony.

BARBARA WOLF: Thank you very much everyone.

REP. JOHNSON: The next person I have on the list is Abby Beale followed by Jan Sopata.

Welcome and please state your name for the record and then proceed.

ABBY BEALE: Thank you.

Hi, Representative Johnson and distinguished members of the Public Health Committee. My name is Abby Beale, and I am here today representing Homeopathy for Connecticut, a group of natural health conscious individuals committed to improving access to highly qualified homeopaths in Connecticut. As you know, we are asking for statutory recognition that will allow nationally certified classical homeopaths the ability to practice here.

By the time my first child was nine months old, he was getting ear infections. Six months and -- excuse me -- many prescriptions for antibiotics later, we were told he needed tubes. As his mom, I wanted to research all my options and came upon this practice called homeopathy. I found a homeopath and took my son who was then 14 months. He was given one remedy and never had another ear infection. I was amazed. How could that be? I really wondered.

As time went on, I continued homeopathic treatment for my son whenever he needed it and then started it for myself. By 2001, I decided to start studying homeopathy by joining a weekend school and by voracious reading.

If the laws in Connecticut had allowed at that time, as they do in most other states, I would have opened a practice many years ago. But because of the Connecticut law of 1893, only allows medical doctors to practice here, I couldn't. So, I continued my studies and now more than 10 years later, I am close to becoming a CCH, a nationally recognized certification for classical homeopaths. It's like the CPA designation for accountants or the CFP for financial planners. If you go to a CCH, you know you're going to a highly qualified professional.

So what does a homeopath do? A homeopath conducts an initial extensive interview lasting up to two hours asking many questions to fully understand the mental, emotional and physical symptoms the person presents with. Then the homeopath takes those pieces and puts them together like a puzzle to match it to one homeopathic remedy. So all a homeopath does is recommend homeopathic remedies, which, by the way, are sold over-the-counter at health food stores. Unlike a medical doctor, a homeopath does not diagnose disease, administer or dispense legend drugs or controlled substances, engage in surgery or any practices that invade the human body.

To become a CCH, I have completed 470 more classroom hours than is required of a medical homeopathic doctors in Connecticut and 356 more than a naturopath. I have 300 more clinical hours than a medical homeopathic doctor and 318 more than a naturopath. I am attaching a comparison document for your review. I firmly believe CCHs are well qualified to practice.

Less than a year ago, I opened a homeopathic consulting office in Massachusetts because I can't practice here. I can practice in Massachusetts, New York and Rhode Island but not in my own state.

Homeopathy is safe, inexpensive and used by over 200 million people worldwide. It would be great for the citizens of Connecticut to have more access to this natural healing option. We urge you to support Raised Bill 6592 with the language change that we are submitting and that I'm attaching it to my testimony.

Thank you for this opportunity.

REP. JOHNSON: Thank you for your testimony.

Are there any questions?

Yes, Representative Ziobron.

REP. ZIOBRON: Thank you, Madam Chair.

And thank you for your testimony. I was reviewing your testimony online and I see you're attachments; however, I do not see the proposed language change in that. Do you have a copy there, and if you do, can you please leave it with the clerk?

ABBY BEALE: Sure, yes.

REP. ZIOBRON: Thank you, Madam Chair.

I -- I do not see that on line -- the language changes.

ABBY BEALE: -- with Barbara -- on -- on Barbara's. If you look on her full testimony, it wasn't an attachment. It was with hers.

REP. ZIOBRON: Oh, it was within her --

ABBY BEALE: -- with hers.

REP. ZIOBRON: Okay. Great. I'll go back and look at that --

ABBY BEALE: You can also find it there, as well.

REP. ZIOBRON: Okay. Great. Thanks for the -- thanks for the tip I appreciate it.

Thank you, Madam Chair.

ABBY BEALE: (Inaudible.)

REP. JOHNSON: Thank you, Representative.

Thank you for raising that, too, Representative.

Are there any additional questions?

Thank you for your testimony.

ABBY BEALE: Thank you.

REP. JOHNSON: Next person is Jan Sopata followed by Louise Sanchione, Sanchione.

Welcome and please state your name for the record.

JAN SOPATA: Yes, good morning Representative Johnson, my name is Jan Sopata. I'm from Fairfield and I am here to testify on Raised Bill 6592 with the proposed substitute language that we were talking about, recommended by Barbara Wolf, allowing for statutory recognition certified homeopaths.

I'm here because I just think it would be a great value to the people of Connecticut to have access to well-trained homeopaths, who achieve the national certification. And I know that no other state has this high standard in place, even though Rhode Island allows for homeopathic practitioners, they do not require that standard.

My experience is as a consumer. I learned about homeopathy from friends who lived in New York. And for the last 15 years, I -- my family and I have driven to New York to get homeopathic advice, but I also want to make clear that even though we use homeopathic remedies, we still always maintain a close relationship with doctors, healthcare providers and specialists. It's not an exclusive method of treatment. It's an adjunct in our experience, but we have found it as a valuable way to help to stimulate the body to heal itself in early stages when symptoms present.

I think it's also important to say that homeopathy represents comprehensive theory and even though it was introduced in the early 1800's, it remains the same. It operates on the same treatment methods for all this time and that the remedies we've taken are gentle and safe and FDA approved, nontoxic, natural and they have no side effects. I think having greater access to this method of treatment would really be a valuable thing.

I, also, think that as this proposal is zero cost to our state, it's cost effective and it's sustainable as the National Certification Organization will be the operator who maintains the list of who is qualified to practice and who has met the continuing education requirements.

So, in my experience, it's valuable, and I believe we need to have greater access to it. I -- I just think Bill 6592 is a win-win proposition so thank you, and I implore you to support it.

REP. JOHNSON: Thank you so much.

Are there any questions?

Yes, Senator Welch.

SENATOR WELCH: Thank you, Madam Chair.

Thank you, Ms. Sopata, for your testimony.

I guess the first question I have for you is were you, at all, involved in the process with the Department of Public Health and the request for a scope, if I may.

Through you -- through you, Madam Chair.

No?

JAN SOPATA: What do you mean?

SENATOR WELCH: I thought there was a request for a scope review for homeopaths with the Department of Public Health -- okay.

JAN SOPATA: Yeah.

SENATOR WELCH: And you guys already sat down.

JAN SOPATA: Yeah, yeah.

SENATOR WELCH: All right. That's it.

Thank you, Madam Chair.

REP. JOHNSON: Thank you.

Any additional questions?

Thank you so much for being here today.

JAN SOPATA: All right. Thank you.

REP. JOHNSON: The next person we have is Louise Sanchione followed by John Porriello.

Welcome and please state your name for the record and proceed.

LOUISE SANCHIONE: Good afternoon, Madam Chair and distinguish members of the Public Health Committee. My name is Louise Sanchione, that is a shout out to my Italian heritage there that's the Italian pronunciation.

I'm a Connecticut native and currently reside in New Haven. I have a doctor's degree in naturopathic medicine, but I consider myself a classical homeopath by profession. I have been studying and practicing homeopathy for over 20 years, most recently in Massachusetts for the past 11 because I cannot practice as a professional homeopath in my own state.

I expect to earn my certificate in classical homeopathy within the next few weeks -- and I would just as an aside to that, I would just like to, you know, there was some questions about certification.

As a naturopathic doctor, in order to receive my certificate in classical homeopathy, I had to submit extensive proof of additional training and supervision in cases and -- and take a test so it's above and beyond what I learned in naturopathic medical school.

The purpose of my testimony today is to request your support for Raised Bill 6592, AN ACT CONCERNING CERTIFICATION OF CLASSICAL HOMEOPATHS, using the additional language the new language that's submitted today by Homeopathy for Connecticut.

In support of this request I would like to make three points. The first is about changes I have seen and experienced in the field of homeopathy over the last 20 years, specifically, in the areas of education and training, certification, science, and public awareness. Over 20 years ago, there were no formal opportunities to study homeopathy, we had to piece together our course of study. Now, there are homeopathic colleges throughout the United States, including neighboring Massachusetts and New York.

Similarly, there were no certification -- there was no formal certification process for professional homeopaths. Now, as mentioned before, the National Council for Homeopathic Certification started only in 1981, issues the nationally recognized certification for those who have completed a rigorous course of study.

Over 20 years ago, scientists -- and even longer, okay -- were researching but struggling with the modern scientific explanation of the -- of the nature of homeopathy to help refute claims that it is just placebo. Currently, nano and material scientists are very close to providing an explanation of the scientific nature of homeopathy.

I have quite a bit more to say so I'll try to summarize.

One of the things that I do -- my work in Connecticut is limited to being an educator and I spoke to many Help Me Grow breakfasts to social workers and case workers. And my focus is mainly explaining how alternative medicines, especially homeopathy, can help with children with parents -- parents -- can help parents with children with special needs, provide an alternative to prescription medication. And what struck me at these talks that I gave, at these Help Me Grow breakfasts, was there was at least one or maybe up to several people who had experienced homeopathy and had a positive affect with it, experience with it.

However, there were many people who didn't know about homeopathy and, more importantly, wanted to know why this information wasn't readily available to them, especially, if it can help children with special needs.

And just in closing, I have to say the Connecticut Department of Tourism is marketing our state as "Connecticut Still Revolutionary." I respectfully submit that allowing the obsolete 1893 legislation to continue to prevent Connecticut's citizens from exercising freedom of choice about their healthcare and highly trained homeopaths from practicing their professions is inconsistent with this slogan. With this in mind, I respectfully request, again, that you support the passage of this bill and bring our great state into the 21st century in the area of alternative healthcare.

Thank you for the opportunity to speak and thank you for your work on this issue today --

REP. JOHNSON: Thank you so much for your testimony.

Yes, Senator Welch.

SENATOR WELCH: Thank you, Madam Chair.

So I guess as I understand your testimony, you are actually licensed to practice in the State of Massachusetts, is that --

LOUIS SANCHIONE: No. There's no licensing for either -- for neither naturopathic doctors nor homeopaths in -- in Massachusetts. So there are about 60 or 70 naturopathic doctors practicing and more than several homeopaths, many of them have their CCH, their certification.

SENATOR WELCH: And -- and just because I'm not familiar with Massachusetts law, please don't take this the wrong way, I'm just trying to find the parameters. Does that mean that -- that I could hang up a shingle in Massachusetts and call myself a naturopath having no training or experience whatsoever?

LOUIS SANCHIONE: It's probably possible.

SENATOR WELCH: Okay.

LOUIS SANCHIONE: Okay. They did just -- it hasn't been approved yet and hasn't been signed by the governor but there is a law -- there is a licensing law that has been accepted, but it took them like over ten, 12 years to get that through.

SENATOR WELCH: All right. And then -- and then if you know anything about that law, actually, I would be keen to hear about it. I mean as I understand most medical professions, it's not just a board certification that allows you practice within a state. In fact, a lot of times you can practice without that board certification so I -- I guess I'm trying to understand maybe a little bit better with respect to the states that do allow the practice of homeopath under what conditions are -- are, you know, what -- what kind of requirements do they require? I mean here we're just saying if you, you know, are certified than that should good enough. What's Massachusetts saying in this new legislation?

LOUIS SANCHIONE: Oh, well, it just -- it just applies to naturopathic doctors but it --

SENATOR WELCH: Okay.

LOUIS SANCHIONE: -- will not exclude homeopaths from being able to practice in the state.

SENATOR WELCH: Understood.

LOUIS SANCHIONE: I know it's confusing.

SENATOR WELCH: Got it. All right. Thank you.

Thank you, Madam Chair.

REP. JOHNSON: Thank you.

Any additional questions?

Thank you so much.

LOUIS SANCHIONE: Okay.

REP. JOHNSON: -- for being here today.

LOUIS SANCHIONE: Thank you.

REP. JOHNSON: The next person we have on the list is John Porriello followed by Howard Wettreich.

Please state your name for the record and proceed.

JOHN PORIELLO: John Poriello from Wethersfield. Good morning -- good morning -- good afternoon, Representative Johnson and other members of the Public Health Committee.

I'm here to testify on Raised Bill 6592, AN ACT CONCERNING CERTIFIED HOMEOPATHS. I support this bill for the statutory recognition of nationally certified homeopaths. To me, this bill is about freedom, freedom to choose for myself who is on my wellness team. My wellness team currently consists of a medical doctor, a nutritionist, a personal trainer and a massage therapist. I would like to add a Connecticut-based nationally certified homeopath to my team.

We are born free, ironically, only the government can restrict my freedom with laws. I see no reason why I should have to travel to one of three neighboring states to stay healthy by employing homeopathy as part of my wellness program.

I would like you to right this wrong that has gone on for too many years in Connecticut.

We've all been hearing for years about affordable healthcare. Although, it has only been a hope and there has been change, but it has not resulted in a lower cost of the individual who has insurance or who is gainfully employed, such as myself. The changes implemented by the federal government have -- have raised insurance premiums and will continue to raise health insurance premiums for years to come.

As a practical matter, this is forcing a lot of people, like myself, into insurance plans that have high deductibles as a way to make catastrophic coverage affordable enough to maintain. This change places more responsibility on the -- on the individual to manage their health and their healthcare dollars in a prudent manner. I believe that by adding a certified homeopath to my wellness team will aid me in coping with the escalating health insurance cost as I work harder to prevent illness.

Certified classical homeopaths have to undergo years of education and training and deserve to be recognized as professionals in Connecticut. I urge your support of this recognition.

Thank you.

REP. JOHNSON: Thank you for your testimony.

Are there any questions?

Thank you so much for being here today and taking the time.

The next person I have on my list is Howard Wettreich followed by Sara Myers.

HOWARD WETTREICH: Good afternoon Madam Chair, Representative Johnson, members of the Public Health Committee. I'll be brief. My name is Howard Wettreich, and I reside in the city of Meriden.

I'm here today in support of and to testify for Raised Bill 6592, it's an ACT CONCERNING CERTIFIED -- CERTIFIED HOMEOPATHS. As I've mentioned I support the bill for statutory recognition of homeopaths in the State of Connecticut for several reasons. Number one, I believe that homeopaths who achieve the highest level of homeopathic education and training through national certification should be recognized to practice homeopathy in the State of Connecticut.

I believe homeopathy is safe, affordable and a gentle system of healthcare. I'm 65 years old, and although I wouldn't say that my health is declining, I do have some common health issues. As a result, I'd like to have the choice of a board certified quality -- a board certified and qualified homeopath for healthcare issues and to provide myself with what I think is best in order to insure my well-being. And that's not say that I would substitute homeopathy for medical care, but I would have homeopathy for me work in conjunction with medical care.

Access to homeopaths in the State of Connecticut is limited and, as mentioned many times before, one would have to travel to New York, Massachusetts or Rhode Island in order to obtain homeopathic care. I think it's time for the State of Connecticut to issue in a new acceptance of homeopathy to include those who have achieved the highest level of homeopathic education, training and worldwide recognition.

Therefore, I ask the committee members for their support of Raised Bill 6592, and I thank you for the opportunity to speak before you today.

Thank you.

REP. JOHNSON: Thank you so much.

Are there any questions?

Thank you so much for being here today.

Sara Myers followed by Dr. David Emmel.

Welcome and please state your name for the record and proceed.

SARA MYERS: My name is Sara Myers, S-a-r-a; and the last name is Myers, M-y-e-r-s.

Thank you for allowing me this opportunity to represent myself here in support of House Bill 6645, AN ACT CONCERNING COMPASSION AID AND DYING FOR THE TERMINALLY ILL.

I am 58 years old, and I have a terminal disease. It's taking my breath away as you can tell so please bear with me. Two years ago and three months ago today, I was diagnosed with amyotrophic lateral sclerosis or ALS, commonly known as Lou Gehrig's disease. This disease is almost exactly 46 years after I was diagnosed as a child with type 1 diabetes. Inadvertently, I've managed to become as expert in living with both a chronic disease and a terminal disease.

ALS is really a tragic disease, and it is killing me right now piece by piece. There is no cure. There is no real medicine for me. Most people with ALS die within three to five years of diagnosis. ALS is a progressively degenerative disease that eventually leads to the total paralysis of the body, including the diaphragm which is controlling my breathing right now. You can see that it is affecting me.

At the same time, it leaves the mind and the ability to feel sensation completely intact. I'm not scared of death, but I am scared of the way ALS is killing me. This is not just another one of life's transitory hardships. It has taken away my ability to earn a living in which my hands are the tools of my trade. And it has completely robbed me of my ability to be independent.

I now require help with almost everything I do, bathing, toileting, dressing, eating. I will soon be in my beautiful wheelchair full time. Every day I lose something else because my ability to breathe is compromised, as you can see, everything I do is exhausting.

This little appearance here is going to cost me about two or three days to recover, but it is well worth it because of my deep desire to see this bill pass.

Choosing to die is the single most serious and difficult decision one can ever make, but choosing to die is sometimes a totally rational decision and this is a choice I would be so grateful to have whether I use it or not. Let me assure you, I'm not depressed, and I am surrounded with the most loving and supportive family and friends that you could ever wish to have. And I'm not ready to make this choice today, but I yearn for the option so that I could end my life without violence and without endangering my friends and family from legal repercussions. Having compassionate care to make this choice and the legal right to do so would be an unbelievable comfort to me. It would allow me to more fully enjoy the life I still have and to sleep easily at night.

This important debate will be challenging, and I know that. I most respectfully caution you to refrain from being influenced by those who may engage in exaggerated -- exaggeration, misleading statistical analysis and misrepresentation. I hope this process will be the measure of our collective wisdom, our courage, our honesty and our humanity. I hope you will think of me when you're thinking about this bill.

Thank you so much.

REP. JOHNSON: Thank you for your well delivered and -- and very brave and honest testimony.

Are there any questions?

Thank you -- yes, Representative Davis.

REP. DAVIS: Thank you, Madam Chair.

And thank you for coming here.

As someone who's over the years raised tens of thousands of dollars for the ALS Association, I appreciate the efforts that it took you to come here and testify in favor of the bill so I just want to thank you for making those efforts and informing us on how you feel about it. Thank you.

SARA MYERS: Thank you.

REP. JOHNSON: Thank you so much.

The next people on the list are Dr. David Emmel followed by John Munno.

A VOICE: Moving testimony.

REP. JOHNSON: Yes. Thank you for being here and please state your name for the record and then proceed.

DR. DAVID EMMEL: Representative Johnson and other distinguish members of the Public Health Committee, my name is Dr. David Emmel, and I'm a board certified ophthalmologist, practicing in Wethersfield. I'm the past president of Connecticut Society of Eye Physicians, and I am one of the current co-legislative chairs. I also participated in the scope review process conducted by the DPH with regard to homeopathy, and I'm here today representing 8,500 physicians in the State of Connecticut in opposition to AN ACT CONCERNING CERTIFICATION OF CLASSIC HOMEOPATHS, HB 6592.

The physicians of Connecticut would like to take this moment to thank the Public Health Committee and the Legislature of Connecticut for passing Public Act 11-209, which authorized the scope of practice review committees. This thoughtful law created a process administered by the DPH to carefully examine scope expansion and request -- request in the full light of their potential impact on the citizens of Connecticut.

The committees are composed of representatives from those groups that would be impacted should the legislation be enacted in accordance with the request submitted.

The Public Health Committee has before it the scope of practice committee report on Classical Homeopath -- Homeopaths. A report that uncovers numerous flaws in the homeopathic or Connecticut requests and provides little if any evidence that the needs are not currently being fulfilled or that any benefit would accrue to the citizens of Connecticut should this concept progress to statute.

Some of the critical findings of this report, the petitioners failed to establish a level of education sufficient to serve public safety. Candidates for homeopathic certification are not required to keep complete accredited education and training programs, unlike all other healthcare and health-related practitioners regulated by DPH.

The petitioners failed to provide adequate data regarding the utilization of homeopathy. The petitioners failed to provide adequate data concerning the demand for homeopathy. And they were to not able to show that Connecticut residents are able -- are unable to access homeopathic services or that health status of its citizens of Connecticut have been negatively impacted as a result of any such inability.

The petitioners failed to show that increasing access to homeopathy would substantially reduce healthcare costs. And the petitioners failed to show that the public would be adequately protected from the misimpression that homeopathic care is a medical profession.

We have heard the representatives of Homeopathy for Connecticut state that homeopathy is not medical practice; that homeopaths are not medical professionals and that they do not diagnose and treat disease and, yet, the training is in homeopathic medical colleges. There is a history, a long history of homeopathic medicine and many of the speakers, who are not necessarily representatives of Homeopathic for Connecticut, talked of healthcare as being equivalent to homeopathy. So there's a -- a disconnect here, and we're concerned that people in Connecticut misunderstand what is going on with homeopathy and what it is.

Classical homeopathy, essentially, reflects the thinking of one man, Samuel Hahnemann at the end of the 18th century, when scientific thought was still in its infancy and medical knowledge was limited to anatomy and crude surgeries. And medical science, in particular -- and medical science since then has progressed literally exponentially. Knowledge increases every day. We have new opportunities for new treatments and new approaches to disease as we understand disease and what its root causes are, whether they're genetic, acquired, infectious or just degenerative, whereas homeopathy has absolutely no scientific basis. And contrary to some of the testimony that's been given today, there is no evidence that supports it on a scientific basis. There is no curriculum in any college, anywhere in the world, that has studies based on the science that is supposed to underline homeopathy.

REP. JOHNSON: Could you -- could you please begin to summarize.

DR. DAVID EMMEL: The scope -- yes, I will summarize --

REP. JOHNSON: Thank you.

DR. DAVID EMMEL: The request to lower the current standard for homeopathic practice in Connecticut to simple CCH certification comes up short on many counts, and we hope that the committee will review the report from the DPH and reflect on its recommendations.

Thank you.

REP. JOHNSON: Thank you so much for your testimony and being here today.

Yes. Senator Welch has some questions for you.

SENATOR WELCH: Thank you, Madam Chair.

So I did read the report by DPH and I guess I got a little bit out of it something a little bit different of what - what you're saying here. It's not that there is a total opposition to licensure. It's just that licensure will cost money. And, yes, there are some questions that, I think, need to be answered and ferreted out before a -- a plan can be put into place.

Is that your understanding, as well, or --

DR. DAVID EMMEL: Well, I -- I am more concerned on the part of the inability of the DPH to actually regulate. There's no ability to -- right now, the training to become certified can be done entirely online. There's absolutely no necessity for anyone in their training to become a homeopath to have any contact with a patient. It can be done entirely online, and there's no certification for that process.

The DPH has no ability to regulate this healthcare profession. They have no ability because there will be no board, there will be no license, there will be no ability to identify and deal with people who are practicing inappropriately.

Right now, it may be true that the homeopaths in Connecticut who are practicing, who are MDs may only have 120 hours of homeopathy, but it is perfectly clear that the homeopaths who wish to practice in Connecticut have no training whatever in medicine. And as these practices become blurred and becomes less clear who is a doctor and who isn't, this is going to impact on the health of Connecticut's citizens.

SENATOR WELCH: Well, I mean I -- I appreciate what you're saying, I guess I understand that to be the universe today but not necessarily the universe should we decide to license this -- this profession and, in fact, we probably could -- correct me, if I'm wrong -- come up with some of the requirements that you just say they -- they aren't required to be, you know, to fulfill so I guess that's it. Thank you.

DR. DAVID EMMEL: Thank you.

SENATOR WELCH: Thank you, Madam Chair.

REP. JOHNSON: Thank you.

Representative Srinivasan.

REP. SRINIVASAN:

Thank you, Madam Chair.

Thank you, Dr. Emmel, for your testimony and for being here this afternoon.

Could you enlighten us on the background of the nine physicians in Connecticut, who I'm told have the certification or the license to practice homeopathy, as well, the homeopathy part, not the MD part. What is it that they have done for certification that qualifies them to be homeopaths in our state?

DR. DAVID EMMEL: Representative Srinivasan, I have to get back to you on the precise details. I do know that they are required to have a certain number of hours of training to be able to call themselves "homeopathic physicians," but I don't know the exact criteria they have to meet, but I will get that to you.

REP. SRINIVASAN: Through you, Madam Chair.

So if -- if more physicians, more MDs, go through this process, whatever the training is, the number of hours to be homeopathic physicians, as well, then, they would be -- they will be given that options to practice both, the MD part, as well as homeopathy, as long as those criteria's are met; is that your understanding, too?

DR. DAVID EMMEL: Yes. And -- and don't forget that -- that the citizens of Connecticut have access to a large number of naturopathic physicians. And if you go on the Internet and -- and Google and find naturopathic physicians, they almost all list homeopathy, and they are trained in homeopathy, maybe not -- to -- to -- in the same type of homeopathy, maybe not precisely to the same degree, but homeopathic practice is available to the citizens of Connecticut.

REP. SRINIVASAN: And the final question, Madam Chair.

The -- the interpretation of the DPH report on the scope of practice for something similar to Senator Welch that I also gleaned that it was a cost factor that was holding them back.

And in previous testimony, I did have a chance to ask them this question but we were told that they're going make it maybe it was in the subjective language that it's going to be cost neutral and this is not going to cost our state anything at all.

So if DPH were to go back and revisit the scope because now it is not a cost factor, there's no fiscal note attached, would you then feel comfortable going with the DPH recommendation as far as the scope of practice is concerned, which as you -- you very appropriately said it's a wonderful thing that this legislation passed recently.

DR. DAVID EMMEL: Well, I -- I fully support the DPH scope review process, but it doesn't change my opinion that approving and putting the imprimatur of the state legislature on a practice that has no scientific basis other than what has been documented to be a, perhaps, placebo affect is serving the citizens of Connecticut.

REP. SRINIVASAN: Thank you very much, Dr. Emmel.

Thank you, Madam Chair.

REP. JOHNSON: Thank you.

Dr. Emmel.

DR. DAVID EMMEL: Excuse me.

REP. JOHNSON: You keep trying to leave.

I don't see that your testimony is online. Have you submitted your testimony to the committee?

DR. DAVID EMMEL: I believe it was submitted. I have every reason to think it was.

SENATOR WELCH: Okay.

DR. DAVID EMMEL: Yes.

SENATOR WELCH: Okay. Very good I just wanted to make sure that we had access to your testimony.

DR. DAVID EMMEL: And attached to my testimony are a number of attachments that we've downloaded from the Internet that -- that -- that showed that there are misrepresentations in the -- in some of the statements that the Homeopathy for Connecticut people have made, especially with bringing to light issues that blur the distinction between a medical practitioner who diagnosis and treats disease in homeopathy because we are concerned about that issue.

REP. JOHNSON: Very good, thank you so much for being here and your testimony.

Representative Jack Hennessy, please.

Welcome and please state your name for the record.

REP. HENNESSY: Thank you.

I'm State Representative Jack Hennessy, representing Bridgeport, the 127th District. Chairman Johnson, Gerratana, Representative Miller, Senator Welch and members of the Public Health Committee, thank you for this opportunity to testify before you. I wasn't planning on testifying but in -- in listening to the testimony, I felt constrained to come before you in support of House Bill Number 6592, raised, AN ACT CONCERNING CERTIFICATION OF CLASSICAL HOMEOPATHY.

So I'm kind of an expert on this. I've been using homeopathy for the last 30 years or so, and I raised three kids. I have a 27-year-old, 22 and a 16-year-old and, basically, raised them through homeopathy not naturopathy.

A VOICE: Naturopathy.

SENATOR HENNESSY: Naturopathy, combination of -- of different things.

I -- I think the issue here is that people try modalities. I really am not one to subscribe to the medical modality because it basically treats symptoms and doesn't treat the underlying condition, the problems. And homeopathy, specifically, deals with the conditions. It -- it triggers a -- a response, a positive response. Like I said, I wasn't here to -- I wasn't prepared, but I -- I can assure you that it works, but it works through experimentation.

I think that healthcare professionals are -- stay in the business by being effective, and if they're not effective, they -- they are not in the business very long so that's one of the things that -- that I can attest to.

And I don't think that it's a placebo effect, although it is of a vibrational nature, homeopathy, which, which you know means you can't really measure it so the medical field has a real problem with that, and I think it's a turf battle, also.

Thank you.

I'd welcome any questions.

REP. JOHNSON: Thank you so much.

I have just one do you -- did you have any particular thing that you or your children experienced that -- that maybe, perhaps, was addressed to the homeopathic method?

SENATOR HENNESSY: Well, my children grew up very healthy. They -- they experienced the normal childhood illnesses, chicken pox and things like that, but nothing of any serious import. They never were really unhealthy and quite robust to this day, my wife and I also.

REP. JOHNSON: Very good.

Are there any questions?

Yes, Senator Welch.

SENATOR WELCH: Thank you, Madam Chair.

Thank you, Representative Hennessy, for coming and testifying. I appreciate that.

And so one of the things I struggle with here isn't necessarily the issue of homeopathy, but it's the issue of the practice of homeopathy and whether or not it should be what this bill kind of looks -- looks to, which is somewhat unregulated. And I -- maybe I'm using the right term but compared to what we typically see with medical practices and that is with licensure, with accountability to the Department of Public Health, with certain standards that can be enforced, you know, either through a regulatory framework or in a court of law.

And I'm curious as to where you are on that spectrum. Are you -- do you have a comfort just saying it's -- it's homeopathic medicine, certification from a national organization is fine, and we don't need to license and regulate them through DPH, or would you prefer to see the licensure?

Through you, Madam Chair.

REP. HENNESSY: I haven't really dealt with certification issues. I just know that we have a medical practice that dates back to the middle ages, and I don't really think it serves the people. The whole aspect of alternative medicine is something that's just been repressed throughout the years.

And the DPH is going to do what it needs to do and that is measure things, and if they can't measure it than -- than there's an uncomfortability. It's the same thing like with nursing mothers. If they can't measure the actual milk, doctors have a hard time figuring out if they get the correct nutrition even though they do.

REP. JOHNSON: Thank you. Thank you so much.

Any additional questions?

Thanks for being here.

REP. HENNESSY: Thank you.

REP. JOHNSON: Next on the list is John Munno and followed by Donna Kosiorowski.

Welcome and please state your name for the record.

JOHN MUNNO: My name is John Munno from Oxford, Connecticut. I thank you for the opportunity to be here, Madam Chair, Representatives and members of the Public Health Committee.

I'm here to testify on raised -- to the Raised Bill 6592, AN ACT CONCERNING CLASSIFIED CERTIFIED HOMEOPATHS. I support the bill for statutory regulation -- recognition. Sorry.

I share my testimony for homeopathy, a natural system of healing that has been in existence for over 200 years. It is widely used in many countries across the world, especially in Europe, South America and India. This system of healing is low cost, effective and safe. It has the ability to help people of all ages from infants to children, to teenagers, middle-aged people, elderly and widest -- with a wide assortment of health conditions both acute and chronic.

Homeopathy has a tremendous potential to assist people with their health concerns and relieve the health and suffering of humanity. As beneficial as homeopathy is as a healing system, as you've heard today, it can't be used very easily in Connecticut since access to skilled homeopaths is very limited in the state. We talked about the current Connecticut law so I will not elaborate on that. Mainly saying that there are not many medical doctors or homeopaths that are practicing homeopathy in the state.

This leaves the consumer with very few options regarding seeking a homeopath as a health practitioner. We mentioned about Connecticut being one of the few states that actually requires licensing for homeopathy. The big thing with homeopathy, it has seen a huge resurgence since the 1970's. It did come out of more of obscurity, and it was repressed early in the 1900's in our country. In the last few years, especially with exposure, such as Dr. Oz, homeopathy is making a huge growth across the United States, and the -- the demand for practitioners has not kept up with it.

Changing the existing law so that skilled certified homeists could legally practice in Connecticut would encourage more homeopaths to work in the state creating more jobs and being able to meet the public demand that exists.

I personally have benefitted from homeopathy for many health conditions. I've been using it for many years and have seen it used, you know, on so many people for health.

Currently, I work in a health food store in Connecticut that sells over the home -- over-the-counter homeopathic remedies. Often I am approached by customers asking for recommendations for homeopaths working in the state. Unfortunately, I cannot provide them with many options as there are few practitioners in my area. If this bill was passed, this situation could be changed.

As more and more people choose to use alternative healing methods, the demand for homeopathy will only continue to increase. And I hope this bill can be passed to bring Connecticut up to the times instead of lagging behind.

Thank you.

REP. JOHNSON: Thank you so much.

Are there any questions?

Thank you for being here today, much appreciated.

Next is Donna Kosiorowski followed by Michael Corjulo.

Welcome and please state your name for the record and proceed.

DONNA KOSIOROWSKI: My name is Donna Kosiorowski. I'm speaking on behalf of the Association of School Nurses of Connecticut. I'm also a member of AFT Connecticut, and I want to say good afternoon, Representative Johnson and Senator Gerratana and members of the Public Health Committee.

I'm in support of Raised Bill 1070, it's AN ACT CONCERNING SCHOOL NURSE STAFFING AND ESTABLISHMENT OF THE SCHOOL NURSE ADVISORY COUNCIL. Along with my testimony, you should have gotten historical perspective. It's a time line. And I'm encouraging the members of the Health Committee to please pay very close attention to the dates on the time line. My timeline starts in 1982, when regulations for school nurses were written, and it's up to March of 2013.

I will emphasize, again, that the regulations for school nurses from 1982 are still what govern the practice of school nursing. I'm here to encourage you to support this bill so that we can bring the regulations and the role of the school nurse into the forefront in Connecticut and improve school health services to our children.

Perhaps, the best way for me to do this, I've testified in front of you before so I'm not going to read my testimony because there's no point in doing that, but I would like share some experiences with you.

We -- we talk about school nurses in terms of healthcare services, in terms of sicknesses and injury, but I think what we forget to bring into the conversation is the role that the school nurse plays in the -- as a member of the educational team. I sit on 504 team meetings in my own district, and, as a 504 coordinator, I attend meetings outside of my district and other towns.

The other day I was at a meeting where the principal was being the principal and had to stop what he was doing so he could become the school nurse because there was no nurse in the school. I've been at 504 meetings where students with attention deficit disorder and need medication at noontime at school don't get it because there's no school nurse to administer it and the educational staff neither has the time nor the desire to look for the child to administer the medication. The nurses would make sure that that happened.

I've -- I've addressed the Public Health Committee since 1999. That was 13 years ago. Please don't let 13 years go by, again, before I address you on this issue. I really would -- would encourage all of the legislators. I've had the opportunity to speak to Senator Gerratana, my own representative, Jason Perillo. We worked with Representative Sayers on a task force, and I've spoken to other legislators so please help us to pass this bill. Let us give the kids in Connecticut the health services that they deserve.

Thank you.

REP. JOHNSON: Thank you so much for your testimony and just a -- just quickly. Could you just do the brief history, perhaps, to address the differences of the students that we have in the school system today from when you begin your time line in 1982.

DONNA KOSIOROWSKI: Well, the timeline is really for the -- the journey that the Association of School Nurses has taken on, but I've been a school nurse since 1985. When I first became a school nurse, most of the children that we see in school now with -- with disabilities, whether they're something you can see or not see, we're not in public schools at that time.

Now, we have inclusion. We have the least restrictive environment, and we have children with multiple number of disabilities. You would never see a child with a trache when I started in 1985. You would never see a feeding tube in 1985. You would never see children with autism and the array of disabilities.

One of the students that I had a few years ago had neurofibromatosis. And for those of you who don't know what that is, it's "elephant man" disease. The teachers at school were beginning to get -- to be honest, fed up with this student because he was beginning to slip academically. He was exhibiting some emotional problems. When you understand neurofibromatosis, that's the disease being exhibited. He was an adolescent. He had growth on his face that certainly made depressed and affected him emotionally and the learning disabilities were because his brain was involved. Had I not been at the table to explain that, the child would not have gotten the services he needs.

We have more children with asthma. We have more children with type 2 diabetes. We have technology that comes to school with the kids now, whether it's for cardiac reasons or diabetes so -- more working parents, more multicultural families. So it's a much different landscape than -- than when I first started.

Thank you for asking that question.

REP. JOHNSON: Thank you for that.

My co-chair has a question, as well.

SENATOR GERRATANA: Actually, Donna, thank you so much for coming and testifying today.

It's not so much a question as probably I need to speak with you. I don't want to take up committee time here, but it goes to school-based health centers. We're working on some legislation in this committee regarding them. And a one of the proposals is a pilot for, if you will, for lack of a better word, a collaboration between school-based health centers, the school nurses and any other medical director or any other medical staff involved and -- and the community. And I just wanted your opinion on that and we can talk more about it.

DONNA KOSIOROWSKI: Okay. Did you want me to address anything?

SENATOR GERRATANA: Well, yeah, the reason I'm bringing this up is that I've heard from (inaudible) school nurses that they feel school-based health centers are completely separate from what they do and there is no need, if you will, for some collaborative approach.

DONNA KOSIOROWSKI: Well, I think that the perspective depends on the personalities of the people that are involved and the individuals.

So, you know, we can discuss that at another time. But in order to have collaboration you have to have a school-based health center and a school nurse to collaborate together. Frequently, you don't have one or the other and they have -- you heard the testimony a few weeks ago from Dr. Garcia from New Haven's Health Department and the CLO from New Haven Schools indicating that the roles of each are very different.

The school-based health center is really the primary care provider in the school. They see kids for sick visits and those kinds of things. They don't do what the school nurses to do in terms of the screenings, the care planning, the integration into the educational setting. So they're very two distinct roles, and I think I would like to see the collaboration improve so I'd be very interested in talking with you.

SENATOR GERRATANA: Thank you.

DONNA KOSIOROWSKI: You're welcome.

REP. JOHNSON: Thank you.

Yes, Senator Welch.

SENATOR WELCH: Thank you, Madam Chair.

I think -- I think it's a great idea that school nurses get together and talk about what's going on. Exchanging information is probably one of the most important things you can do to improve the environment.

I do have a question on the bill and that is in Section 1 of the bill, under subsection a, we're adding language that says the regional -- the local or regional board of ed shall maintain a staffing ratio of school nurses to students that is appropriate to the size and health needs of the student population in order for a more healthy and learning environment. And I guess what my question is, is how -- how do we determine and who enforces this -- this requirement?

DONNA KOSIOROWSKI: Well, to -- to determine what you need, there is a formula that the National Association of School Nurses provides. And I'd be happy to share that with you. You look at the acuity of the children in the building, their health needs. It's sort of like in a hospital where you have more nurses in intensive care than you have on the floor, the ratio of nurse to patient. So if you have very acutely ill children, you would need, obviously, more nurses.

The accountability or the enforcement -- one of the reasons we want regulations looked at, again, is because there really is no enforcement at this point other than at the local level. And it's very difficult for local districts and local health departments to -- to look at the regulations and figure out what qualifications they should be looking for in a school nurse. So the School Nurse Advisory Council is not just for school nurses to get together to talk, we would like agencies, including the State Department of Ed, AFT, the Connecticut Nurses Association, Association of School Nurses to -- and -- and, hopefully, some legislators, to look at what services are we really providing in school and -- and how do we efficiently and safely do that.

SENATOR WELCH: So just so I'm clear, it's not necessarily the council that's going to determine this number it's -- there's actually a national standard and formula that's out there.

DONNA KOSIOROWSKI: Well, there is a formula. If the legislators decide they want to give the council the authority to make those -- those requirements that would be great but usually it's my understanding and -- and, perhaps, you can correct that an advisory council is -- is simply to make recommendations.

SENATOR WELCH: And -- and it is. And that's why -- that's why I'm confused because it's, actually, one of the specific recommendations that the advisory council supposed to come up with is -- it's, sort of, taking me a second to get there -- it is school nurse staffing levels.

DONNA KOSIOROWSKI: Right. I -- I don't really think that was going to come out of the council. I think that we were looking to you all to set that as -- as a law so that districts don't have a choice and that they would have to base their ratios on the needs of the students. Who determines the ratio is what the advisory council and the national association would do. Does that answer your question?

SENATOR WELCH: Well, I'm not sure because when I read this it says that the council is supposed to give a report to the General Assembly --

DONNA KOSIOROWSKI: Uh-huh.

SENATOR WELCH: -- and one of the things it's supposed to opine on is the staffing levels so, I guess, if what you're telling me is, you know, we're supposed to take a look at that, we're supposed to come up with recommendations, but at the end of the day it's on your shoulders, I understand that, if that's what you're saying?

DONNA KOSIOROWSKI: Right, the legislation --

SENATOR WELCH: Okay.

DONNA KOSIOROWSKI: -- would -- would dictate that.

SENATOR WELCH: Right. All right. Thank you.

REP. JOHNSON: Thank you.

Representative Srinivasan.

REP. SRINIVASAN: Thank you, Madam Chair.

Thank you very much for your testimony.

Good afternoon.

And in the same vein of thought as Senator Welch, one of the things I've had difficulty in getting the hands across is a number -- and I know you did say you will send that to us. Is that actually a number that there is out that says for X number of students in a school, we would have, you know, this many of number of nurses available in the school system?

DONNA KOSIOROWSKI: Yes. What the National Association recommends -- and this is where there is some confusion -- their first recommendation is one to 750 but what that means is every child in the school is healthy and comes from, you know, intact families. The number goes down to one to 500, if you have students that are -- you have a mix of students with special needs. If you have more special needs students, it's one to 250. It goes down to one to 100 when they're very acutely ill, and it could be as limited as one on one. And we do have some students who require one-on-one nursing in school.

REP. SRINIVASAN: Thank you very much for that.

For the first time, I'm hearing those numbers and I appreciate that, you know, I've trying to get those number for quite some time and I appreciate that information.

The -- going to the second half of the -- of the bill, you know, in the same section, we were talking about not the size, which you did mention, but the health needs. And you gave a wonderful analogy about hospital setting between, you know, between intensive care and the floor, where, obviously, the ratio is very, very different. But could you tell us from a practical point of view in a school system, how in an acute setting you would suddenly be able to change the numbers of the nurses that are needed on a particular day or a particular -- in a week if the kid is sick because, obviously, that's going to -- that health status is going to be not something constant but will always be in flux.

DONNA KOSIOROWSKI: Well, there's a certain amount of consistency in terms of what we have to do and then it's -- it's also like being in an emergency room where you never know what's going to come through the door. So I think you make your best assessment of what an appropriate staff would be, and I don't think that there's a flexibility. Although in our district there is because we do have an extra nurse who doesn't have a school assignment so we can ask her to help when -- when things are busier.

There are most days -- I urge all of you to spend a little time in a school health room because I think it would be a very interesting experience for all you, but it, you know, we have to look at the -- the kids that we have now and based on the statistics and the data that we have in terms of visits and the types of things that we do see, we -- we try to staff accordingly.

REP. SRINIVASAN: And my final question to you, through you, Madam Chair.

You mentioned acutely ill students coming to school. I mean I'm having a little difficulty comprehending that. Who would be these -- or what would be the nature of an acutely ill child coming to school?

DONNA KOSIOROWSKI: We have -- currently, we have -- we're responsible for kids from age three to 18, and we have severely disabled students in our high school in a self-contained classroom who require one-on-one care, traumatic brain injuries. We also have, for the first time in my experience as -- or, actually, the second time, I'll be planning tomorrow to reenter a student who has a DNR order. So those are the types of situations that we're dealing with.

Acutely ill, too, we have seizure disorder who might have multiple seizures during the school day. We have kids with dual diagnoses, our student with type 2 diabetes and a seizure disorder who's very poorly controlled in -- in both places so those are the types of kids that I would talk about. Kids who have traches need to be suctioned frequently.

REP. SRINIVASAN: Thank you very much.

Thank you, Madam Chair.

REP. JOHNSON: Thank you.

Are there any additional questions? Excuse me.

Thank you so much for your testimony.

DONNA KOSIOROWSKI: Thank you.

And I'll make sure you get the NASN information about the numbers.

REP. JOHNSON: Yes. That would be great and, also, perhaps, a little bit of information on the -- the nature of the school population based on some of the changes since 1982.

DONNA KOSIOROWSKI: Okay.

REP. JOHNSON: Thank you.

The next person I have on the list is Michael Corjulo followed by Verna Bernard-Jones.

MICHAEL CORJULO: Good afternoon.

REP. JOHNSON: Welcome and please state your name for the record and proceed.

MICHAEL CORJULO: Good afternoon, Representative Johnson, members of the Public Health Committee. My name is Michael Corjulo; I'm an APRN. I'm the president-elect of the Connecticut School Nurse Association. I'm also the health coordinator of the ACES School District. It's an honor to be testifying in front of you again.

I'm going to just try to build on my co-worker's, Donna's testimony, in support of Bill 1070, AN ACT CONCERNING SCHOOL NURSE STAFFING AND ESTABLISHMENT OF A SCHOOL NURSE ADVISORY COUNCIL, which I am also very supportive of.

The addition to the wording that we were just discussing with the staffing levels, I don't -- I'm not sure that it was made clear that the current regulations that are over 30 years old only require one or more school nurses per district. And it seems like what's happened over the 30 years is this has created a significant disparity in school nurse resources in Connecticut.

For example, from where I'm -- in the region I work, Hamden has 16 school nurses for 14 schools with an average school nurse to student ratio 1 to 409, whereas the neighboring city in New Haven has 30 nurses to cover 53 school sites with an average school nurse to student ratio 1 to 770.

Governor Malloy's 2011 education letter to the Connecticut General Assembly noted that Connecticut has the widest academic achievement gap in the nation.

I would propose that just as education reform is a step toward addressing the achievement gap, this proposed legislation is a step toward addressing our state's healthcare gap. For many of Connecticut's economically disadvantaged in minority children and adolescents, the school nurse may be their most successful -- accessible source of healthcare, addressing immediate needs while advocating and coordinating with community medical providers. Qualified school nurses are capable of addressing student health issues that positively impact the time students spend in class ready to learn, a foundational component to improving any educational success.

One of our principals put this in perspective for me this year. Stating when I was a principal at my other school that did not have a nurse on site and a student came to me with a health problem, my two common options were to call 9-1-1 or send the student home. I was not qualified to assess if it was safe for them to return to class or survive the bus ride home.

Lastly, I just want to use asthma as an example, I'm a certified asthma educator. Our rate of asthma in Connecticut schools is ten to 18 percent. Cities, like New Haven, have 15 to 18 percent of the students in schools with asthma. Our nurses in our public magnets schools or ACES, we assess students with acute asthma systems every single day and have to decide is it safe for them to be back in school -- to stay in school, is it safe for them to get on that bus for their 10-, 20-, 30-minute ride home and make it home okay.

Schools need to have nurses. I think the detail about exact ratios is something we should have further discussion but what we know is that having just one school nurse for a district or having an inadequate number of school nurses is not safe, and it's putting a lot of our school children at risk.

Thank you.

REP. JOHNSON: Thank you.

Any questions.

Thanks so much for being here today.

MICHAEL CORJULO: Thank you.

REP. JOHNSON: The next speaker is Verna Bernard-Jones followed by Mary Jane Williams.

Welcome and please state your name for the record and proceed.

VERNA BERNARD-JONES: Good afternoon, Madam Chair and members of the committee.

My name is Verna Bernard-Jones. I am a school nurse at West Middle Elementary in Hartford. I'm also president of the Health Professionals of Hartford School District, and I'm also the president of ASNT. And I'm here to testify in favor of SB Number 1070, AN ACT CONCERNING SCHOOL NURSE STAFFING AND ESTABLISHING A SCHOOL NURSE ADVISORY COMMITTEE.

My colleagues that went before, basically, told you a lot about, you know, how it is with school nursing but I just want to emphasize that in recent years school nursing has just really been the focus of -- of many things with healthcare. You may not have known, but it was a school nurse that recognized that H1N1 was affecting the population.

A school nurse is the first person that students see in school. They have to come in get their physicals and we have to address all their health, medical and mental health needs.

I want to talk to you just a little bit about a recent study that was done by the Institute of Medicine in collaboration with the Robert Wood Johnson Foundation. They did this joint study, and it was a study on the future of nursing. And I just want to quote some of the things that was said.

This study said that in the 21st Century, the health challenges facing the nation have shifted dramatically. The healthcare system is in the midst of great change as care providers discover new ways to provide patients and good care and to deliver more primary care as opposed to specialized care.

They also state that nurses are well poised to meet these needs by virtue of their numbers, their scientific knowledge and their ability to adapt. The trends have really changed in over the past 20 years, and we need the state regulations to change.

As Donna said before, it's been since 1982 that there was any kind of change, any look at the regulations. That's over 30 years. And I just have to reiterate what she said that there is so many more medically fragile children in school. To have regulations that just say that a district can only have one nurse is just absurd at this time.

So we want this advisory committee so that we can sit down together, the Association of School Nurses, Connecticut Nurses Association and people from the Department of Education and DPH, we want to be able to sit down and look at these regulations and decide what we can do to make school nursing more effective and to really serve the school population in Connecticut.

So I would just ask you to just please help us to make this a reality.

Thank you.

REP. JOHNSON: Thank you so much for being here and taking the time to provide your testimony.

Are there any questions?

Thank you so much.

VERNA BERNARD-JONES: Thank you.

REP. JOHNSON: The next speaker is Mary Jane Williams followed by Lynn Rapsilber.

Welcome and please state your name for the record and proceed.

MARY JANE WILLIAMS: Good afternoon, Representative Johnson and esteem members of Public Health.

I'm Mary Jane Williams. I'm chair of government relations for the Connecticut Nurses Association, and I'm a registered nurse. And I'm here to speak in strong support of Raised Bill Number 6391, AN ACT CONCERNING THE PRACTICE OF ADVANCED PRACTICED REGISTERED NURSES.

And I'm here to represent all nurses in Connecticut, but I'm also here because I served on the task force that did the compromise language in 1999 under the -- under the tutelage of Senator Melody Peters and Representative Winkler, at which time, we were promised in five years we would go back and we would renegotiate this language. I believe the time has passed and heeding the Robert Wood Johnson Institute of Medicine recommendations, nurses should be allowed to -- to practice to the full extent of their education and training and be full partners with physicians in all related healthcare providers.

I've listed in my testimony the current impediments to the regulatory environments, what the exclusive restrictions are, what the restrictions that are constantly faced by APRNs are and what has caused these impediments. And I -- I want you to know that the author of these is Dr. Barbara Safriet, she was the associate dean at the Yale School of Law, and she has been promoting the cause of APRNs for last 30 years.

The advanced practice registered nurse is not licensed as a generalist as is an MD. The APRN is educated, certified and licensed within a specific specialty, which defines the extent of their practice. The scope of practice of a registered nurse is, in fact, determined by education, specialty certification and licensure. An example, if I wanted to be an advanced practiced registered nurse in gerontology, I would study specifically at the master's or doctoral level the field of gerontology. I would then sit for a certifying exam by a nationally recognized agency and become certified as a geriatric nurse practitioner. That is the only practice that I would be practicing at the advance practice level because my education would define my scope of practice and limit my scope of practice.

So I request, although it is always spoken to and addressed as a scope of practice determination, it is really a request that directly relates to the authority to practice.

We are asking you to grant us this authority.

Thank you and I would just like to bring to note because my time is out but I have submitted testimony in opposition of Senate Bill 1064, AN ACT CONCERNING MEDICATION ADMINISTRATION IN NURSING HOMES and -- and testimony in strong support of AN ACT CONCERNING A SCHOOL NURSE STAFFING AND ESTABLISHMENT OF A SCHOOL NURSE ADVISORY COUNCIL.

Thank you.

REP. JOHNSON: Thank you so much for your testimony and your work on this issue.

Do I have any questions?

Yes, Representative.

REP. CONROY: Thank you.

Can you just give us a little background about 1999, you said there was a compromise, the language, what that was about.

MARY JANE WILLIAMS: There were a couple of issues that occurred in the 1997 and the 1998 legislative session. And at the end of that session, we were told by Senator Peters that we would come to meet with the groups that control this in the '98/'99 session. So Senator Peters brought together a committee, that committee was composed of representatives from all of the advanced practiced specialty groups and the Connecticut Nurses Association, which was myself and Tom Regan, who is a lawyer with Brown Rudnick and our official lobbyist.

And we sat for about four months and carved out compromised language that removed the -- under the direction of and spoke to written collaboration and also spoke to restrictive authority. And that was passed in the -- in 1999 by -- it came out of the Senate and went to the House, it was passed. And we've been operating underneath that practice act now since 1999.

When we were told you know, as practice evolved, that this also would evolve, this would change and would evolve. And we've been -- it's been pretty difficult, I think, to -- to be heard because of the controversy out -- I -- I'm really -- I've been practicing nursing now for 49 years, and I would like to say that we are only going to have healthcare by all health providers. It's not going to be one group. We are all going to have to work together. And that's how we see this evolving so that's why I'm here today.

REP. CONROY: Thank you.

MARY JANE WILLIAMS: You're welcome.

REP. CONROY: Thank you, Madam Chair.

REP. JOHNSON: Thank you.

Any other questions?

Thank you so much.

MARY JANE WILLIAMS: You're welcome.

REP. JOHNSON: The next one is Lynn Rapsilber followed by Kathy Grimaud.

Welcome and please state your name for the record.

LYNN RAPSILBER: Hi, my name is Lynn Rapsilber, and I would like to thank Senator Gerratana, Representative Johnson and members of the Public Health Committee for raising this bill.

I am a nurse practitioner and the current chair of the Coalition for Advanced Practice Nurses. In 1999, the APRN Practice Act changed and the practice for Connecticut advanced practice registered nurses became independent. For 14 years, APRNs opened their practices, served many underserved populations in the state. APRNs are fully licensed and insured at the same level that physicians and solely responsible for all their patients care. For 14 years there have been no required physician involvement with the APRN and patient, no supervision, no oversight, no co-signature, no chart review, no patient review.

By statute, a physician is not responsible for APRN practice and APRN patients, the APRN is solely responsible and this has been true for 14 years.

This legislation is not about autonomous practice. That happened in 1999. What this bill is about is removing the existing language that APRNs be in the possession of a written collaborative agreement with a physician. APRNs can and do consult and collaborate with many physicians and healthcare providers. There is no mandate to consult with whomever has signed the agreement just that the mandate to have the possession of this agreement.

The judgment of the APRN determines when and with whom she will consult. You will hear how this agreement requirement has evolved to significantly be obstructive to access to care and you will hear how it has caused practices to close in Connecticut. Will APRNs have more authority than they do today under their current license if the agreement were not required? No, absolutely no more authority. Practice will remain the same. The parameters of the APRN practice do not change. The scope remains the same; the license remains the same. And as for the consultation, it remains the same as it is today. It is the judgment of the APRN taking care of the patient that determines when and with whom they will consult. That remains the same.

I also wanted to bring up because Kathleen Grimaud had to leave, she is the CEO of Community Health Center in Torrington, Connecticut. It was established in 1998, she has one physician, six APRNs and 6,000 patients.

To add to cost to train an APRN in the community health center arena is 56 less percent than a physician, and APRNs care for 95 to 98 percent of primary care conditions that come through the door. APRNs in her center see more patients than the doctor and losing their collaborating physician, 6,000 patients will be in jeopardy.

Lastly, this agreement stifles innovation and health care delivery. Nationally, APRNs have created models of healthcare that can't be duplicated in Connecticut by virtue of having this collaborative agreement. Also existing providers are threatened with closure. APRNs want to provide care in Connecticut and this mandated provision is not solving any healthcare problems, rather it is posing a distinct disincentive to opening the doors in Connecticut to care for patients.

REP. JOHNSON: Thank you so much.

Are there any questions?

Representative Conroy.

REP. CONROY: Thank you, Madam Chair.

We recently had the scope of practice regulation go through. Did the APRNs apply for that process?

LYNN RAPSILBER: Yes, we did file an application, that happened in last August, and DPH -- the process itself was underfunded and, therefore, they have to be selective on who they choose to pick for their scope of practice. Our application was not one that was chosen.

The process is up for review this year, and we don't know if the funding is going to be there for that but our concern is, in fact, the healthcare needs of Connecticut is eminent now and we can't wait another year or two to submit another scope request. So the legislative body was our only recourse.

As I stated in our testimony, we do not believe that this is a scope of practice issue. Nothing changes in the parameters of our care; nothing changes in our competencies, in our licenses and our credentials. We only we need to get this agreement signed that's the only commitment. The practice stays the same.

REP. CONROY: Do you know how many organizations put in for scope of practice change and how many were picked?

LYNN RAPSILBER: I think there were ten or 11, and I think they only picked three.

REP. CONROY: Okay.

(Inaudible) one more question. With the Affordable Care Act rolling out soon, do you know how many more patients will be needing healthcare -- primary healthcare providers in the state?

LYNN RAPSILBER: 191,000 patients will be added to the Affordable Care Act for insurance and about 1,000 -- 120,000 of those will be Medicaid patients so there's going to be a need for more healthcare providers.

REP. CONROY: Thank you.

And just one final question, you know, I've sat here before and we listened to this and a lot of the opposing testimony will be citing patient safety concerns, and I know there's been lots of studies out there on patient safety for APRNs. Did you have any of that information on how safe the practice is?

LYNN RAPSILBER: Well, we've been a discipline that's been studied over 40 years. Recently, there was an article in Nursing Economics that cited a systematic review of outcomes from 1990 to 2008 so they looked at a lot of data. And they compared other providers, MDs and teams without APRNs to APRN care, and basically, what they found out is that APRNs provide high quality cost-effective care. We play an important role in improving healthcare outcomes and that reviewing these studies should address any discussion whether care provided by APRNs it should be looked at that we can augment the lack of physician shortage and delivering care to patients in the future.

REP. CONROY: Thank you for your questions --

answers.

And thank you, Madam Chair.

REP. JOHNSON: Thank you.

Yes, Representative Cook.

REP. COOK: Thank you, Madam Chair.

Thank you for testifying and mentioning the great work that the Torrington Community Health Center does.

Could you tell me if -- how this could benefit or hurt the school-based health clinics?

LYNN RAPSILBER: I think it could only enhance the school-based health clinics. I think when you do not have to be required to sign a physician agreement, it can allow an APRN to go in and fully operate in a community health center arena. Unless they're federally funded and that becomes a national issue which that still is a concern with Kathy Grimaud's center, as well.

REP. COOK: Thank you.

Thank you very much, Madam Chair.

REP. JOHNSON: Thank you.

Any additional questions?

I just have one question in terms of the collaborative agreement, does this, do you know, increase the cost to the APRN or the doctor you have the agreement with?

LYNN RAPSILBER: You'll hear testimony about the costs of collaboration from some of the folks who will be coming up, but I can tell you that the cost for a -- to an APRN to provide this collaborative agreement, they can pay anywhere from $50 a month to thousands of dollars to physicians to have this agreement signed. And there's really no benefit that they get other than having this piece of paper signed that may sit in a drawer. It doesn't do anything to affect the nurse practitioner's judgment, patient care, their ability to care for that patient.

REP. JOHNSON: Thank you. Thank you for your testimony and your work.

LYNN RAPSILBER: Thank you.

REP. JOHNSON: The next person I have on the list is Dr. Daren Anderson followed by Pauleen Consebido.

Welcome and please state your name for the record.

DR. DAREN ANDERSON: Thank you.

My name is Dr. Daren Anderson. I appreciate the opportunity to testify before you today. I am a practicing primary care general internist and the chief quality officer for Community Health Center Incorporated in Middletown. I really appreciate the chance to speak in favor of Raised Bill 6391. I also bring the regrets of Dr. Margaret Flinter, our senior vice president and clinical director, a family nurse practitioner herself who wasn't able to be here today but has submitted testimony in support of this bill, as well.

So I've been a practicing primary care provider for 14 years in Connecticut, and it's given me an opportunity to work with many nurse practitioners in many different settings. I started at Yale as a resident and since that time have worked in community health centers in New Britain. In Waterbury, I've worked at the VA Connecticut healthcare system as the director of primary care. And then, in my current role as the chief quality officer, I continue to see patients in our Waterbury site but also have the role of fostering continuous improvement and the transformation of primary care, particularly, for vulnerable populations that are served at community health center.

And most importantly, we are trying to create the system that is going to take care of all the additional patients that are going to be seeking primary care services as the Affordable Care Act becomes reality. And I just want a second with the previous speaker said about the importance of recognizing that that influx that we'll be seeing, already being seen in places like Massachusetts, will have a great impact on our ability to provide primary care services. And as such, it makes sense to remove any needless impediments to providing primary care as I'll address in a second.

So nurse practitioners in our health center provide care in many different capacities. Some of them are assigned to our school-based health centers, some specialize in psychiatry and HIV care, in women's health but most of them are primary care providers for diverse panels of patients.

In every situation, regardless of where they practice, they're fully vetted and hired through a rigorous credentialing process. They're privileged and appointed, re-privileged, reappointed only on the basis of high performance. I review their charts. We conduct rigorous performance appraisals on an annual basis. That's the standard to which we hold all licensed providers, not any one particular, such as nurse practitioners.

And I reviewed the language that's in plain language description of the request that was submitted to the Department of Public Health last fall. It makes a clear and compelling case for the change in language that's sought by this bill, 6391. The request presented evidence-based support for the safety and quality of care provided by APRNs across the country and supporting data that shows that it is equally true that states that have this requirement and states that don't have similar safety and quality of care.

So in today's practice environment, every primary care clinician, whether it's a nurse practitioner or an MD or anybody else, needs to consult and collaborate with other providers and disciplines in primary care, specialty care, nursing, pharmacy, just to name only a few. This is the nature of practice today and we do so by phone, by video or in person when the need arises. However, the requirement that's written collaborative agreement with a single provider is simply doesn't make sense in this practice environment. And as the previous already noted, it doesn't practically require them to do anything specific in terms of seeking collaboration. We all seek collaboration when it's necessary.

So we're developing a transformative model of primary care community health center based on technology and evidence-based practice. Nurse practitioners are an essential part of that transformation. We need them to be able to practice to the full scope of their license as has been noted before. The regulation of their practice should reflect their essential role as licensed, independent providers.

It's time to make this modest change to the language of the statutes and bring Connecticut to the fore a leader and the first choice place for nurse practitioners to practice, and I'm fully supportive of the bill.

Thank you.

REP. JOHNSON: Thank you so much for your testimony.

Are there any questions?

Yes, Representative Conroy.

REP. CONROY: Thank you, Madam Chair.

Thank you, Dr. Anderson, for your testimony.

And when you were speaking it kind of put a light bulb on in my head here. You were at the VA primary care --

DR. DAREN ANDERSON: Yes, I was.

REP. CONROY: All right. And I retired from there and I'm trying to remember was the VA exempt from having to have a collaborative agreement with nurse practitioners?

DR. DAREN ANDERSON: Uhm --

REP. CONROY: Do you remember?

DR. DAREN ANDERSON: The VA has a large -- has a good size staff of nurse practitioners. I'm actually not sure of the answer to that I don't want to speak incorrectly.

REP. CONROY: Okay. Because when you were saying that I think the VA did not have to have a collaborative practice agreement in the federal setting so I wasn't sure if you were familiar with that.

DR. DAREN ANDERSON: No, but I'd be happy to find out in the (inaudible).

REP. CONROY: Thank you.

That's all.

Thank you, Madam Chair.

REP. JOHNSON: Thank you.

Representative Srinivasan.

REP. SRINIVASAN: Thank you, Madam Chair.

Thank you, Dr. Anderson, for your testimony this afternoon.

We did not have this collaborative agreement once upon a time. We now have it, and we also have a system by which this collaborative agreement can be removed and that is, obviously, through DPH as a scope of practice but as -- as obviously that was not picked this year and so that's not going to happen through DPH.

Could you -- or I know I'm told that others would be telling us as to what if -- what are the challenges of the difficulties that are being felt by APRNs because of this collaborative agreement.

That is the pocket I'm not getting a handle on. I fully agree that -- that the need for primary care is only going to increase. I definitely firmly believe that everybody delivers excellent health care, as I've said this before earlier in the day and -- and what I'm not able to understand is in this collaborative agreement, loose as it is, you know, what is the hurdle that the APRNs are facing such that we cannot wait for due process and go through DPH when they are able to pick up -- pick this up for the scope of practice review?

DR. DAREN ANDERSON: Yeah, thank you for the question and the opportunity to respond. I think that most importantly it limits the nurse practitioner simply in that she's required to find a physician to sign that agreement. And although in an organization, like mine, with over 50 providers, that's not difficult. I mean some of them on in rural location or there are locations where there are smaller number practices that there may not be somebody readily available. There may not be somebody willing to do that either so it limits their ability to practice where the need is most -- is most felt.

REP. SRINIVASAN: And what do you call -- thank you for that clarification.

The operative word was "may." Somebody "may" not find, "may" not find definitely understand that and that's what I -- I -- that was my sense, too, that it is possible that the collaboration cannot occur. But is that really not happening? There's a difference between "may" and "reality" and that is what I would like to get into. What are the hardships that we are facing, that the APRNs are facing through this collaborative agreement?

DR. DAREN ANDERSON: Yeah. I suspect some of the speakers coming after me will be able to speak more directly to that. Within our organization, we have a mechanism to provide that, but what I would envision is a location where there isn't a practicing MD providing primary care and that -- that is a very likely scenario in -- in the more rural parts of our state where a nurse practitioner may want to deliver independent care in that location, the requirement to find an MD who's out there who has to sign that agreement would likely limit her ability to do that or his ability to do that but I'll rely on the speakers coming after me to speak more directly to that experience in that sort of area.

REP. SRINIVASAN: Thank you very much for the answer.

Thank you, Madam Chair.

REP. JOHNSON: Thank you.

Just a -- just a kind of a speculative question, if there's, say, a nurse, an APRN working in a facility, like yours, or some other specialty area part time but also would like to deliver services on his or her own part time, would that be something that the providers in your organization or, perhaps, in some other institutional typesetting, they would be able to sign onto -- to a collaborative agreement in that circumstance?

DR. DAREN ANDERSON: I think our collaborative agreement would cover them only to the extent they were practicing within our community health center. If they were practicing out of, you know, outside of our walls or outside of our delivery system then it would not cover them for that I don't believe.

REP. JOHNSON: Okay.

Any other questions?

Thank you so much.

DR. DAREN ANDERSON: Thank you.

REP. JOHNSON: The next person is Pauleen Consebido and followed by Steven Zuckerman.

Welcome and please state your name for the record and proceed.

PAULEEN CONSEBIDO: Pauleen Consebido. Good day Senator Gerratana, Representative Johnson, Senator Welch, Representative Srinivasan and members of the Public Health Committee. Thank you for this opportunity to testify on House Bill 6391, AN ACT CONCERNING THE PRACTICE OF ADVANCED PRACTICED REGISTERED NURSES. My name is Pauline Consebido. I'm a certified registered nurse anesthetist or CRNA and a licensed advanced practice registered nurse.

I'm here today representing the Connecticut Association of Nurse Anesthetists. nurse anesthetists have providing anesthesia care to patients for 150 years. There are more than 45,000 nurse anesthetists across the United States. We are a part of Connecticut's approximately 3,800 licensed advanced practiced registered nurses. The administration of anesthesia is within the scope of practice of CRNAs and is, therefore, a recognized specialty in both nursing and medicine.

We provide anesthesia in every setting in which anesthesia care is delivered. This includes hospitals, obstetrical units, ambulatory surgical centers, office-based practices, the U.S. military and Department of Veteran Affairs healthcare facilities.

In the State of Connecticut, there are two anesthesia models in which nurse anesthetists practice. Nurse anesthetists are either a part of the anesthesia care team in a hospital or outpatient setting or contract with a freestanding surgical center. In the hospital or outpatient setting, the anesthesiologist and nurse anesthetist work together as a team to provide anesthesia coverage for several anesthetizing locations at one time.

In the surgical center or office-based practice, nurse anesthetist's work with a surgeon to provide anesthesia care to patients. Both approaches of anesthesia delivery serve our patients, the citizens of Connecticut well.

I would like to state clearly CANA's position regarding this bill. We are not seeking a legislative change to our section of the statute. At this time, Connecticut CRNAs do not experience those same concerns with access to healthcare as our APRN colleagues. Since the beginning of discussions on this most important legislation, CANA has communicated this position to the members of the APRN Coalition, to the leadership of the Public Health Committee, to the staff of the Department of Public Health and our anesthesiologist colleagues. We support our APRN colleagues and this bill as it is currently written.

As a number of insured individuals and families is expected to increase for the full implementation of the Affordable Care Act, a decrease in healthcare costs while increasing access to healthcare becomes increasingly important for the citizens of Connecticut.

Once again, thank you for the opportunity to address this committee.

REP. JOHNSON: Thank you so much for your testimony.

Are there any questions?

Thank you so much for being here and taking the time.

PAULEEN CONSEBIDO: Thank you.

REP. JOHNSON: Steven Zuckerman followed by Claudia Epright.

DR. STEVEN ZUCKERMAN: Good afternoon.

REP. JOHNSON: Good afternoon and welcome.

DR. STEVEN ZUCKERMAN: My name Dr. Steven Zuckerman. I'm a practicing ophthalmologist in Danbury, Connecticut, and also on the board, the executive board of the Connecticut Society of Eye Physicians. I'm here to represent my portion of the medical society along with Dr. Frank Castiglione. We represent over 1,000 physicians in the specialties of ophthalmology, ears nose and throat, dermatology and urology.

I want to thank the committee for your thoughtful work in this complex area of healthcare for the citizens of Connecticut. And we are appreciative and respectful of the contributions of our advanced practiced registered nurses, but we must oppose the request that removes the requirements for a collaborative arrangement with a physician but allows collaboration as an option.

In recent years, APRNs gained the ability to provide health services independently but in collaboration with a physician. Since that time, they have repeatedly asked this body to remove the requirements of collaboration each time without success. This is precisely the reason that Connecticut Legislature instituted a scope review committee process under the Department of Public Health. Connecticut physicians appreciate the hard work that went into enacting Public Health Act 11-209 authorizing scope of practice review committees. This is a thoughtful law that has created a process administered by the DPH to carefully examine scope expansion requests in the full light of their potential impact on the citizens of Connecticut.

The APRNs did seek a review by the scope committee late last year but the DPH chose not to review that request at this time so the APRNs came to the Legislature. There's little doubt that many groups believe repeatedly seeking scope of practice expansion leads to incremental increases in their practice.

Some states do allow the APRNs to practice without collaboration, usually a large state with a large rural population but Connecticut is a small state, roughly 60 by 80 miles.

The services provided by the APRNs in more rural areas of this country are of necessity, more independent, but not in Connecticut. The Connecticut State Medical Society studied this issue and found no shortage of physicians willing to collaborate with APRNs. In fact, the medical society proactively set up a APRN assist program to allow the matching of APRNs to physicians willing to collaborate, and it has rarely been used but it is not -- there is no shortage of physicians.

The requirement we believe for this collaborative arrangement is simply a safety net, and we would stand behind it as it is currently being practiced in Connecticut.

REP. JOHNSON: Thank you for your testimony.

Are there any questions?

Yes, Representative Srinivasan.

REP. SRINIVASAN: Thank you, Madam Chair.

Thank you, Dr. Zuckerman, for your testimony this afternoon. I'm glad to see you here.

And you brought a very important point which was being discussed by earlier people who gave testimony to us that we will be hearing somewhere down the line in the afternoon. But in your opinion and for the Connecticut State Medical Society when the APRN requests for a collaboration there -- to the best of your knowledge, there has never been a problem getting that collaboration, whether it be urban area or as it described in some certain rural area, even in our state, that collaboration maybe difficult to get?

DR. STEVEN ZUCKERMAN: That's correct. The medical society set up this APRN assist for that reason. It has rarely been used, although you'll certainly hear individual reports that I think that the society believes is a -- their own agendas to not collaborate, not wish to collaborate or find that there's some difficulty. In fact, the -- also, the AMA found that in those states where nurse practitioners have been given complete authority to be independent, they simply don't migrate into underserved areas. They tend to migrate to those areas that already have primary care services, roughly the same distribution of MDs and APRNs. There's no migration to underserved areas and there's no difficulty in those areas finding a physician that's willing to collaborate, in general.

REP. SRINIVASAN: Thank you very much.

Thank you, Madam Chair.

REP. JOHNSON: Thank you.

My co-chair has a question.

SENATOR GERRATANA: Thank you for coming today, Dr. Zuckerman.

I just have a quick question, how -- how many years does this collaboration been in statute?

DR. STEVEN ZUCKERMAN: I think the collaboration has been in statute since '99 -- '98, since the allowing of independence.

SENATOR GERRATANA: Yeah. I think you're right.

DR. STEVEN ZUCKERMAN: So it's been brought up multiple times but it -- it's always been referred back to the original law, which was set up to allow the APRNs to be independent, with collaboration, so certainly the late nineties.

SENATOR GERRATANA: Thank you.

REP. JOHNSON: Representative Conroy.

REP. CONROY: Thank you, Madam Chair.

I'm not sure you're familiar with the National Governors Association Report from last year.

DR. STEVEN ZUCKERMAN: I'm not sure. Which part?

REP. CONROY: It identifies in Connecticut that there's 39 federally designated health professional shortage areas and that in their report they're saying there's 434,000 people in Connecticut that live in a primary care HSPA. Are you familiar with those numbers, at all?

DR. STEVEN ZUCKERMAN: No, I'm not. I'm sorry.

REP. CONROY: And when you're saying that the rural states have nurse practitioners without, you know, practicing independently, do you know which states those are?

DR. STEVEN ZUCKERMAN: You know, I specifically asked my society today and what they said was they will investigate and give you the exact data as to which societies. What I asked them also was simply is the overwhelming majority of states requiring this collaboration, and the answer was yes. I did ask, specifically, which states were allowing the separation. They also told me that seven states have recently asked for the separation. And all -- six of them, we're the seventh -- six of them have denied that severing of the collaborative requirement, and we're the seventh.

REP. CONROY: Thank you.

Thank you, Madam Chair.

REP. JOHNSON: So I just have -- I just have one more follow-up question. Do you think that the -- the agreement, the collaborative agreement, perhaps, is one of the reasons that the current configuration of the people who are practicing as APRNs and doctors have to have a collaborative agreement and doctors will sign onto these agreements because they're in close proximity to the APRN who's practicing. And that, perhaps, they might -- the APRNs may spread out more without the collaborative agreement?

DR. STEVEN ZUCKERMAN: Well, it does sound like a logical consideration. The AMA, as I said before, when they studied it, found that in those states with independent APRNs, there was no spreading out of services to underserved populations; that there's a similar tendencies that drive internists, family practitioners and any physician to a location becomes in attractive location becomes in an attractive location for an APRN, as well. In fact, they provided me data today that said that only 50 percent of APRNs are -- are providing primary care services; that many of them are actually looking to become more specialized, as well.

So our efforts, necessarily, to believe that it's going to -- by severing the tie, it would result in a better spread care throughout the state, at least, doesn't nationally appear to be playing out.

REP. JOHNSON: Representative Sayers.

REP. SAYERS: Thank you.

Thank you, Doctor.

Doctor, do you have APRNs in your practice?

DR. STEVEN ZUCKERMAN: No, not in my practice. We are -- in our -- in our specific area relying more on optometric care. Scope of expansion laws tend to overlap so we do see these issues coming up over and over so I can't speak from personal experience just as a member of the society.

REP. SAYERS: In the collaborative agreement, what do you see that collaboration as meaning?

DR. STEVEN ZUCKERMAN: To us, it's a safety net. And that the requirement that a APRN practice under some supervision or with the -- it is not supervision directly on a patient care, but it is a -- an overall review and arrangement with an internist to be able to provide those services for those patients when the questions, consultations, expertise is required.

There is a blurring in our society about who does what in medicine, and there is a constant effort among nonphysicians to continually acquire greater and greater privileges blurring that division with usually a statement that are costs will go down. But those costs generally don't go down over -- over time because they then, secondarily, demand that their cost procedure should equal a physician.

If an MD is doing a service and a non-MD is doing a service why should there be a blurring of payments. So it starts as, usually, as an access issue, then it becomes and independence issue, then it becomes a financial issue. But in -- to society, it becomes a blurring of the quality of the physician, who has studied for countless hours and significantly more years, in terms of -- of becoming an expert in their field.

REP. SAYERS: And, actually, it's not supervision. It's very specific that it is not -- not supervision.

So you said it was an increase -- looking for an increase in their scope of practice. How would that change their practice?

DR. STEVEN ZUCKERMAN: I don't -- if I was an APRN practicing without the safety net of a physician behind me, I believe that there would be an extra risk to my practice, to incurring risk with malpractice, to not having a collaborative arrangement increasing the risk that a judgment of -- of medical malpractice might be brought against me.

I work in a collaborative arrangement with multiple physicians and nonphysicians in my practice. And we are constantly collaborating on a given patient on a given day. So though it's not APRNs, we have non-MDs working us, seeing patients in that type of an arrangement, and we have formed that type of collaborative agreement.

One of the speakers before who's an internist works in collaborative arrangements with APRNs. And in fact, our belief is that it's the model of the future. We love the collaboration. I think as we go forward under Affordably Care Act, we're going to see more of those collaborative efforts, not less. In fact, there will not be enough internists, there will not be enough ophthalmologists, there will not be enough physicians. We really need those physician extenders, whether it's nurse practitioners, independent nurse practitioners, whether it's physician assistants.

We need to build, I believe, a team approach and that type of collaboration I know that this is a written arrangement for collaboration but that type of collaboration occurs every day in my practice. And I believe it is in the best interest of our patients to maintain those collaborations as both my -- my practice and -- and the previous physicians' practice already have those types of arrangements whether it's written or not. It just happens to be part of the safety net written into the law right now.

REP. SAYERS: And actually that would be my next question. Do you have collaborative agreements with the other physicians that you collaborate with and, if not, why not?

DR. STEVEN ZUCKERMAN: Well, the MDs, of course, we don't have collaborative arrangements. In the practice we're all medical doctors so we don't have to have that. The non-MDs who are hired by our practice are under an employment agreement with our practice as employees. So it's not written as a collaborative agreement. It is simply an employment agreement. So I can't say that it's -- it's the same arrangement as an independent APRN would have with us.

Now, for the non-MDs in our practice or even for the MDs in our practice, to ever to take any risk beyond their medical expertise when we believe it's dangerous so we have an employment agreement which leads to a collaboration which then becomes a protective mechanism to reduce our risk of malpractice, poor judgment and to improve outcomes for our patients.

REP. SAYERS: Right, right. And so but you still continue to collaborate with other physicians without having a written collaborative agreement and does that -- I'm not clear really where the collaborative agreement increases the scope of practice. I haven't heard that --

DR. STEVEN ZUCKERMAN: Well --

REP. SAYERS: -- and that's really my question. I mean, how does it increase the scope of practice because I'm not hearing that it does?

DR. STEVEN ZUCKERMAN: What I see in the outside community -- now outside of my practice. There are nonphysicians who are in our community -- I practice in Danbury -- who have a wonderful spirit of collaboration. They are absolutely fantastic. When a complicated patient comes in, they are instantly referring them to a specialist. They know the limits of their training and they refer quickly.

However, there's also another type of non-MD that I've seen where they do not know the limits of their expertise, unfortunately. They have not had the training to know when a referral is necessary. They simply do not refer the patients in an appropriate manner. The patient is referred late, often in my field, the patient may have a blinding condition or they're much more along in their severity.

So in -- what I think you're alluding to, which I think is very true, is that the best doctors, MDs, non-MDs, even a nurse practitioner, the best healthcare providers absolutely know the limits of their training and refer. I refer within my practice. I refer outside of my practice. And as an MD, I feel competent when I know that a referral needs to be done because the non-MDs in my practice are under the umbrella of the physicians in my practice, we are constantly educating them about what is an appropriate referral, how much is within their level of training, what our comfort zone is.

Sometimes you don't know what you don't know, if you've heard that expression. There are doctors in our community even though we don't have no collaborative arrangement with them who instantly will refer appropriately, but my concern is - is that limited group of health practitioners who, unfortunately, without the umbrella, the protection, the education, the constant working with a physician, they do make mistakes. And we see those patients coming to us later with more advance disease because they simply didn't know or they tried to treat beyond the level of their training. And it -- it does happen on a day-to-day basis. It's not a written collaborative agreement in my practice but because we're there working with them, we believe that that is the model for the future.

REP. SAYERS: And the non-MD that you're talking about in your practice, are we talking about medical assistants?

DR. STEVEN ZUCKERMAN: No, no these are -- these are doctors but not medical doctors in my practice.

REP. SAYERS: Doctors but not medical doctors.

DR. STEVEN ZUCKERMAN: Optometry in my practice.

REP. SAYERS: Right but they have a right to an independent practice so --

DR. STEVEN ZUCKERMAN: They do have a right to an independent practice. That is correct.

REP. SAYERS: Right. I'm still haven't heard where the collaborative agreement increases the scope of practice. You're saying this is a scope of practice issue so I'm trying to determine where the collaborative agreement, which is basically what you're telling me is basically a practice agreement --

DR. STEVEN ZUCKERMAN: But it --

REP. SAYERS: And you're talking about referral that some refer early some refer late. Some doctors refer early; some doctors refer late. I mean that is -- that is more about the person's practice and their skills than -- I mean, that has something to do with scope.

DR. STEVEN ZUCKERMAN: No, this is not an issue of scope.

REP. SAYERS: Right.

DR. STEVEN ZUCKERMAN: We believe it's an issue of a safety net that it provides the back up. It provides, hopefully, the collaboration increasing education, increasing the comfort level --

REP. SAYERS: No.

DR. STEVEN ZUCKERMAN: -- with which patients are appropriate to treat --

REP. SAYERS: -- you're telling me that it's not a scope of practice issue than a collaborative agreement.

DR. STEVEN ZUCKERMAN: Even the speakers before had said it is not a scope.

REP. SAYERS: Right.

DR. STEVEN ZUCKERMAN: -- of practice issue.

REP. SAYERS: -- and I would agree.

DR. STEVEN ZUCKERMAN: Right. This is -- this is simply a safety net issue as it's written into the law. And we also believe it should be reviewed by the DPH and then those whatever comes out of that committee would probably -- I believe be acceptable language.

REP. SAYERS: And I think that's only for scope of practice issues. So if this is not a scope of practice issue, it should not actually go before DPH but thank you.

REP. JOHNSON: Thank you, Representative.

And thank you so much for your testimony.

Yes, Representative Perillo.

REP. PERILLO: Madam Chair, thank you very much.

Representative Sayers asked a number of very, very good questions. I just want to follow up on a few, and I want to go back to some of the things that I think I heard you say.

In the course of your answers to Representative Sayers, you mentioned that you drew a distinction between knowing when to refer and when not to refer. And I believe you said the best MDs know when to refer; is that correct?

DR. STEVEN ZUCKERMAN: Yes.

REP. PERILLO: Would the natural corollary to that be that the worst MDs do not.

DR. STEVEN ZUCKERMAN: Absolutely.

REP. PERILLO: I think, precisely, to Representative Sayers' point, at the end of day, there are good practitioners and there are less good practitioners. So then should there not be a collaborative agreement for all levels of practitioners?

DR. STEVEN ZUCKERMAN: Well, I'm not disagreeing with the possibility. However, our -- I think our perspective is -- is that the worst MDs not to say are better than other practitioners, but they have a certain level of training and expertise based on hours and hours, five, ten years of training, post graduate. So we hope that the advanced training that they receive will allow them to make a decision without the requirement of a collaborative agreement among physicians, which at this point doesn't exist.

So, yes, I mean how do we protect this society, in general, against any physician, any MD, any non-MD, who should be making better more timely referrals? It's certainly a good question, but we don't think that taking the collaborative language now would improve the quality of care for the residents of Connecticut. So it's in the statute right now and simply we believe it should stay. If we want to move forward in other areas that that certainly is good area for discussion.

REP. PERILLO: Thank you, sir, very much.

And I just want to clarify something that I believe Representative Sayers questioning did bring to light and I think you did agree with is that this is not a scope of practice issue. And that indeed removing the -- the, you know, the collaborative relationships would not indeed change what an APRN can or cannot do?

DR. STEVEN ZUCKERMAN: That's correct.

REP. PERILLO: So just given that and if I could just add my two cents. I had the good fortune of being able to be intimately involved in the drafting of our legislation for DPH in the scope of practice review process back in 2011.

In fact, Representative Ritter and I, I think, finalized that language by hand on the back of -- back of a piece of paper, but it's a good law and my vision of that and others who are were on the Public Health Committee may agree or disagree but my vision of that was that the DPH process as stated in, you know, in 2011, would be for things that are indeed changes in a scope of practice.

What came to mind immediately for us were dental hygienists who wanted to expand their scope, optometrists who wanted to expand their scope, podiatrists who would come to us and wanted to expand their scope of practice. In all of those instances, in all of those cases, there would have indeed been additional services, procedures, assessments that could have been performed by that class of practitioner.

And it seems that you are agreeing with us that, in this case, that would not be the case. There would be no additional scope of practice, no additional procedures or assessments provided.

So I --

DR. STEVEN ZUCKERMAN: I look at it from a medical point of view and sometimes I get --

REP. PERILLO: I'm doing the same thing.

DR. STEVEN ZUCKERMAN: Yeah, so from a medical point of view the scope of practice, I agree, is the same. You are practicing the same type of medicine, seeing the same type of patients, nothing changes.

Sometimes the law and that's why I don't know how to interpret the DPH, sometimes the law of scope of practice might include a collaborative arrangement. In other words, does the law of requiring a collaboration as it exists right now, is getting that in -- is that under the body of -- of scope of practice expansion, or is it not under the body of scope of practice. I -- I simply don't know -- I'm just separating the medical issue from the legal issue.

And from the issue that's brought before the State here, the DPH, yes, they refused to review it at -- at least at this time. Did they -- I don't know if they didn't review it because they felt it wasn't a scope of practice issue or because they simply couldn't reach it at this point in time.

In other words, if they had looked at it, they might have said this is not a scope of practice issue at all, and we're going to push it forward. I don't -- I'm trying to distinguish, as I think you are, between the medical and the legal interpretation of the scope of practice. Does a collaborative agreement fall under some type of legal scope of practice because that's how the law's written, and -- and that's not an answer I can give you. I can only say, as a medical practitioner, there's no change in the scope of practice as a medical answer.

REP. PERILLO: That clarified things I suppose. Thank you.

DR. STEVEN ZUCKERMAN: Thank you.

REP. JOHNSON: Very good.

Okay. Thank you so much for your testimony, and I think that's it for questions.

And I have to make an announcement now.

There are a number of people standing in the doorway, and that's not -- not good for fire exits or whatever other types of exiting we must do. There is an overflow room in 2E. So if you can't find a seat here, then please go to 2E. And we try to call a few people in advance so if you're here to testify on this particular bill then we will -- kindly stay in the room so we can get to you quickly but, otherwise, if you're down the list somewhere, perhaps, 2E would be a better spot.

Thank you for clearing the doors.

The next person I have here is Claudia Epright and then followed by Dr. Roy Zagieboylo.

Welcome and please state your name for the record and proceed.

CLAUDIA EPRIGHT: Thank you very much.

My name is Claudia Epright. I am a consumer and advocate and currently a member of the consumer advisory board for Connecticut's Health Insurance Exchange on the consumer experience and outreach subcommittee. I am -- I wish to offer testimony to all of you regarding HB 6391. I want to thank you for the opportunity to offer the testimony today regarding this bill.

On October 1st of 2013, Connecticut is on track to begin enrolling the currently uninsured for medical coverage through the Connecticut Health Insurance Exchange, now known as Access Health Connecticut. Since 2006, the health care community and the network of health care reform advocates have known that there was a shortage of primary care physicians to handle the large numbers of uninsured in Connecticut, as well as around the country.

Many states that are preparing for implementation of the Affordable Care Act have already given advanced practice registered nurses the ability to set up private practice. They have the education and licensure which allows them to provide basic primary care for the most common of health conditions. They currently will consult with specialists the same way that doctors do in order to provide the highest level of care to their patients.

Currently in Connecticut, an advanced -- registered -- excuse me -- advanced practiced registered nurse must have a letter of collaboration with a doctor in order to practice. This is a barrier because if the doctor dies or chooses to close his or her practice the advanced practiced registered nurse must also cease to treat his or her book of patients. This puts the patient in the position of having to find a new source of medical care. It can create havoc in a patient's life, especially, if the patient is in the midst of some long-term treatment protocol. It also puts additional strain on the existing practices since most primary care offices are stretched to their limits dealing with existing books of patients.

Once the Affordable Care Act and enrollment period begins, the demand for primary care services will dramatically increase putting additional strains on a system currently under stress. Many legislators, as well as many private individuals, are working hard to see that Connecticut can provide the best of health care to its residents.

Connecticut is currently among the leading states in the development of this health insurance exchange. As a leading state in health care reform, I believe we need to act on options that will help improve the health of our work force.

This really is going to be an issue of access to care. We already know that there is going to be a shortage and the goal of the insurance exchange is affordable, accessible healthcare for everyone.

I believe that HB 6391 would allow for increased access to health care for the currently uninsured. Network affordability and network adequacy are two major -- I heard it -- two major issues with the Health Insurance Exchange and I urge this -- this panel, the Public Health Committee, to vote in favor of giving the APRNs the expanded -- the ability to practice without that letter of collaboration because I do believe it will considerably help the availability of health care after October 1st and January 1, '14.

Thank you.

REP. JOHNSON: Thank you so much for your thoughtful and well-delivered testimony.

Are there any questions?

Yes, Representative Srinivasan.

REP. SRINIVASAN: Thank you, Madam Chair.

And thank you very much for your testimony.

We have repeatedly heard this afternoon that the need is going to increase, and I definitely believe in that, but what we cannot even get our arms across is this collaboration is what we're talking about here. We're not talking about the availability of physicians. We're not talking about the availability of APRNs. We're not talking about the medical services available in the state. The issue for us is how does this collaboration, as it exists, inhibit or prevent this access from occurring that is what we're trying to grasp here?

And, of course, we were told earlier that others would be coming down the line giving us instances and, in your opinion, where does this collaboration prevent the -- the access from being a reality because if there are not that many people to provide, whether it be physicians or APRNs, there is not going to be access. The collaboration I do not see as an obstacle. Of course, you did mention about the death of a physician and you did talk about one of those situations, which, you know, obviously, we can understand that but where else would this collaboration come in in giving access to our patients?

CLAUDIA EPRIGHT: Well, one of my concerns is that the average age of physicians in this country is 50 or older, which means that many of them are -- are aging. They're aging out. And as a result, many of the practices will close, and when those -- when those doctors age out and retire, currently, an APRN connected with one of those doctors would not be able to maintain that practice.

Now, if you were to remove the block, the letter of collaboration, then if that doctor should -- that they have -- that the APRN has a collaboration with should choose to retire or close their practice, the APRN without need of the letter would be able to maintain that practice and keep it open.

And I'm thinking about the availability of care for some of the more rural areas of Connecticut. I live in Deep River, and we are, I guess, we're considered to be a rural area. We have limited public -- public transportation system. My representative is shaking his head saying, None. So in order for us to be able to access care, we have to be able to drive somewhere and there are -- there are a lot of people who cannot afford, maybe cannot afford the gas, can't afford the time, may not have a car. I think availability of care is going to be a greater problem once the Affordable Care Act kicks in.

We're looking at adding 69,000 people to the number of folks that now require care and you ask anyone anywhere how long it takes to get an appointment with a doctor. You can't just go in today, the -- the number of acute -- they call -- my doctor calls them acute appointments, the number of acute appointments gets used up very quickly. You're very early in the day, maybe you only have about three or four during the day that are -- that are retained for the people that need acute care. And then long term, if you want to, you know, you got three or four months ahead you've got to schedule your physicals.

So I really think that if we could get -- if the APRNs could set up their own practices, it would allow for doctors to seek -- spend more time with the patients because right now you're looking at a five-or ten-minute visit with a doctor. With and APRN even with the -- the -- I'm sorry I'm a little nervous -- the PA, physician's assistant will spend more time with me when I'm at the doctor than my primary care doctor will because she has the time. And I think that the APRNs would also be able to spend more time with their patients. You know there's not much a doctor can tell you in five minutes. It takes me that long to explain to him what's going on.

So it's -- I think that removing this barrier would increase accessibility and also increase quality of care because the APRNs are trained in a different model. They're trained in a nursing model, which is a more holistic approach to health versus the medical model, which is the way doctors are trained and that's focusing on symptoms.

I can't say enough about my own doctor. He's trained in both Eastern and Western medicine so I get the benefit of both worlds, but I know that's not true for everyone who has to access healthcare through whatever professional.

REP. SRINIVASAN: Thank you very much for your testimony. You're doing a phenomenal job. There's no reason to be nervous at all. You're doing great, you're doing great.

Just to follow up on that. Are you aware of -- of your organization giving us some kind of a number, you know, about the -- the occasions where the APRNs practice has been restricted, limited, not able to open up, whatever, hence reducing the access because of this collaboration?

CLAUDIA EPRIGHT: I, personally, am not aware of any information but I certainly can do some research, and I would be very happy to get that information to the -- to the Public Health Committee.

REP. SRINIVASAN: That would very helpful to us and we would appreciate that very much.

Thank you.

Thank you, Madam Chair.

REP. JOHNSON: Thank you.

Yes, Senator Welch.

SENATOR WELCH: Thank you, Madam Chair.

I guess just to follow up on Representative Srinivasan's question. Do you know of an APRN who had a collaborative agreement and had that doctor retire or something such as a collaborative agreement is no longer in existence?

CLAUDIA EPRIGHT: I'm sorry. I do not know of any such --

SENATOR WELCH: You don't. Okay.

CLAUDIA EPRIGHT: -- personally know of any such any situation.

SENATOR WELCH: Okay. Thank you.

Thank you, Madam Chair.

REP. JOHNSON: Thank you.

Any additional questions?

Okay. Thank you so much for being here today.

CLAUDIA EPRIGHT: Well, thank you for the opportunity to testify.

REP. JOHNSON: Okay.

We're going to have Dr. Roy Zagieboylo, if that's how I say your name, thank you. And then we're going to be following doctor with Professor Stephen Mikochik and Claude Holcomb.

DR. ROY ZAGIEBOYLO: Well, good afternoon, Senator Gerratana, Representative Johnson and -- and Representative Srinivasan and other members of the Public Health Committee.

My name is Roy Zagieboylo. I'm a family physician and a past president of the Connecticut Academy of Family Physicians. I've been practicing in Connecticut since 1985. In addition to the past 23 years, I've been part-time faculty at the University of Connecticut School of Medicine. And I'm here today on behalf of the Connecticut Academy of Family Physicians in opposition to Bill 6391.

The medical home concept is being recognized as a patient-centered approach to primary care. This is supported by the Affordable Care Act and integral to the development of accountable care organizations. The team approach to care is more proactive in management of preventive healthcare and chronic disease, reaching out to patients for improved care. It requires the organization to monitor their own quality of care. Other innovations, like, group visits, e-mail communication with patients, same-day visits, are also going to help improve patient care and meet patient needs.

One of the key principles of a patient-centered medical home is that each member of the health care team has to work up to the full aspect of their license. For physicians, that's going to mean stepping back from total control of patient care from when they walk in the office to when they leave. And for APRNs, it's going to be likely to have an increased care in the more chronic disease management and preventative health care, using physicians as more in-house collaborators. So this -- this is the future of medicine is the medical home, we hope.

Certainly, to provide APRNs full independence seems like that would undermine the patient-centered team approach to care. A certain percentage of those APRNs would divorce themselves from the team model for independent practice that's what they have the option to do.

With millions of Americans gaining health insurance, we need more primary care providers, both nurses and physicians, working together in a coordinated integrated health care team. Providing care in underserved parts of the country requires creative systems and new and different models of care. Each layer of a patient-centered medical team must build on the other and not be isolated. The team based -- the team-based approach ensures the patient gets the right care from the right professional at the right time.

Several studies have shown that a regular source of primary care and continuous care with the same physician over time leads to better health outcomes and lower costs. And medical homes are designed to emphasize that. A recent survey by the Common Wealth Fund concluded that adults with medical homes have enhanced access to care and receive better quality care. The survey defined medical homes as regular health care providers that offer timely, well organized and enhance access.

Given these benefits of the medical home, we question of APRNs would have an interest in joining a medical home if they are in independent practices, it seems a contrary concept.

Personally, I am the medical director of a 340-bed nursing home who has medical assistants, and I'm the collaborating physician for them -- APRNs and I'm the collaborating physician. I'm the medical director of Masonic Care Hospice team, and I have APRNs and I'm the collaborative physician with. I must have missed a big source of income because I don't get paid for that. And I also do review their work, and I wouldn't work with them if they weren't qualified.

And that is my definition of collaboration that I'm willing to work on this and that I think works to provide better care in those settings, in both those settings in which I work with nurse practitioners. One of them trained in my office as part of her clinical duties when she was getting her licensing.

I think that this is a new world. I'm also on the -- the board of the Saint Francis PHO O'Connell Care Organization, which was just approved in January. And just shoot me for that, too, by the way. If I go to any more ACL meetings it'll drive me insane. But the ACL concept is sound and the ACL concept is putting the responsibility of the finances and the clinical outcomes to the people providing them rather than their old fee-for-service model that just rewards people that do more and more and more whether appropriate, inappropriate, good outcome, bad outcome.

So I believe in the principle, and I believe that principle requires team work and it requires APRNs and PAs working with primary care. It doesn't require them working in some other part of town and referring to specialists. Almost by definition with lower level of clinical hours of training, if they're not using specialists more than a primary care physician, then they're doing the wrong thing. It helps -- it helps push towards that fractionated triage to specialist care that's more expensive than the worst outcomes.

Thank you.

REP. JOHNSON: Thank you very much, much appreciated taking -- your taking the time to be at yet another meeting.

DR. ROY ZAGIEBOYLO: Yes.

REP. JOHNSON: Are there any questions?

Yes, Representative Cook.

REP. COOK: Thank you, Madam Chair.

Thank you for your testimony.

And we don't want you to shoot yourself dead.

DR. ROY ZAGIEBOYLO: (Inaudible.)

REP. COOK: My question, I chair the Primary Care Committee, the subcommittee, here at the Capitol and been instrumental in working with the Department to roll out primary care statewide. And we've had hundreds of practitioners that have, you know, been committed and jumped on board and done yeomen's work in -- in the vision that we have.

Part of our concern, though, with primary care is to find those qualified people that would be able to -- to be in an office and help collaborate care and give -- give information if the mother of a newborn child calls in and says my child has a fever, you know, that part of the primary care home conversation that we're really striving for to keep people out of the emergency rooms that we, you know, and give them care and help them with, you know, just the everyday routine questions.

Would -- would by expanding this -- and I hate to use the conversation of scope -- but by expanding this and -- and moving this bill forward would that not open up the ability for -- for these people to fall into that role, as well.

DR. ROY ZAGIEBOYLO: There's a great need for primary care. If this bill passes, are there suddenly more schools out there producing more individuals? Are they -- you know, can you see twice as many patients somehow because now you're not collaborating. I don't see -- would it attract more people to the state, maybe is the argument. I don't really think so in a setting that I want them attracted to.

I don't see how it would increase providers. I think the things that are going to increase providers, you know, we could talk for hours about how to push the training of more primary care providers whether it be nurse practitioners or physicians, but it's really a separate issue. And if anything, I -- I just don't see taking away the collaborative agreement leading there to be more of them working in this, you know. Will settings open up where they can become independent? If they do, I'm -- I'm really not in favor of those settings.

You know, if you set a collaborative wall for the APRN who's here who practiced 20 years and could easily practice independently, it's the same rule for the new graduate who just finished up. And I don't -- I don't envision more setting, you know, I don't envision how this bill is going to increase current care in the State of Connecticut.

REP. COOK: So is accountability -- is accountability one of your primary concerns at that point from what I'm gathering from you?

DR. ROY ZAGIEBOYLO: I think that I would not -- I think we're all accountable when we see patients . Right? And I don't want to devise a system that helps people go the old route of having more send out to specialists and have this specialist-based system, and I don't want to have a system that will tease people into thinking they're more qualified than they are because I must be able to.

I can envision a health center that added new APRNs and had their senior APRN, who then retires, and the ones who've been in practice a couple of years feel like I've been doing this a year, I -- I know my limitations, I've seen enough, I'm good enough to stay with this and not have the backup they really need. I -- I mean, who knows?

REP. COOK: Thank you.

Thank you, Madam Chair, for allowing my questions.

REP. JOHNSON: Thank you.

Representative Sayers.

REP. SAYERS: Thank you.

Thank you, Doctor.

You said that you saw collaboration as review of their work, or I'm not clear could you just clarify that.

DR. ROY ZAGIEBOYLO: I am willing to collaborate with these nurse practitioners because I'm able to look at their work. I'm able to talk with them. I'm able to give them feedback. If you wanted me to collaborate with you as an APRN and you weren't willing to do that, I wouldn't do it. Now that's not in the law. The law's specifically vague and I was here in 1999 and they pushed having that be vague so it wasn't more restrictive, so it was more open. That doesn't mean that as a physician if I'm going to collaborate with a nurse practitioner, I'm just going to sign my name and have them send me a check that's ridiculous in my mind.

REP. SAYERS: Okay. And -- and by the way I was here in '99, too, and I do remember when we did that -- that legislation, and it wasn't specifically vague. It was that the intent was to have a collaborative practice --

DR. ROY ZAGIEBOYLO: Right.

REP. SAYERS: -- and another physician identified it as that they collaborate with other physicians, as well, and when you collaborate with them, do you look at their work?

DR. ROY ZAGIEBOYLO: Certainly. Now, you're mixing up collaboration and consultation. My partners and I collaborate, we see each other's patients, we read each other's notes. And if one of partners didn't want to show me his note in my office, he wouldn't be working with me. I -- in order to collaborate, realistically, we have to share and communicate.

REP. SAYERS: Okay. And so if there wasn't a written collaborative agreement, do you believe that the APRNs would no longer collaborate with anybody else?

DR. ROY ZAGIEBOYLO: Correct. I think in certain -- certain one's would have the ability not to. They collaborate with other APRNs. They join a group. They'd -- they'd -- I gave you the scenario of a health center that sees it as -- has a senior APRN that's been there for years, their doctor retires, they say we don't need to replace him. And they have other people and then that person retires and they have all new -- newer APRNs. And the model has always been we collaborate with each other.

REP. SAYERS: I just --

DR. ROY ZAGIEBOYLO: That's fine.

REP. SAYERS: I disagree with you -

DR. ROY ZAGIEBOYLO: I mean if that's what you want.

REP. SAYERS: I suspect that the truth of the matter will be that there will -- some people will always collaborate and there are others that do not whether they're a physician or an APRN. They're not inclined to collaborate.

DR. ROY ZAGIEBOYLO: And you can design the law which way you want, but you can try to push it one way or the other. There are people that do the wrong thing no matter what you do.

REP. SAYERS: Exactly.

You said you -- oh, you teach out at UConn?

DR. ROY ZAGIEBOYLO: I teach within -- I'm in the Family Medicine Department of the University of Connecticut. I've taught medical students. I have medical students in my office. I have 30 percent of my teaching time is in the residency program at family medicine residency.

REP. SAYERS: So when you review that work of those students and you review the work of the APRNs, one of the things -- I work for the Department of Public Health and reviewed both physician's notes, APRN notes and a number of other provider's notes. And I will tell you, they're -- physicians' notes are usually very sparse. It's very difficult even though he may well -- and I'm not saying that he doesn't know what he's doing -- he's just not very good at documentation. And I'd rather take an APRN and the documentation they have to have to review any day of the week over a physician.

DR. ROY ZAGIEBOYLO: I have a different experience. I have good notes from the APRNs that I reviewed that work in the nursing home and for hospice and if the family medicine residents that I helped train, or the medical students in my office have lousy short notes or if one of my partners does, they'd get a talking to.

When I have a new partner come in, I review there notes. There's no requirement to do that. I renew their -- I review their notes for at least a couple of months, giving them feedback. I also have their bills next to their notes before I send the bill in to make sure the coding in correctly. And -- and I give them internal feedback both about their quality of care and their notes, and I can't speak for any other individuals. I've looked at a lot of notes that were good and looked at a lot of notes that were bad.

I can tell you what we're teaching our family medicine residents and medical students now and what Medicare and other insurance regulations are about what must be in a note. And if it's not, it's Medicare fraud; it's insurance fraud and the people should be called on it and they are.

REP. COOK: And I will tell you this summer, I had the opportunity to take some of the family medicine students out with me on home visits for nursing care, and as part -- it was part of their training, and I think that's an excellent adjunct for them to be exposed to that because so much of future care may be home care. And a lot of times I think doctors don't think of in terms of what happens in the home.

DR. ROY ZAGIEBOYLO: And my medical students go out with the hospice nurses to home visits with the hospice nurses.

REP. COOK: Right. So but -- but the thing of it is what I heard from you is that new APRNs will probably act beyond their scope of practice where older more experienced APRNs will not, and I'm not sure --

DR. ROY ZAGIEBOYLO: -- The more years you train, the more -- to a point the better you are, right. You have to have --

REP. COOK: True of anybody.

DR. ROY ZAGIEBOYLO: You have to have a certain level of training to get experience.

REP. COOK: That's true of anybody.

DR. ROY ZAGIEBOYLO: And the number of clinical hours that a graduating APRN has is about equivalent to the clinical hours of a graduating medical student, and then we go on -- in family medicine, we go on for three years. They just limited the work to 80-hour weeks for three years on top of that clinical experience. So, yes, I think, APRNs by the nature of the business and their training are less experienced when they graduate and, obviously, are going to gain experience from the ones that are good are going to get better as they gain clinical experience. And they're going to be able to know their limitations better. It's the nature of the beast that you have to put in a certain number of hours.

REP. COOK: And, though, for the last question that I had is that do you think that anything will change if there's not a written agreement?

DR. ROY ZAGIEBOYLO: I don't think the world will end, didn't change -- you know, the world didn't end when we went to collaborative agreement. I think it will only work to help separate team work, to help separate the team approach to care. It won't do anything to add to the team approach, but it will only potentially hurt the team approach to care.

REP. JOHNSON: Okay.

Thank you so much for being here today and providing testimony, much appreciated.

Okay. We have Professor Stephen Mikochik and followed by Claude Holcomb.

Welcome and thank you for being here and please feel free to state your name for the record and proceed.

STEPHEN MIKOCHIK: Thank you very much.

My name is Stephen L. Mikochik -- can you hear me?

REP. JOHNSON: Yes, your -- your microphone is on.

Thank you so much, sir.

STEPHEN MIKOCHIK: My name is Steven L. Mikochik and I am a emeritus professor of constitutional law at Temple Law School in Philadelphia, and I'm a visiting professor of jurisprudence at Ave Maria School of Law in Naples, Florida. And in some past life, I was an attorney and a disability expert for the Civil Rights Division U.S. Department of Justice.

I'm here at the invitation of the Family Institute of Connecticut, and I'm here to testify against House Bill Number 6645, which, in my opinion, is uncommonly bad bill. They're two issues that I'd like to briefly touch on. One is the deficiencies in the bill, and the second is whether the bill can be improved.

Concerning the deficiencies, Senator Meyer, who I understand is a principle sponsor of the bill, identified himself some of the deficiencies in earlier testimony and I need not repeat it. But if you look particularly at the waiver provision in Section 7(b), it is literally possible that at the time that a patient receives the initial diagnosis of a terminal condition that that patient can have a lethal dose in hand that day. There is no set requirement for consultation in can be waived under 7(b).

The attending physician has to refer for a psychiatric or psychological evaluation, if there's an indication of clinical depression. There is no requirement that that attending physician have any training in identifying clinical depression. There is a requirement that the attending physician evaluate the competency of the person requesting the lethal dose. There is no requirement if you look at the definition of attending physician that that physician be really familiar with the patient's history and background. All that requires is that the patient -- that the attending physician be in charge of the terminal care. It could be a specialist that just has seen the patient once or twice. And even the witnesses to the written request don't have to have familiarity with the patient. For example, they can attest to the document based on receiving an ID that this is really the person who is representing that they are.

All right. So there are clearly serious problems. I assume the bell tolled for me?

REP. JOHNSON: Well, please proceed and summarize some more of your testimony.

STEPHEN MIKOCHIK: Let me then go to the main issue which can the bill be rehabilitated? And I think the answer is simply no. It is a recipe for elder abuse.

There is no requirement that at the time the individual patient, the elderly person, ingests the medication -- ingest doesn't mean take it and put in your mouth -- ingest means swallow, so you're bridging the gap, by the way, using that definition between assisted suicide and euthanasia. There is no requirement that there be an objective witness. An heir who would benefit from the estate if the individual died not only can attest to the statement where the individual is requesting the lethal dose but be the only witness present at the time the drug is taken. There is no requirement at the time the drug is taken that the individual patient be judged to be competent.

Senator Meyer ended his testimony by saying that section, I believe, 16 of the bill, indicates that anyone who coerces someone to take a lethal dose commits murder. How can you prove that under this bill? There is no requirement for an objective witness. There is no requirement even if you take the definition of self-administer as it stands, which is merely to swallow that the patient involved take the medication and give it to themselves, and the physician is required, required to falsify the death certificate and say it was the underlying condition and not the lethal medication that was the cause of death.

If there was coercion of a frail elder who decided at the last moment she didn't want to take the medication, how could you prove it?

Thank you very much.

REP. JOHNSON: Thank you.

Are there any questions?

STEPHEN MIKOCHIK: If you have any questions, I can answer them.

REP. JOHNSON: Yes, Senator Welch.

SENATOR WELCH: Thank you, Madam Chair.

So I guess the -- the first thing I want to do is understand what it is you just said because it's not something that I thought of and if I'm stating this correctly or incorrectly, please, let me know; and that is, you're saying as the bill's written it requires -- it requires that the individual be competent at the time they tell their doctor --

STEPHEN MIKOCHIK: -- or at least the physician says that they're competent.

SENATOR WELCH: -- the physician -- you're right -- you're absolutely --

STEPHEN MIKOCHIK: Right.

SENATOR WELCH: -- the physician says they're competent at the time that they ask for the prescription, but there's no secondary analysis done at the time they actually ingest the -- the pill.

STEPHEN MIKOCHIK: If -- if it's there, I haven't seen it.

SENATOR WELCH: Okay.

STEPHEN MIKOCHIK: And I've read the bill a number of times. It simply isn't there. By the way, it's not there in the Massachusetts legislation that the good people of Massachusetts decided was, also, uncommonly silly and they rejected it.

SENATOR WELCH: Well, then -- then I guess that leads me to maybe my next question and it sounds like your familiar with some of these laws elsewhere --

STEPHEN MIKOCHIK: Uh-huh.

SENATOR WELCH: -- to -- to what extent does our -- does the bill before us differ from what we see in Oregon, what we see in -- in Washington?

STEPHEN MIKOCHIK: Oregon, Washington, Massachusetts -- the Massachusetts bill that was defeated, all have, essentially, a 15-day waiting period. I would submit to you that even the 15-day waiting period is in significant. Just think about how long it would take someone to digest the fact that they had a terminal condition. All right you wake up from a car accident and the doctor tells you, you know, it looks like you -- you -- you may die within the next six months. Do you think it's going to take 15 days for you to be able to make a rational decision, again, let alone one day, which is what your bill provides?

SENATOR WELCH: Well, then if I may, through you, Madam President.

And so that's kind of one of the concerns I have is what does it mean to be competent and to what extent does or does not depression impact a decision or finding of competency? And I don't know based on --

STEPHEN MIKOCHIK: Can I -- can I address that. I'm sorry.

SENATOR WELCH: Sure absolutely.

STEPHEN MIKOCHIK: If you look at the --

SENATOR WELCH: Feel free.

STEPHEN MIKOCHIK: -- the -- the seminal Supreme Court decision in 1997, Washington versus Glucksberg, where the Supreme Court said there was no substantive due process right to die. One of the things the Justice Rehnquist -- Chief Justice Rehnquist wrote for the majority on was that about 95 percent, he said, of all people who attempt suicide are clinically depressed. Many, if not most of them, if they receive adequate treatment, recount the request for suicide. All right. That many doctors aren't trained in actually identifying clinical depression. So it becomes very important that there be an adequate determination of whether the person is, in fact, clinically depressed.

You know, it is odd to me, Senator, that if somebody is charged with a capital offense and raises an insanity claim, we almost always automatically determine whether they're competent to stand trial. And we don't do that by the judge that is sitting over and saying you look competent to me. What do we do? We send that person for psychiatric and psychological evaluations. Why do we do that? Because life is precious, and we don't want to take it away unless we absolutely have to. Why is it that we afford that process to people accused of capital offenses.

For that matter why do have witnesses at executions when a prisoners receive lethal doses to ensure that it's done in a humane way, but this bill neither requires a psychiatric evaluation, nor does it require an objective witness at the time the medication is taken.

SENATOR WELCH: Now, it -- it sounds like you've had experience advocating with justice or -- on behalf of justice on behalf of persons with disabilities, and I don't know to -- to what extent you've been working with that community.

With -- with respect to this bill, and -- and -- and bills like this but you've heard -- I'm assuming you heard the testimony this morning about individuals with disabilities being concerned about how they go in and out of terminal illness -- or in and out of -- I'm inartfully saying this but, at times, they're conditions appear terminal; at times, they're not terminal. And then also the fact their emotional state changes because of their disability at times.

And I don't know to what extent you've had experience dealing with individuals like that and would care to comment on the firsthand experience you might have.

STEPHEN MIKOCHIK: Well, let me -- let me structure this for you and see what you think. What's the policy reason why states like Oregon or Washington State have recognized assisted suicide for terminal patients? I think the policy reason is based on the recorded reasons why people in those states have requested assisted suicide.

The two principle reasons seem to be because they don't want to be a burden to their families and they don't want a loss of dignity and autonomy. But disabled people are socialized to feel the same way that they're a burden on their families that because of their disability they've lost dignity and autonomy.

If we're going to say to somebody with a terminal condition who's expected -- and, of course, this is subject to a lot of variation. I mean one can't bank necessarily on a diagnosis that the person will die in six months -- but let's assume for the sake of argument the prognosis is accurate. And we sit down and say, Look, isn't it awful for this person to feel a lack of dignity and self-respect for this six-month period. Let's let them instead of getting the love that they need for their dignity from their family, let's let them kill themselves because they think nobody loves them -- all right -- because we don't want them to endure the six months.

What about the disabled person, who's enduring these problems for 60 years, isn't there a stronger reason to provide that lethal dose to the disabled person with a severe chronic disability. And why should we limit it to the disabled person with a physical disability. What about a disabled person with a severe psychiatric disability and what about a disabled person who is unable to take the medication and put it to their mouth? Is it fair to disadvantage them, after all, we've given the right to other people?

And what about the disabled person who's never been really communicative. Can't we assume that nobody would live in his condition and if he could speak, he'd want to take this medication. And what about the disabled person who says I don't want it, well, you can't be rational to say you don't want it living in that condition. If you were rational you would want it so we're going to give it to you anyway.

That was happened in the Netherlands. That's what could happen here.

SENATOR WELCH: And -- and I guess, through you, Madam President, I just have one more question, Madame Chair.

And that is do the other states statutes require that the individual seeking physician-assisted suicide or compassionate aid in dying, do they require that they have a terminal illness?

STEPHEN MIKOCHIK: As they stand right now, they do. Washington and Oregon did. The legislation that was defeated in New Hampshire, I think, it was three years ago, said that the condition must be incurable and in reasonable medical judgment would result in premature death. I assume that it would include Parkinson's disease, I would assume that would include diabetes. I would conclude -- assume that would include muscular dystrophy.

So, in New Hampshire, there was this beginning process to do what I think was always intended to use terminal condition as the first step but, eventually, extend it to include other disabling conditions.

Remember a terminal condition is a disabling condition. I mean think about federal law it says a disability is a major -- an impairment, physical or mental to a major life activity. Clearly, somebody with a terminal condition is also going to be disabled. So all we're doing in this legislation is we're singling out one group of disabled people, and we're saying we, the State of Connecticut, think your lives are so less quality that we're going to offer this to you. We're going to offer you the lethal dose.

Well, once we say some class of disabled people, some class of Connecticut's citizens, all right, should be treated in a less equal fashion. We think their lives is -- are of such low quality, they -- they should have access to ending their lives. Then what stops us to -- from extending that to another group whose lives we think also are less worthy of living.

SENATOR WELCH: Thank you.

Thank you, Madam Chair.

REP. JOHNSON: Thank you.

Representative Ziobron.

REP. ZIOBRON: Thank you, sir.

And thank you, Madam Chair.

Your earlier testimony is quite compelling, sir. However, I -- I learned some things. You stated that you didn't think this bill could be fixed. So my question to you would be do you think a law or a bill could even be written to address the compassionate reasons why this bill is before us today?

STEPHEN MIKOCHIK: The compassionate reasons would be look there is no requirement in law, and I think it would be questionable constitutionally, for law to require that an individual continue with life sustaining treatment.

So if an individual felt, for example, that he didn't want to continue with a respirator. I don't think Connecticut law or any state law can require that. All right. But that's not the State coming in and saying that we're offering you the opportunity to die. It's the State coming in and saying, Look, based on our common law tradition, government can't enforce you to continue with treatment. Now, maybe your reason for not continuing treatment is because you want to die but maybe it's because the treatment is very invasive, or maybe it's psychologically repulsive to you, or maybe it's causing ancillary complications. There could be a host of reasons why someone would decline life-sustaining treatment, but at least when the State says that that we can't require you to continue with life-sustaining treatment, the State isn't saying, Okay, it's all right for you to kill yourself. And that's what any assisted suicide bill says. That it's all right for this class of citizens to kill themselves.

REP. ZIOBRON: So just to clarify, then, so what you're saying in -- in your testimony is that there is no way a bill could be written, at all, to get to the intent of the bill we have before us.

STEPHEN MIKOCHIK: If there was, I assume it would have been done by now. If you look at the legislation that has been proposed throughout the United States, the same pattern is there, whether it's the Oregon bill, whether it's the Washington State bill, whether it's the Massachusetts bill. Time and again these criticisms have been raised. Time and again they've been rejected, all right, not only by Massachusetts but every legislature in the United States that has considered assisted-suicide legislation has rejected it.

Once it's exposed to the deliberative and thoughtful legislative process rather than news bites in a referendum campaign, this legislation and if you compare the legislation there's one template going on, has been rejected by legislatures unanimously.

REP. ZIOBRON: And through you, Madam Chair.

I -- I had the opportunity to watch the PBS special on -- on this issue from Oregon, and at the time they, kind of, followed a patient and I was surprised to see the number of medications that are required in Oregon. And I don't know if you are aware, but can you tell me if the medication were talking about here is the same as it one pill or is it a number of series of steps, like it is in Oregon?

STEPHEN MIKOCHIK: Given the fact that the principle sponsor of the legislation couldn't respond to that in his prior testimony, neither can I.

REP. ZIOBRON: Okay. I'm sorry. I stepped out.

And lastly, if you could just clarify for me, sir, you mentioned that you are here at the request of the Family Institute? Are you also being paid by them for your testimony?

STEPHEN MIKOCHIK: No. They paid my airfare, but I'm picking up my own meals.

REP. ZIOBRON: Great. Thanks for your honesty.

And thank you, Madam Chair.

REP. JOHNSON: Thank you so much.

Okay. Any additional questions?

Thank you so much for your testimony.

STEPHEN MIKOCHIK: Thank you very much (inaudible).

REP. JOHNSON: Okay. The next person we have is Claude Holcomb followed by Debbie Gould.

Welcome and thank you being here today and please state your name for the record when you get situated and then proceed to give the testimony.

A VOICE: (Inaudible.)

CLAUDE HOLCOMB: I am Claude Holcomb. I am a resident of Connecticut, and I am here to speak about AN ACT CONCERNING COMPASSIONATE AID IN DYING FOR TERMINALLY ILL PATIENTS, Raised Bill Number 6645. This bill will turn into a suicide law for doctors. If this bill goes into law, then the Connecticut Legislature will be lowering the bar for doctors to make decisions about helping people to die.

I have a severe disability because of a doctor's care when I was born, coming out my mother's womb. Instead of attending to my birth, the doctor was having a cigarette. Now if I have to go into a hospital, I wonder if I will come out alive with my severe disability if this legislation becomes law.

It is human nature for people to read into the laws and interpret them however they want them to be implemented. How far will this law go? We've seen in history how one man killed a great number of people who were not perfect in his eyes. Are we opening the door for this to happen today?

We have to look at the whole picture of why many people in Connecticut want to kill themselves. People who have a terminal illness don't want to live with the illness. Some people cannot get the treatment they may need to slow the illness down and/or to alleviate the pain. Some people may have depression. So if there is an opportunity for a doctor to end their life, or prescribe a drug for them to end their life, they would not have to think about their depression any more.

The elderly population may think, why am I still alive? I cannot do anything for myself in this life without help. Doctors may decide to eliminate people with disabilities as a way of protecting resources and ensuring a better use of their time.

I do not understand why some doctors believe in killing people who want to die and believe that this is the choice of the person. All people have a place in this country. This state is not poor. It can help people who are sick and are living with pain. Doctors have medications to help people live with their illnesses and for them to continue to contribute to our society.

I am not a religious person, but I believe all people have a place in this world. People should not have to make a choice to take their own lives. It is tragic to have a law to say it is okay to have a drug to end a person's life if they feel the time is right. Some doctors do that now quietly, without a law to tell the doctor and patient what they can decide to do. Doctors prescribe morphine in dosages that will cause death, sometimes making it easy for family members when an impasse is reached. In the disabled community, we need help to live, not die.

Does the Hippocratic Oath prevent doctors from harming their patients? This legislation permits doctors to go against their own ethical code. People with disabilities cannot stand by and watch this legislation happen. You let a group from Oregon into Connecticut to tell Connecticut how its citizens should live and die. We have a doctor as a --

REP. JOHNSON: -- Do we have your testimony in writing?

CLAUDE HOLCOMB: (Inaudible.)

REP. JOHNSON: If there could be some assistance with summary and that would helpful.

CLAUDE HOLCOMB: (Inaudible.)

A VOICE: Thank you. Are there questions? Does anyone need clarifications?

REP. JOHNSON: I think if you -- if you would please make sure that we have a copy of the testimony because I know people come in and out of here because we have meetings and other votes that we have to have so as long as we have our testimony then in that circumstance we can go back and review these things before we vote.

Thank you so much for being here. I really appreciate your being here and providing your testimony. And we will be glad to have someone ask questions in writing to if you leave your e-mail address and -- and we'll be in touch so thank you. It was very, very good that you were here. Our staff is right over here to the -- to the left.

JULIETTE MEYER: May I ask a (inaudible).

REP. JOHNSON: Yes, please do (inaudible).

JULIETTE MEYER: I am Claude's domestic partner.

REP. JOHNSON: Please for the record identify yourself.

JULIETTE MEYER: I'm sorry. I am Juliette Meyer, Claude Holcomb's domestic partner. And he was put in the position of making my life and death decision four years ago. I'm very much -- I would be or could be under this law a candidate for assisted suicide. As the previous speaker alluded to, most people cannot conceive of being in constant pain. And many, many people throw around the remark if I were in constant pain, I would kill myself, or someone told me my pain would never end.

In 1984, July 12th, I woke up one morning and found I had a terribly painful neurologic problem that has no solution. And I -- I am a breast cancer survivor. And four years ago, I got kicked in the face by a horse. And the original decision, whether I should live or die was put off by the fact that I did die twice during my hospitalization. Claude had to make all the medical decisions. He was told there might be a hasty end to me as there was or that I might be left in a vegetative state. He, who is my healthcare agent, decided I very much should live and be given the chance. And now because of the results of the wonderful treatment, I survive for which my gratitude is unbounded.

I have several other conditions that cannot be easily remedied, including a second painful condition. Would you then just looking at me as the person before you, elect that I be killed. Many people would --

REP. JOHNSON: I -- I just want to say this is not about people who are in pain. This is about people who are at the very, very end of their life so keep that in mind as you -- as you go through with the testimony.

JULIETTE MEYER: Absolutely. I apologize but I only meant that people make hasty decisions about what they think they could live with or could not. And whether it's pain or any other suffering, they make those decisions often --- often based on what they think they might be able to live with or couldn't.

Thank you.

REP. JOHNSON: Thank you so much for all you've done here today. We really appreciate it.

The next person on the list is Debbie Gould followed by Dr. Garrett.

Debbie Gould, is Debbie here?

Okay, Dr. Schneiderman Garret.

There we go. We can go back to Debbie if she (inaudible).

PAT GARRET: Good afternoon.

My name is Pat Garret. I am a retired advanced practiced registered nurse in family practice, and I am reading for Dr. Henry Schneiderman.

So thank you, Senator Gerratana, Representative Johnson, members of the Public Health Committee.

My name is Henry Schneiderman, MD, an internist/geriatrician from Bloomfield, Connecticut, here to support Raised Bill Number 6391, AN ACT CONCERNING THE PRACTICE OF ADVANCED PRACTICE REGISTERED NURSES, with its crucial purpose to remove the requirement that they practice in collaboration with a licensed physician.

Safe patient care does not require any such collaborative agreement. APRNs have proven their efficacy and dedication for decades. They are exceptionally vigilant to minimize any patient risk. Just as I, the physician, know when to seek consultation so, too, does the APRN.

An overlay of regulation merely burdens time and efficiency and conveys inappropriate disrespect. This requirement becomes a major barrier for APRN practice because physician willingness and availability are often lacking. The present undersupply of primary care physicians will worsen sharply for decades to come. The care and health of human beings depends heavily on APRNs and will to an increasing degree.

APRNs show consistent, admirable, willingness to get their hands dirty and to meet the patient where he or she lives physically, medically and emotionally. We complete collaborative agreement per regulation but talk about patients together for the same reason that I talk with physician colleagues. APRNs provide a counterweight to some runaway costs in healthcare, and it is time they be empowered to practice independently as they so deserve.

They are an integral -- they are integral to the solution not the problem.

New Jersey has just put forward a bill to allow full scope of practice to APRNs. Our State of Connecticut should to the same. There is every reason to do so and no down side.

Thank you.

REP. JOHNSON: Thank you very much.

Are there any questions?

If not, thank you for your testimony today.

Next is Hanzel Morgan followed by John Bailey -- Foley, I'm sorry. Dr. Foley, sorry.

Hanzel Morgan?

Okay. Debbie Gould?

Are you Hanzel?

DANIELLE MORGAN: No. I'm Danielle Morgan.

REP. JOHNSON: Oh, Danielle, okay.

DANIELLE MORGAN: Is that correct?

REP. JOHNSON: Looks like a Z to me. I apologize, Danielle, oh dear.

DANIELLE MORGAN: Good afternoon, Senator. Gerratana, Representative Johnson and members of the committee. My name is Danielle Morgan, and I am a family psychiatric nurse practitioner.

I provide psychotherapeutic and psychopharmacologic services for persons living with mental illness in Connecticut. I have a private practice in New Haven where I treat, approximately, 400 patients, and I have a collaborating physician. She is one of the many collogues with whom I collaborate to manage my patients as they seek wellness and symptom relief. She will soon be readying herself to transition all of her services to New York City. She is the collaborating MD for, approximately, 20 to 30 APRNs in New Haven County.

When she leaves, many hundreds of mentally ill patients will be without care if we are unsuccessful in striking a mutually compliant collaborative agreement with another MD. I have had disruptive and ill-informed interactions with psychiatrists in the past as I have attempted to find a collaborator.

Additionally, I am a member of the medical staff that serves two not-for-profit clinics here, offering psychiatric services primarily to our most indigent of mentally ill people. Between both clinics, we manage, approximately, 2,000 patients most with serious and persistent mental illness. My collaborating MD in these facilities is close to retirement. He brings years of wisdom, a healthy respect for my independent practice and a generous relationship with these financially-challenged clinics. When he retires over the next few years, the 2,000 patients we serve may experience a break in these services given the current legislative mandated collaboration.

Collaboration is one of the main clinical and ethical mandates that all practitioners of medicine are encouraged to employ in our quest for optimal patient care. It happens naturally as we consult with each other daily in providing care and forming relationships among each other. We respect our colleagues in various specialty practice settings and, ultimately, refer patients back and forth as their medical needs change. The process of mandating collaboration with regulatory statute destroys its true spirit and provides a forum for great misuse of power, misassumption of patient responsibility and indentures APRNs to physicians for whom previously collegial relationships are forced to become parental.

If we are unable to find a reasonable and knowledgeable collaborating MD willing to sign this document, our practices close and our patients are not able to access care. Nothing changes in the day-to-day operations of my psychotherapy and medication management practice whether I have a written collaborative agreement with an MD or not, but the act of needing to have one constructs a level of administrative dictate that can bring patient access to mental health care to an immediate and unnecessary halt.

This current public health policy overtly restricts the establishment and maintenance of mental health services. At a time when this access of care needs to be most available to our most vulnerable population, I urge your support of this legislation to help reverse proven bad policies.

SENATOR GERRATANA: Thank you very much for your testimony.

Representative Sayers.

REP. SAYERS: Thank you.

Thank you for coming to testify here today, and I think you bring out one of the practices of APRNs that are the most difficult with trying to find collaborative practices, and really I know a few years back we heard from APRNs in Northeastern Connecticut that their physician had retired and they were having such a difficult time trying to find someone else that was available because we have a shortage of psychiatrists in the state. It makes it really difficult and, yet, here we are up here, this year, looking at expanding and making sure that we meet all the mental health needs of the residents in the state and seeing what we can do to do better, and we're going to have this real problem in terms of providing the services so thank you so much. And I know this is a really one of the areas that's worse -- in terms of finding collaborative practices so thank you.

SENATOR GERRATANA: Representative Srinivasan.

REP. SRINIVASAN: Thank you, Madam Chair.

Thank you very much for your testimony and bringing out for us one of the difficulties that your practice is encountering.

Could you clarify whether the collaborative physician, was he or she a psychiatrist also for your practice or was he of a different specialty?

DANIELLE MORGAN: No. We are encouraged, perhaps, mandated, to have physicians who practice in the same specialty practice so both of my collaborating physicians are, indeed, psychiatrists.

REP. SRINIVASAN: Thank you for that clarification.

And one more question, if I may, Madam Chair.

The time frame that you've been given, the notice that you've been given between the physician moving out of state -- I thought it was New York that you said -- and the gentleman who's retiring, are they looking at very short time spans by which you have to make sure that you meet the current mandate of the collaborative agreement?

DANIELLE MORGAN: My New Haven base collaborating physician has made it clear that after her children finish their high school careers, her part-time practice in New York City will become her full-time practice. So, again, that will hamper, approximately, 20 to 30 of us in New Haven County who have all, sort of, band together over the years in trying to find collaborating physicians and have had moderate success, not success, and currently success (inaudible).

The gentleman with which I collaborate -- with whom I collaborate in my indigent clinic is constantly talking about retiring so that is quite impending. And he offers services, quite frankly, free of charge. He sees patients; he offers consultations. He's a wonderful, wonderful human being. And I don't know how we're going to replace that given some of the financial demands that psychiatrists currently make.

REP. SRINIVASAN: Thank you. The final question, do -- is there a financial agreement between you and the first collaborator, the lady who could be moving to New York City?

DANIELLE MORGAN: That is the only way that psychiatrists will engage with us is through financial agreement.

REP. SRINIVASAN: Thank you. Thank for the testimony.

Thank you, Madam Chair.

SENATOR GERRATANA: Certainly. Are there any more questions?

Representative Conroy.

REP. CONROY: Just a follow-up question on that, would you share with us what that costs your practice a year?

DANIELLE MORGAN: When I call my collaborating physicians for consult, it is $200 a conversation.

REP. CONROY: And how often do you think you call them in a year?

DANIELLE MORGAN: I meet with her, electively, approximately, three to four times a year for about an hour and a half to discuss cases, medical service management issues, all sorts of things. But when I -- and those -- those are set at a different fee, a higher fee.

But when I call her for consults, just on the phone, then it is $200 a conversation.

REP. CONROY: You probably don't bill that much for the visit?

DANIELLE MORGAN: It takes me, approximately, four hours to make that money.

REP. CONROY: Thank you.

Thank you, Madam Chair.

SENATOR GERRATANA: Thank you.

Are there any more questions?

If not, thank you for your testimony.

Next is John Foley followed by Dr. Nardino.

DR. STEVEN LEVINE: I am not Dr. John Foley.

SENATOR GERRATANA: No, I was going to say you don't look like Dr. John Foley.

DR. STEVEN LEVINE: Dr. Foley was unfortunately was called away on a personal emergency.

SENATOR GERRATANA: Are you going to read his testimony?

DR. STEVEN LEVINE: I am. If that (inaudible).

SENATOR GERRATANA: Very good. Just identify yourself. Thank you.

DR. STEVEN LEVINE: My name is Dr. Steven Levine. I'm a practicing otolaryngologist in Trumbull. I am the immediate past president of the Connecticut Ear, Nose & Throat Society. I am also the chair of the Connecticut State Medical Society's specialty society committee.

I am here on behalf of the more than 7,000 physicians and physicians-in-training of the Connecticut State Medical Society. We present this testimony to you today in strong opposition to House Bill 6391, AN ACT CONCERNING THE PRACTICE OF ADVANCED APRN.

This legislation would grant nurse practitioners, nurse psychotherapists and certified nurse anesthetists the authority to independently practice within a rather broad and vaguely defined scope of practice, what is now considered the licensed practice of medicine in Connecticut.

Current statute requires a critical bond between the APRN and collaborating physician to ensure that the patient receives the right care for the right reason at the right time. These functions have been mutually identified by the two parties. The physician has assessed the abilities and the talents of the APRN, and there is an assurance the physician is willing to assume the responsibility for the APRN's delivery of medically-necessary services and treatment based upon a set of previously established protocols.

APRNs are valuable care resources, but they are not a substitute for a trained and licensed physician. We do not believe that quality of care is well served by substituting the medical and technical skill of an APRN for the education, training and experience of a licensed and practicing Connecticut physician.

To be clear, this proposed change will not address the growing shortage of physicians in our state, particularly, in primary care practice.

A physician's medical education and training is fundamentally different than that of a nurses. Medical education and training is more extensive and scientifically rigorous and has greater depth of clinical judgments.

Physicians must have a minimum of ten years of post-secondary training in patient diagnosis and therapeutics just to be licensed in this state. The vast majority of physicians have additional years of education and training. Medical education and training provide the knowledge base necessary to understand and handle the vast array of illnesses and injuries that are presented in a direct patient care practice.

This knowledge cannot be acquired in a few years of college-level training or related master's study. Physicians complete an average of 3,200 hours of clinical training in medical school. And 9,000 hours during residency compared to 500 hours for APRNs.

In addition, physicians must complete a minimum of 50 hours of continuing education every two years by statute along with five mandatory courses --

SENATOR GERRATANA: Thank you, Dr. Levine. Can you please summarize your testimony? I must apologize. I can't find it here online either, Dr. Foley's testimony. But go ahead and summarize. Thank you.

DR. STEVEN LEVINE: As best as I can.

Commonly presenting -- and this I think is the crux of the issue -- commonly presenting problems in medical practice is easy to diagnose. We physicians spend 80 percent of our training on the rare and the unusual. It's the opposite of thinking of almost every other profession that you can think of.

Patients will not be well served if advance practice nurses are allowed to practice and prescribe independently without appropriate physician direction, knowledge and involvement.

At a time when quality care demands more stringent standards, this bill will lower the standards of care and, therefore, the quality provided to Connecticut's patients. Thank you.

SENATOR GERRATANA: Thank you, sir.

Representative Sayers.

REP. SAYERS: Thank you.

Doctor, are you aware that the Nurse Practice Act actually requires collaboration for all nurses? It uses that word in the Nurse Practice Act.

DR. STEVEN LEVINE: I'm not sure I understand the question. Say it one more time, please.

REP. SAYERS: Are you aware that the Nurse Practice Act --

DR. STEVEN LEVINE: The proposed act --

REP. SAYERS: The practice act under which all nurses in Connecticut practice requires collaboration?

DR. STEVEN LEVINE: I'm not aware.

REP. SAYERS: Okay. And so -- I mean what we've heard in a lot of testimony that if this signed collaborative agreement goes away, it wouldn't be any collaboration, when, in fact, the Nurse Practice Act does require collaboration. It doesn't require a written agreement, but it does require collaboration or a collaborative practice.

So what do you think will change if the written agreement went away?

DR. STEVEN LEVINE: I believe that when you are removing the written agreement, allowing now for an expanded scope of practice to independently writing of prescriptions, I think you cross that boundary and that the scope of practice that people for discuss may or may not be there. I disagree. I think this is a scope of practice issue.

REP. SAYERS: And by the way, they do have the right currently, we're not adding the independent right to -- they have -- they are authorized prescribers in Connecticut, including all narcotics, as well, so that would not change. We need not be changing anything in terms of their ability to prescribe medications.

DR. STEVEN LEVINE: We can agree to disagree about the definition of the law.

REP. SAYERS: Well, we could but the law is pretty factual. They do have authority to prescribe --

DR. STEVEN LEVINE: Yes, they do.

REP. SAYERS: -- without supervision.

DR. STEVEN LEVINE: With collaboration.

A VOICE: (Inaudible.)

DR. STEVEN LEVINE: That's not what's before us today.

SENATOR GERRATANA: Sorry. I wasn't sure who was going to have the last word.

Okay. Are there any other -- shall I say questions?

Yes, Representative Maroney -- I know.

REP. MARONEY: Hi. Thank you very much, Dr. Levine.

Can you expand on assuming responsibility, you had said, in the relationship, they assume the responsibility for the nurse practitioners. Does that impact on the doctors' liability insurance or they -- I would assume the nurse practitioners have their own liability insurance but just, you know, for my own benefit, if you could --

DR. STEVEN LEVINE: My understanding is that -- is that through these collaborative agreements, there is an assumed liability by the physicians collaborating.

REP. MARONEY: Okay. Thank you.

SENATOR GERRATANA: Thank you.

No other questions? Thank you for your testimony.

DR. STEVEN LEVINE: Thank you, Senator Gerratana.

SENATOR GERRATANA: You're welcome.

Next is Dr. Nardino, followed by Sherry Marinone, I believe. Sheryl. There we go.

DR. ROBERT NARDINO: My name is Robert Nardino. I'm from Madison, Connecticut. And Senator Gerratana, it looks as though Representative Johnson departed with the rest of you who will remain.

SENATOR GERRATANA: No, she'll be back, she'll be back.

DR. ROBERT NARDINO: Thank you very much for the opportunity to give this testimony. I'm the governor-elect for the Connecticut Chapter of the American College of Physicians. And I represent that group of 2,000 practicing internal medicine physicians in opposition of Bill 6391.

I won't read my whole testimony, much of it is similar to my colleague, Dr. Levine, but the American College of Physicians has policy which states recognition of the very important role that advance practice nurses play in meeting our growing demand for primary care. But they want to point out that physician and nurse practitioners complete training with different levels of knowledge -- I think you heard that several times today -- that are not equivalent but complementary.

And -- so the ACP regards advance practice nursing as a distinct and complementary profession. And the ACP opposes any policies or regulations that have the consequence of replacing or substituting nurse practitioners for physicians.

It seems to me we've had a lot of discussion here today and, perhaps, some misunderstanding even on my part about scope of practice versus collaboration. Perhaps, someone could define collaboration, but I wonder what even the purpose of that -- of that clause is if not to allow a relationship with the physician. And I know the word "supervisory" is anathema of the people here.

But I guess I have trouble understanding about the essence of collaboration. And so, to me, eliminating collaboration represents a big change.

SENATOR GERRATANA: Thank you very much. Actually, in the Nurse Practice Act, there is a definition of collaboration. It means a mutually agreed upon relationship between an advance practice registered nurse and a physician who's educated, trained or has relevant experience that is related to the work of such advance practice registered nurse.

And then it goes on to say what it shall address so that's basically -- it is actually defined in statute.

DR. ROBERT NARDINO: So if I may, I think many physicians would define it as my colleague earlier did. If we were to enter into this type of collaboration, in essence, we would want to be sure about the knowledge and skills and abilities of that person with whom we're collaborating and understand the setting and, again, for lack of a better word "scope" under which they're practicing.

SENATOR GERRATANA: Well, thank you for your testimony.

DR. ROBERT NARDINO: Thank you very much.

SENATOR GERRATANA: Are there any questions?

Yes, Representative Sayers followed by Representative Conroy.

REP. SAYERS: Thank you, Doctor.

And actually, I would agree with your organization in that it is -- nursing is a very distinct practice. It is not a physician. It is very different from a physician's practice nor do nurses want to be a physician. Because the way they approach -- the way they provide care is very different and very distinct.

And I'm just looking, collaboration is working with each others to do a task, is a process where two or more people or organizations work together to realize shared goals. And that's what I see as collaboration in the collaborative agreement. It's also the collaboration that is intended in the Nurse Practice Act. And when I say the "Nurse Practice Act," I am not an APRN. I'm an RN. And that is in my practice act that says so that is -- and it is no different from the -- the collaborative agreement so it really doesn't change -- look at in terms of scope. We're not talking about scope. We're talking about written agreement versus a verbal agreement. And I don't really think that you will find that once that written agreement goes away that things will change very dramatically.

Many times the working arrangements between APRNs and the physicians that they work with are such that it works well for both of them. And they probably will continue those types of working arrangements, though, different than any other physicians working together.

DR. ROBERT NARDINO: Sure. May I respond?

So I think, you know, it was mentioned earlier about the idea that we don't have these collaboration agreements in writing with other members of the health care team so, let's say, a physical therapist or a dietician or even a nurse. I think this really what this goes to, though, is the issue that, in essence, we're practicing in a much more similar and overlapping way. And so I think that that's where the definition of the collaboration, at least to many physicians, is very important, and what the boundaries are of that collaboration are. So I don't know if that clarifies it.

REP. SAYERS: Well, I think I understand what you're trying to say, but what I'm also saying is that I think the practice of nursing is very different from the practice of -- the physician practices medicine. It's not meant to be the same: how they approach problems, how they approach care is very, very different. And in fact, most people might have both. They might have an APRN that they see for routine -- if some one of those physicians said earlier, chronic disease management. When they need, say, surgery, they would go to a physician and have an assessment and evaluation.

DR. ROBERT NARDINO: Well, they would go to a surgeon.

REP. SAYERS: Right. So, you know, it is very distinct and different. And I'm not trying to say that it's the same. And I can see that it could work well together in collaboration because I think that people will find that they need both levels of care. What I'm trying to say is that the written agreement sometimes is more likely to get in the way of that because people see that as all encompassing, and I'm not sure I can see where that makes a difference and I don't think it will should this legislation pass.

DR. ROBERT NARDINO: Can I also -- I would just add that the American College of Physicians strongly endorses the concept of the patient-centered medical home, and I know that was mentioned earlier. And in our view that is really the nature of collaboration that we think is most appropriate. People working, again, as was mentioned, to the top of their license or, you know, this is terminology that, as a practicing physician, I don't usually use. But in a way that's complementary, in a way that gives patients the best, you know, the best quality and the best access, hopefully, to care.

REP. SAYERS: Thank you. And I -- and I would agree with that because that having a medical home does call for that type of collaboration. And I think that will happen with the APRN. I don't see that as not happening. And I think that's a fear that people have. And in Connecticut, you know, we're the land of steady habits, we fear change. And I think that's part of the problem. So thank you very much.

SENATOR GERRATANA: Representative Conroy.

REP. CONROY: Thank you, Madam Chair.

Thank you, Dr. Nardino.

Do you work with any APRNs in your practice?

DR. ROBERT NARDINO: I work for a very large organization what was until recently Hospital of Saint Raphael so there are APRNs in that -- in that organization, quite a few.

REP. CONROY: Did you have a collaborative agreement with any one of those?

DR. ROBERT NARDINO: Did I, specifically? No, I don't specifically.

REP. CONROY: Do you know what kind of training they have to be an APRN?

DR. ROBERT NARDINO: Additional -- specifically to be hired at Saint Raphael's or to -- or just in general?

REP. CONROY: You're a family physician, an internist?

DR. ROBERT NARDINO: I'm in internal medicine physician.

REP. CONROY: So you do family medicine?

DR. ROBERT NARDINO: I do internal medicine. There's a difference.

REP. CONROY: All right. So you don't see pediatric patients, at all?

DR. ROBERT NARDINO: I do not.

REP. CONROY: All right. So you'd probably -- you would have worked with adult nurse practitioners?

DR. ROBERT NARDINO: Correct. For example, our Haelen Center is a subspecialty clinic for people with HIV infection, and we have several APRNs working in there. And, again, working -- I'll guess I'll have to use the term "collaboration" but, in essence, really under the supervision of HIV specialists.

I know you'll say, no, by law, but that is -- that's what the current --

REP. CONROY: I think that might be where we get a little confused.

DR. ROBERT NARDINO: Right.

REP. CONROY: -- you know, you work with others in your practice, but you don't have that written collaboration. But with the nurse practitioners, you need to have a written collaboration.

DR. ROBERT NARDINO: I understand. I do.

REP. CONROY: So do you think it would -- the practice of a nurse -- the nurse practitioners will change without this written collaboration?

DR. ROBERT NARDINO: Well, I'll just go back -- I think I'll have to go back to the ACP, you know, position statement, which is, you know, concern about any change of policy that would allow advance practice nurses to replace physicians.

So, now -- okay, so we can all speculate about what will or will not happen. Right? Is it likely to happen that, you know, physicians will be replaced? No, it's not likely to happen. It's very unlikely to happen. Okay. But this is -- this is viewed as giving advanced practice nurses the same authority -- I'm looking for the right word -- as physicians.

REP. CONROY: I'm fortunate that I had asked the Federal Trade Commission to look into this bill, the APRN bill for me, and it was the 11th hour and I finally got the response yesterday right before the public hearing which is fortunate. And a couple of the things -- and it's a lengthy, lengthy letter that they did send me.

They said, "removing this requirement has potential to benefit consumers by expanding choices for patients, containing costs and improving access."

And it's almost like, you know, the elephant in the room when it says, "maintaining an unnecessary and burdensome requirement is likely to deprive consumers of the benefits that increased competition can provide."

And I almost feel like we almost have this elephant in the room -- in the room right now when you're saying we're not going to be cutting into a turf. But there is going to be having some competition out there because we're going to be having more providers. Is that anything that you're feeling?

DR. ROBERT NARDINO: Again, I think that is why -- not that reason precisely. I think it's very clear that we need to provide more and expanded primary care for the people of Connecticut, for the people of the United States.

And everybody is struggling for -- to find ways of how to do that. The ACP feels that the patient-centered medical home with a team, you know, led by a physician that could serve the needs of the most complex, medically complex patients; and people working in this kind of collaborative arrangements is the best way. And I think that this is viewed as, perhaps, allowing a way to go counter to that model.

Now, that's not the only model of care. So I guess I probably didn't answer the question that the FTC wants answered. I know that the AMA has, you know, a direct response. And certainly, we'd be happy to provide you, again, with their response to this.

REP. CONROY: And I think that's pretty much the whole committee's work here is to make sure that we're getting enough of our residents having affordable, accessible health care. And we're getting statistics that, you know, we're not able to meet that right now. And what's going to happen in another year. I don't see this as expanding the scope.

You know, everyone -- we're professionals in this medical profession and we need to have a collaborating agreement with each other. I'm not so sure that it needs to be in writing. It's just still feels like it's a little parental oversight to me.

DR. ROBERT NARDINO: I would also wonder that if concern was about people taking advantage or, you know, heard, perhaps, stories of -- not "perhaps" -- we've heard stories of how these arrangements could even be exploited. That rather that removing it, perhaps, addressing it with different language to prevent that from happening.

I guess, it's not -- I shouldn't be telling people what to do.

REP. CONROY: Well, I thank you for your answers. Thank you.

Madam Chair.

SENATOR GERRATANA: Representative Srinivasan.

REP. SRINIVASAN: Thank you, Madam Chair.

Thank you very much for your testimony.

In the scenario that was presented to us by the previous person who gave us testimony where a physician could likely move to New York and the other person is thinking of retiring imminent -- is talking about that and that happens all the day -- you know, very frequently. And given the fact that the average age of most of the practicing physicians in Connecticut are well above 50 and 55, we know that. Are you concerned that the APRNs may not be able to get the collaborations that they need? And here we are talking about access and then the physicians are, A, retiring. We know that. Physicians are not coming to Connecticut. We know that, too. So are we posing an extra hurdle as far as access is concerned?

DR. ROBERT NARDINO: I guess as a -- as a physician, I tend to rely on data and so I think it's really important for us to know, you know, the extent or scope of that problem. You know, to specifically say is it a concern? Yes, it could be a concern. I think it could be. I think it's very important to know what the extent of that problem is.

REP. SRINIVASAN: When physicians, you know, ask for a phone consultation with a colleague, there is never a charge involved in that? You know, obviously, I'm a practicing physician, myself, we do that all the time. And it's a quick part of the consult. It's a quick consult over the phone. It doesn't cost you or me anything when we ask our colleague to do the right thing by the patient.

But here we heard, clearly, that we have to pay a certain fee and how many hours they have to work to recoup that. Would you see that as more of a hindrance in terms of good health care because of the financial reasons an APRN may not be calling on that physician because there's, obviously, a price to pay.

DR. ROBERT NARDINO: Of course, of course. And I think -- I guess I -- that would take me back to my previous comment about addressing the definition of these collaborations and the rules of the collaboration. And I think, clearly, we would have to agree that that's a practice that shouldn't be tolerated.

REP. SRINIVASAN: Thank you. Thank you for your testimony.

Thank you, Madam Chair.

SENATOR GERRATANA: Thank you.

Are there any other questions?

If not, thank you very much.

DR. ROBERT NARDINO: Thank you.

SENATOR GERRATANA: Thank you for your testimony.

Just to let everyone know that our cafeteria, here in the Legislative Office Building, will be open this evening until 7 p.m. They will be available if anyone -- I know it's the early bird, I guess, dinner, but if you wish to, you can certainly get your dinner there. Thank you.

Next is, I think, it's Sheryl Marinone followed by Kate Wheeler.

SHERYL MARINONE: Good afternoon.

SENATOR GERRATANA: Good afternoon -- good evening.

SHERYL MARINONE: I'm Sheryl Marinone in support of Raised Bill 6391. Thank you, Senator Gerratana, Representative Johnson and members of the committee. You're all saints for putting up with this all day long.

I am a nurse practitioner in private practice here in Connecticut. I currently have a collaborative physician. He signed my agreement many, many years ago without any financial stipend. I was fortunate back then.

The health care environment has changed considerably since that time. And because of his age, he's way beyond retirement age and I have some concerns about him retiring, I've been spending this past year, looking for -- or actually longer than that -- looking for another collaborative physician so I wouldn't be in the position of not having one.

As you probably may have heard Dr. Grady was killed in a car accident suddenly one night. He was one that I was approaching. Another one had died of breast cancer not long ago.

In the meantime, I have many physicians that I collaborate with all the time who are wonderful doctors. If I have questions, they answer them, or you have to have your radiologists and your surgeons and the people that you send patients to. It's just part of what you do.

I lost my place.

So in the meantime in this daunting task of finding another collaborative physician, I decided to go to some of the doctors that I collaborate with on a daily basis, aside from my collaborative physician. And the answers that they said, Well, let me look into it. And they're all very kind. And the answers that they were getting from talking to their malpractice insurance carriers. They recommended not signing it. And some had talked to their attorneys who recommended not signing it. And the reasons being is because of the presumed liability. And they didn't want to take on that liability.

I did have one doctor who agreed to sign, and he said for $10,000 a year he would be my collaborative physician. While I don't make the salary he needs and that would have been me out of business. An NP's salary is much lower than an MDs salary.

So the State Department of Public Health recognizes me as an APRN certified nurse practitioner. I'm highly trained to make medical management decisions and independently I feel very confident in my ability to do so.

Unlike the statement that someone had made earlier today about you don't know what you don't know, you don't know. I don't know what he was saying. But I know what I know, and I also know what I don't know. And I refer out when I'm not comfortable with something and when I don't know something.

I have -- I do believe I give excellent care, and I have excellent feedback from my patients. I don't advertise. I get all of my patients through word of mouth.

SENATOR GERRATANA: Thank you.

I have your testimony here in front of us, too. And I know I can read along with what you are reading, also.

SHERYL MARINONE: Exactly. It's basically, there would be 2,000 patients that would be without care if I was to leave.

SENATOR GERRATANA: You know, there has been testimony about referring or having to, you know, to refer a patient to another medical provider, health care professional, and that was also alluded to before. And I just had a quick question on that. You know, because you touched on it in your testimony a little bit, you know what you know and what you don't know. And I think one of the physicians also testified and said, you know, this, you know, having an APRN means that there would be many more referrals.

Would you care to comment on that at all or --

SHERYL MARINONE: I don't see how it would be any more referrals than they're already seeing. I'm not -- you able to manage your patient to the best of your ability. When you're not comfortable with something, you're going to refer them out. It's the way everybody does. Even physicians will do that.

I have physicians who actually call me and have me see their patients because I know more about what I do than they know so they're going to refer to me, as well, as I refer to them.

SENATOR GERRATANA: Through collaboration, I guess.

SHERYL MARINONE: I am fortunate to have a very good group of MDs that I work with. It doesn't seem to be that problem that I'm seeing here as much.

SENATOR GERRATANA: Or hear. Well, thank you very much for your testimony.

Are there any or -- oh, Representative Srinivasan.

REP. SRINIVASAN: Thank you, Madam Chair.

Thank you for your testimony. I'm sorry for the difficulty that you're going through in terms of acquiring a new collaborative agreement partner.

I hope your answer is going to be "no" for this, but are you aware that as you talked about your lawyers recommending the physicians and doctors sign the collaborative agreement for, obviously, for the malpractice reasons. Are you aware that in the event -- and I'm hoping you never have been -- in the event that an APRN is sued, is that automatically so far in the presence that in your experience from your colleagues, does that automatically go to the collaborative physician who has signed the contract with them?

SHERYL MARINONE: It is my understanding in a lawsuit that I would be responsible for my care, and he -- it was told to these MDs that it was a presumed liability but not an actual liability.

REP. SRINIVASAN: Right. Thank you. Yes, I do understand that it's a presumed liability, but in the realty that this agreement has been around for this length of time, are you aware or could you get back to us at some point, hopefully soon, that in the event an APRN who has an agreement, has been sued, has that suit automatically been extended, unfortunately, for both -- both the APRN, as well as the physician.

SHERYL MARINONE: Yeah, I would have get back to you on that.

REP. SRINIVASAN: Thank you. That would help us a lot. I would appreciate that.

Thank you, Madam Chair.

SENATOR GERRATANA: Thank you.

Representative Sayers.

REP. SAYERS: Thank you.

Do you carry liability insurance?

SHERYL MARINONE: I do.

REP. SAYERS: So that in the event that you -- there was -- a suit was brought, they would go after your malpractice insurance?

SHERYL MARINONE: Correct.

REP. SAYERS: And as in most cases, they look at the deeper pockets --

SHERYL MARINONE: As I understand they would, yes.

REP. SAYERS: Right. Is that the only reason why they would go after the physician?

SHERYL MARINONE: I would believe that would be the only reason.

REP. SAYERS: Would it make a difference if you didn't have a written collaborative agreement and you worked in the same office?

SHERYL MARINONE: That's a good question, as everyone is equal and we wouldn't need to have an collaborative agreement. I would think, but I don't have the real answer for that. I would think that I would still be responsible for myself and there wouldn't be a deeper pocket.

REP. SAYERS: Right. But they still could go after the whole practice that you're a part of.

Thank you.

SENATOR GERRATANA: Thank you.

Thank you.

Next is Kate Wheeler followed by Linda Angotto.

KATE WHEELER: Thank you.

SENATOR GERRATANA: Hi Kate.

KATE WHEELER: Thank you, Senator Gerratana, Representative Johnson, and members of the Public Health Committee. I want to thank you for this opportunity to provide testimony in support of 6391 to remove the collaborative practice agreement in Connecticut.

My name is Kate Wheeler. And I'm a professor of nursing at Fairfield University and the coordinator of the psychiatric nurse practitioner track there. I have certified as an advance practice psychiatric nurse. I'm also certified as a psychoanalyst in hypnosis and in eye movement desensitization and reprocessing, which is an evidence-based treatment for post traumatic stress disorder.

Since 1984, I've been practicing, independently, seeing patients. Now I see people out of my home, usually, ten to 20 hours a week of patients for psychotherapy and medication management.

Since I coordinate the psych NP program at Fairfield, I get a lot of calls from alumni and former students who are looking for a physician to collaborate and they can't find anybody. So, often, they are unable to practice as they wish and despite the very low incidence of lawsuits against nurse practitioners, there's very few physicians that want to collaborate. My understanding is they have been told or asked by the AMA or the Connecticut Medical Association that, you know, that the increase in their liability insurance, and why would they do this.

So the problem, though, I think is as Representative Conroy suggested. It's the elephant in the living room. It is really about restraint of trade. APRNs charge less, and that it threatens the physicians' income. It's interesting that APRNs are safe to prescribe in states, like Vermont and Maine and New Hampshire, where there's less people. And yet, in populace states where there's more competition in terms of more psychiatrists, that we're not safe. And that's not really true because there's no more lawsuits in these non-populace states for APRNs than for APRNs anywhere.

So it's sort of obvious what's going on in that in Connecticut a lot of the psychiatrists are not on the insurance panel, but the APRNs are. So patients are denied access to care. Psychiatrists charge more money.

SENATOR GERRATANA: Dr. Wheeler, could you please summarize.

KATE WHEELER: Yes.

SENATOR GERRATANA: Thank you.

KATE WHEELER: One psychiatrist in my area, I tell everybody to go to because he's very kind and he takes all the APRNs. He's a Jungian analyst so when we go we talk about archetypes and dreams and psychoanalysis, which is very interesting, but he's not really interested in meditation. And I call my APRN and colleague if I have a question because it's been pointed out that, you know, nurses collaborate. And that's what we do. We're mandated by our nurse practice act and also our scope and standards. Thank you.

SENATOR GERRATANA: Thank you so much.

Are there any questions?

If not, thank you for coming today and testifying.

KATE WHEELER: Thank you very much.

SENATOR GERRATANA: Thank you.

Next is Linda Angotto followed by Vanessa Pomarico Denino.

Hey, Linda.

LINDA ANGOTTO: Senator Gerratana, Representative Johnson and members of the committee, my name is Linda Angotto. I am a nurse practitioner practicing at Regency Heights in Stamford.

I am reading the testimony of Lisa Cloutier in support of Raised Bill 6391.

I am an APRN working in the area of mental health. I am board certified in both adult and child adolescent mental health nursing.

In the course of my career, I have worked in various capacities and have managed my own private practice for eight years, serving both adults and children. I started outpatient practice while working for a psychiatrist in his private practice. He closed the practice after being involved in a malpractice suit. I have nothing to do with the case and, suddenly, my own practice was in jeopardy because I was losing my collaborative physician.

The physician arranged for his colleague to cover me while I found a replacement. I was able to contact a physician I had worked with in the past and things went well for a number of years.

Without warning, my practice was in jeopardy again. My collaborative physician -- we were not in the practice together -- underwent a difficult divorce and closed the practice he shared with his spouse and took a job with a hospital. Again, I had to find another physician.

At this point, I was solely responsible for the care of over 200 patients. Finding a new physician was daunting. The AMA claims there are physicians available for collaboration, but I did not find that to be an accurate statement. I phoned everyone I had ever crossed paths with and heard basically the same thing. I'm not interested in the increased liability. Or they would only provide collaboration if I closed my own practice to work with them.

I finally found a physician through a colleague. Again, hundreds of cases were in jeopardy because I had to find another physician and none of these situations were of my own doing.

I enjoy collaborating with physicians. I collaborate informally with physicians of all specialties while providing excellent care for my patients. I am not objecting to the idea of collaboration. I am objecting to the fact that my entire career is dependent on the signature of another professional.

I was the victim of a malpractice suit, not my own, and a divorce, again, not my own.

SENATOR GERRATANA: Yes, you can summarize.

LINDA ANGOTTO: I sincerely hope you will consider supporting the removal of this barrier to our practice. Nurse practitioners provide an important service to our community, and we have proven over 13 years in Connecticut our capability of providing this care in an independent world.

SENATOR GERRATANA: Thank you very much for reading Ms. Cloutier's testimony.

Does anyone have any questions, comments?

No. Thank you so much.

Next is Vanessa Pomarico Denino followed by Diane Croll.

VANESSA POMARICO DENINO: Good afternoon. My name is Vanessa Pomarico Denino; I am a nurse practitioner and the president of the Connecticut Advance Practice Registered Nurse Society. We represent the interests of nearly 4,000 advanced practice registered nurses in the state of Connecticut.

Thank you for raising this bill at our request. You have a copy of my testimony so I will not be redundant and read that, as well. I, also, hope you have a copy of the written testimony from my three physician colleagues, as well. And if you do not, I'd be happy to you supply you with that.

What I would like to do is clarify some of the questions that have come up earlier regarding how many states allow independent practice just to clarify some of the misinformation.

Currently, in the United States, 20 states require collaborative agreements; 12 states require supervisory agreements; 16, plus the Washington DC, have autonomous agreements; and 12 states are pending legislation for independent practice.

There have been some questions regarding limited liability for nurse practitioners. All nurse practitioners carry the same limit of liability as our physician colleagues. The Department of Labor Statistics project that 130 percent increase for nurse practitioners will be forthcoming. The American Academy of Medical Colleges projects a shortage of 36,000 physicians by 2015, just two years away. That will increase to over 90,000 shortages of physicians by the year 2025.

What I am asking is for you to consider that the lack of the collaborative agreement does not mean lack of consulting. Nurse practitioners will continue to consult and will increase the access of care to all of our patients.

Thank you.

SENATOR GERRATANA: Oh, thank you very much. I was following along in your testimony, also.

Are there any questions?

If not, thank you very much for coming today.

Diane Croll followed by Kathy Sullivan-Conger.

DIANE CROLL: Senator Gerratana, Representative Johnson, and members of the committee, my name is Diane Croll. I live in Trumbull, Connecticut.

I worked as a family nurse practitioner for 14 years. Five years ago, I began a temporary six-week assignment at Bridgeport Health Care Center in Bridgeport, Connecticut. The assignment was extended for a second six weeks and became full time. After learning that the division of the company I was working with was to be sold to New York firm, I approached the owners of the skilled nursing facility and they agreed to sign the contract with me.

As a result, I started my own company and have been providing care for the residents since that time. There is approximately 170 residents, aged between 19 and 102. The nursing home length of stay -- oh, I'm sorry -- prior to the nurse practitioner presence, there was approximately ten to 15 residents hospitalized at any given time. Since I've been there, there have been closer to three to five residents at any time. And many times there are two or fewer. Right now, I have three.

The nursing home length of stay has increased dramatically from 195 days to 373. Indicating that when residents are admitted, they are most likely to stay at the facilities rather than now being returned to the hospital.

I've cared for many residents with wounds. In some cases limiting or eliminating the need for wound center visits, as well as associated transportation costs. I provide good care and improve the health status of some individuals who have been able to be discharged back to the community under the Money Follows the Person Program.

When facility staff members have not been able to do so, I have inserted foley catheters, IVs, displaced feeding tubes, removed PICC lines and sutures and performed cerum en removal, eliminating the need for emergency department and specialists visits, as well as associated transportation costs. In more than 50 cases, when it was appropriate, I have assisted individual's families and conservators in completing advance directives and have provided palliative care allowing terminally ill residents respectful, peaceful, and mostly pain-free deaths in the facility rather than have them transferred to the hospital where end of life care would probably have been more aggressive and certainly much more costly.

I work with the facility staff to change medications to align with the Medicare and Medicaid insurance companies' formularies and wherever possible to reduce costs. I have a very supportive collaborating physician, whom I contact when needed. And I also work with the residents' physicians in house. I believe the work I do is vital for the residents and cost saving for the state.

I support this bill as it would allow me to continue my practice should I not be able to continue the current collaborative practice that I do have. Thank you.

SENATOR GERRATANA: Thank you very much.

Are there any questions?

No. Thank you for testifying today.

Next is Kathleen Sullivan-Conger followed by Donna Montesi-Enters. I apologize for that.

KATHLEEN SULLIVAN-CONGER: Hello, Senator Gerratana --

SENATOR GERRATANA: Hello.

KATHLEEN SULLIVAN-CONGER: -- Representative Johnson and members of the committee, my name is Kathleen Sullivan-Conger. I am a mental health advance nurse practitioner. I have been assessing, diagnosing and providing medication for five years and working in the field of psychiatry for 17 years.

Throughout my career, I have always provided services to populations of people in financial and emotional disparity, and I am a nurse educator with UConn and also work in private practice.

Here, I provide services to military families, children, professionals, paraprofessionals, from various large companies, school systems, hospitals and surrounding casinos. I am continuously requested for my services for difficult cases by therapists and by primary care providers. I provide services to approximately 75 to 100 people per week.

Regarding the collaborative agreement, I have struggled throughout my career to maintain a proper collaborator. And in 2012, I left my physician and its center serving a population of disparity because of this problem. This was a federally qualified facility.

This issue not only caused loss of provider at the center but created financial issues for me, such as loss of wages, sick and vacation time, educational funds, retirement opportunities, and health benefits. For the first time in my career, I do not work with populations of disparity under Medicaid or Medicare because I do not have my own practice to make this choice, and I fear starting one under the circumstances in Connecticut.

I was also employed in the past at the women's state prison. And while running a full mental health program, with some of the most fragile inmates, I received high recommendations for -- by federal oversight for the excellence in the recovery services that I developed and implemented.

I would be eager to provide recovery services in my community to children and women.

There is no research of facts that prove harm from APRNs providing care without a collaborative agreement. Personally, my colleagues and I are doing an excellent job working independently. There have been no safety violations or increase in adverse health occurrences in this state that allow APRNs to work without a written collaborative agreement simply because we all collaborate. It's part of our job. We enjoy it.

APRNs are leaders in holistic care, and we collaborate continuously to provide those services. We're looking to continue this type of practice and be creative in practice.

I'd also like to add something. The last part of my testimony has been reviewed by others prior to me about the states that have the collaborative approved agreement, have no collaborative agreement, including Rhode Island. What I'd like to add is something that I've noticed we haven't talked about today, is that in my private practice, I provide services to families who help -- who come in and -- when they get help from me on a weekly basis, thank me for seeing their middle school children and their high school children. They have private insurance and are scrambling to find a provider, a prescriber, who will see them as there is a lack of psychiatrists in our area.

SENATOR GERRATANA: We are aware of that. Thank you so much. It's very interesting the work that you do, too. Thank you for your testimony.

Are there any questions?

If not, thank you for coming today.

KATHLEEN SULLIVAN-CONGER: You're welcome. Thank you for this opportunity.

SENATOR GERRATANA: Next is Donna Montesi -- I believe it's Enters. And I apologize again, with the handwriting -- followed by Marissa Patterson.

Hello.

DONNA MONTESI-ENTERS: Hello. Honorable Chairs and committee members, my name is Donna Montesi-Enters.

I'm an adult nurse practitioner, certified in wound care. My practice setting is the skilled nursing facility, and I also manage 24 nurse practitioners for a large medical practice. My physician colleagues refer patients to me for wound care.

I am here today to present the testimony of Lynn Price, former chair of the Connecticut APRN Coalition and current member of the Connecticut APRN Society of Health Policy Committee. She is unable to be here today due to her own practice commitments. Lynn's full written testimony has been submitted.

The four major points that I'm going to present are as follows: point one, Connecticut already has problems with patient access to primary care. Conservative estimates indicate that 410,000 residents will gain insurance through public and private mechanisms in 2014. We need to remove barriers to provide practice if we have any hope of meeting the current anticipated need.

Point two, evidence over the past 30-plus years negates the current statute's presumption that a physician's agreement is needed to ensure safe APRN practice. The evidence consistently demonstrates that APRNs achieve high marks for desirable health outcomes, patient satisfaction and safety. Requiring physician approval of board certified licensed APRN practice fails to meet any public policy interest.

Point three, APRN education, national board certification and state licensure requirements provide assurance for our ability to provide safe, effective patient care. The 30-plus year record of evidence clearly and consistently demonstrates that we meet and exceed the standards set by our physician colleagues for public health and safety.

Point four, innovative practice models developed in the 14 years since the imposition of the mandatory agreement remains fragile, precisely because of the mandate. The Institute of Medicine and National Governors Association after review of the evidence recommends removal of such barriers. Eliminating the mandatory agreement will ensure existing practice models and lead to new APRN innovations in providing meaningful access to health care.

SENATOR GERRATANA: Thank you. Are you through? Or -- oh, thank you very much. I was following along on the testimony from Lynn Price. She's an attorney, also --

DONNA MONTESI-ENTERS: Yes.

SENATOR GERRATANA: -- apparently. So very interesting.

Are there any questions?

If not, thank you and thank you for reading Attorney Price's testimony.

Next is Marissa Patterson followed by Dr. Elizabeth Visone.

MARISSA PATTERSON: Hi, my name is Marissa Patterson. I'm a registered nurse and a family health nurse practitioner student, graduating this coming May. I'm here in support of Raised Bill 6391.

As a student, I am very concerned about my potential to practice to the full scope of my abilities after graduation. The collaborative agreement requirement in Connecticut does not exist in many other states and has been shown not to play a role in patient safety, satisfaction, quality of care, or medical expenses, as my colleagues have spoken about previously.

I have spoken with my own nurse practitioner preceptors and faculty, who wish to go into independent practice, but are unable to do so due to the restrictions of the collaborative agreement.

More --

More importantly, I am considering leaving the State of Connecticut after I graduate to practice in an APR private practice in one of the many states that do not have this unnecessary requirement.

Collaboration with my physician and other colleagues is a matter of course for me. I seek their advice in the same way I would seek the counsel of other medical APRN or PA colleagues with more experience than I.

A component of all of my course work is information on when and whom to refer to and what interdisciplinary collaborations will improve the health of my patients.

I have studied the Institute of Medicine Report and am strongly in support of Connecticut adopting the standards in line what their recommendations. State Legislators should work to remove practice act barriers and allow nurse practitioners to practice as autonomous authority without risk of losing their practices due to written agreement requirements.

Not only will this provide more availability of qualified primary care practitioners for patient care, it will make Connecticut a more attractive place of work for a new APRN graduate and other potential employees.

I hope this bill will be passed. I know it will cause many of my classmates to consider remaining in the Connecticut area for practice. Thank you.

SENATOR GERRATANA: Thank you. I am on the Institute of Medicine website. Had they done a report on advanced practice nurses or registered nurses, or?

MARISSA PATTERSON: I don't have their report with me. I do remember we studied it, actually, in one of my classes and I can't give you the date, but I can get that for you.

SENATOR GERRATANA: Okay, I'll do a search. But it was regarding APRN, is that correct?

MARISSA PATTERSON: Yes.

SENATOR GERRATANA: Okay, thank you so much. Are there any questions? No. Thank you for giving your testimony.

MARISSA PATTERSON: Thank you.

SENATOR GERRATANA: Next is Dr. Elizabeth Visone, followed by Elena Schjaviland.

ELIZABETH VISONE: Thank you.

SENATOR GERRATANA: Thank you.

ELIZABETH VISONE: Senator Gerratana and the rest of the Committee, nice to be back. I'm Dr. Elizabeth Visone. I'm a doctorally prepared nurse practitioner. I work in the Willimantic area in one of those underserved areas of the State of Connecticut.

Before I read my own testimony, I'm going to read the testimony of two other nurse practitioners. The first one is Pat Casey. In 2011, Pat decided to open her own practice, a house call company.

She could not get a collaborator. The doctors were either confused about signing or they wanted very large fees to sign on to be her collaborator. She finally did get a doctor to agree. For every dollar she got, she took in 70 percent was her income, 40 was for overhead, and everything else was a profit for her collaborator. That doesn't add up to 100, does it? That's more. Okay, just reading what she wrote.

After one year he wanted an increase in his fees. I think she was getting, he wanted 70 percent of his, of her income. I think that's what he was asking for and he wanted an increase after one year, even though she had only consulted him three times in that one year. She ultimately had to close her company. She is now working for another company as a nurse practitioner and they're having trouble finding a collaborating physician for her to work with. So again, leaving patients without care.

The next is Kathy Groff, who works in an education facility. In September of 2008 her supervisor, who was also her collaborator, left his position. The new physician would not sign the agreement, so therefore she was unable to care for her patients and had to send them to urgent care centers instead of caring for them in their center.

It was only after DPH intervened did her new physician supervisor sign the collaborative agreement and that took four months for it to happen. So for four months, patients were using double services in the State of Connecticut by urgent care.

I am very lucky. I have a collaborating physician. Unfortunately, my collaborating physician is a couple of years older than I am and will be retiring in five years. When he retires, I am almost positive I will not be able to find another collaborator, even though I have lots of good relationships with the physicians in my community.

The reason for that is probably the way I process, I provide primary care for the patients of Willimantic, but I also see them in the hospital as well as the nursing home, and I'm not sure there's a physician who would be willing to collaborate with me in all three of those settings. Thank you. Any questions?

SENATOR GERRATANA: Thank you very much. I don't know? I don't see any. Oh, Representative Sayers.

REP. SAYERS: Thank you. And you just mention where you practice is really a very difficult area to even find a physician.

ELIZABETH VISONE: Yes.

REP. SAYERS: And I know from some consulting that I've done with like residential care homes and people that have mental health problems, after 5:00 p.m. the only option they have in that area is to go to the emergency room.

ELIZABETH VISONE: The emergency room. Yes.

REP. SAYERS: Because there's no physician available. Now you go to a physician on call, and it really amazes me, so thank you for the work you do.

ELIZABETH VISONE: Thanks.

SENATOR GERRATANA: Thank you. Representative Maroney.

REP. MARONEY: Thank you very much for your testimony, Dr. Visone. I was just wondering, and I apologize if this had been asked of someone else before, but what are the requirements for the continuing medical education for nurse practitioners?

ELIZABETH VISONE: The State of Connecticut does not require, the state does not require us to have any continuing education. However, my license, my board certification in fact does, and it's actually fairly complicated what I have to provide, something like 75 hours, but I also do a lot of precepting for new practitioner students so I tend to use, get my CME CEUs through that, instead of going to conferences, although I will tell you that I will be going to the National Nurse Practitioner Conference, one, to pick up some CEUs as well as present my own research.

So while we're not required, I can't think of one nurse practitioner that I know that doesn't go to at least one program a year and there's plenty available for us, and we do go.

REP. MARONEY: And are those, that 75 hours annually? Or --

ELIZABETH VISONE: No. It's actually 150, a tabulation of 150 the way they score it, over five years.

REP. MARONEY: Thank you.

ELIZABETH VISONE: You're welcome. Any other questions?

SENATOR GERRATANA: Thank you, Representative. I don't believe so. Thank you. Next is Elena Schjavland, followed by Lenore Crosin, sorry.

ELENA SCHJAVLAND: Madam Chairman, that was excellent on my last name.

SENATOR GERRATANA: Thank you.

ELENA SCHJAVLAND: And Members of the Committee. My name is Elena Schjavland. I am a nurse practitioner, and I'm here to support Bill Number 6391. I really thank you for this opportunity to speak about health care and access, to talk about vulnerable populations and this onerous requirement.

I'm a geriatric nurse practitioner, so I'm Connecticut licensed. I am board certified as an adult and geriatric. I have a private practice. I do house calls.

SENATOR GERRATANA: No worries. No worries.

ELENA SCHJAVLAND: Okay. I practice in southeast Connecticut in Mystic and the local area, Rhode Island to Route 2, up to Norwich, down 395 and out to Saybrook, and I spent over 12 months when I started, before starting my practice, trying to find a collaborating physician, and this is really to render care to my geriatric patients. I specialize in dementia, Alzheimer's, memory disorders and geriatric consult. This is a tough, tough group.

But procuring the agreement was extremely difficult and I can shed light on how I tried to attempt that, including the Connecticut Medical Society website.

And I did take extreme care to explain my vision for care, because it's huge. It's a model that is very much needed right now, specifically for home visits.

It was the hardest thing to do a collaborative agreement. It was harder than being in the military for 20 years, and I did that.

My background includes years employed in critical care, in ICUs, in the military, but yet when I came to dialogue with physicians, I had a tough time.

I'm extremely fortunate to have finally connected with a physician to be collaborator and that was a serendipitous meeting at an Alzheimer's Association meeting. He knows that there's a lot of patients out there with access problems. He knows there aren't enough doctors seeing geriatric patients. He knows that behavioral issues with dementia and Alzheimer's are catastrophic to patients and to the families.

I don't know what I'm going to do if he moves. He's a really renowned physician and if he is scooped up by UMass or another academic institution, I'm lost.

In my practice I've diagnosed many different reasons for memory disorders, including basilar artery brain aneurism, non-dementia depression, (inaudible) temporal. I refer. I collaborate. I send people on to other areas and highly attuned medical groups.

I'm offering a unique level of care to geriatric patients and let me summarize. It's tough to get a collaborative agreement. Many steps were unsuccessful. It tends to be personal, litigious and financial and I support this bill because I think I can recruit other nurse practitioners to Connecticut and geriatric work without it. Thank you.

REP. JOHNSON: Thank you so much for your testimony and I wonder, yes, Senator Bartolomeo, followed by Representative Sayers.

SENATOR BAROLOMEO: Thank you, Madam Chair. I was struck as you talked about all of the different places that you work and where you travel and I'm just wondering, do APRNs, are you able to employ anyone under your care? Are you able to employ RNs to work with you or for you?

ELENA SCHJAVLAND: Well, again, we collaborate and if my practice ever got large enough, and I believe right now there's that need. I currently have 72 panel patients from September, with an average of three consults per week, that I will be looking for supportive staff, administrative staff, more likely from my practice, social workers and other nurse practitioners because registered nurses probably wouldn't really be utilized to their maximal capacity in what I do.

REP. JOHNSON: Thank you. Representative Sayers.

REP. SAYERS: You know, when I worked for the Health Department as a surveyor and went to many of the nursing homes in the areas that you serve, I know what a difficult time they even have getting physicians to cover their patients, that there's very, very limited practice out there, so thank you for all the work you do.

It is really important, and actually in the state we have very, very few geriatric physicians, so when we get more people to practice in that specialty area, as all of us age here in the state, it's really very, very important. Thank you.

REP. JOHNSON: Thank you so much for your testimony today.

ELENA SCHJAVLAND: Thank you.

REP. JOHNSON: I want to make an announcement at this point. Just to let everyone know the cafeteria will be open for another hour, so you still have a chance to have some food before you're here without anything at all. Okay. The next person here is Lenore Crosin, followed by Erin McCarthy. Okay. I guess Lenore Crosin isn't here but Erin McCarthy is, followed by Kate Stevens. Thank you. Thank you and welcome and please state your name for the record and proceed.

ERIN MCCARTHY: Yes. My name is Erin McCarthy. I am a final year psychiatric mental health nurse practitioner student at Yale University. Today I would like to voice my support for Bill 6391 and discuss its pertinence to psychiatric mental health nurse practitioner students and new graduates.

The health care system in the United States is changing dramatically. By 2014 the Affordable Care Act will provide 32.1 million individuals with benefits for mental health and/or substance use disorders.

Additionally, 30.4 million citizens with pre-existing behavioral health conditions will receive benefits from federal parity protections.

This means that there will be 62.5 million new patients needing services in addition to those already being treated.

The tragedy in Newtown exposed the desperate need for increased accessibility to behavioral health services in America. Despite only being at the state level, implementation of RB No. 6391 would be a small step with a large impact.

That is, removing the written agreement requirement for Connecticut licensed APRNs has many positive implications, including increasing the number of autonomous clinicians in response to the growing patient population, fostering genuine interdisciplinary collaboration and teamwork, lending support through examples to other states who are contemplating similar legislative modifications and promoting overall progress in behavioral health and substance use treatment.

The question of the definition of collaboration has come up a lot today and I actually had it defined from the Merriam-Webster online dictionary, and it is in its most simplest form, to work jointly with others or together especially in an intellectual endeavor.

This definition has characterized my role as a student nurse practitioner, shapes many of my successes and will be a requisite component of my career as I transition to being a licensed provider.

Despite this, I struggle with the limitations imposed by the written collaborative agreement, as I believe that it marginalizes the holistic role of the APRN and promotes a somewhat inflexible, coerced, collaborative agreement between physicians and nurse practitioners.

This sentiment is reflected by the Robert Wood Johnson Foundation Initiative on the Future of Nursing, who quote, believe that all health professionals should practice to the full extent of their education and training so that more patients may benefit.

Collaboration, as it is currently recognized by the State of Connecticut appears to be a less a joint endeavor based on chosen partnerships, problem solving, learning and more a formality, which ultimately limits APRNs from practicing in the manner which best (inaudible) their patients. Thank you for taking the time to hear my testimony and I look forward to seeing the progress of this bill.

REP. JOHNSON: Thank you so much for your well-timed testimony. Much appreciated. And I wanted, does anybody have any questions? Thank you so much for being here. Much appreciated. Okay, Nanette Alexander followed by Joanne Iennaco. I'm sorry. I skipped Kate Stevens. Yes, please sit down here.

NANETTE ALEXANDER: It's a much more comfortable chair in some ways.

REP. JOHNSON: We'll give you that privilege for a short time.

NANETTE ALEXANDER: I'm Dr. Nanette Alexander. I'm a doctor nurse, as I like to tell my patients. So I don't confuse anybody, I also have a clinical doctorate.

I'm not going to read my testimony. You have a copy of it. I'm going to briefly overview my physician's testimony in support, and it's Dr. John Rogers. He is my collaborating physician. He's also the owner or a shareholder of our corporation, and to paraphrase it so you don't have to hear it (inaudible) you have a copy.

We collaborate with each other every day. Those of us, or those who are privileged to be in our office get to hear us through the doors, get to hear us in the hallways. He brings me in for skin conditions, I bring him in for pulmonary issues and we have a free flow of information with myself, him, the other nurse practitioners in the practice and the other physicians. So collaboration happens every day.

Under the employment agreement, I get paid, and I think it's two confusions here, so that's why I want to read the testimony.

We have employment agreements, which require more supervision, and that's the purview of an employer, and I would say that you know, Doctor Zagieboylo has a good practice and his employment agreement is to read every chart and it's his right to provide quality from his practice.

That's not a scope for practice issue. That's an employment agreement, okay.

The other testimony was interesting when Dr. Zagieboylo talked about the ETO and having these medical home models. CMS is actually having models for nurse practitioner run medical home models in states where they can practice to their full autonomy.

So the medical home is not just for physicians by CMS' definition. There are pilot projects for nurse practitioner run medical home models in the states where they provide home care, full care, hospital care.

So I wanted to define that but you know, this medical home model is great but it's not just physician run in other states where physicians aren't required by a written agreement.

And I think the other part is, you're looking for the Institute of Medicine is the Future of Nursing and that link directly is in my testimony as well as my physician colleague, John Rogers because we talk about that.

There's not enough primary care providers. How do we get them?

With employment agreements you do limit the ability to create new models. In states that don't have these, you have a free range. There's (inaudible) Clinic and other models that may erupt, hopefully in a good way, and I'm not going to belabor that point, but we're taking away that free model and the ability to grow health care for our consumers.

REP. JOHNSON: Very good. I think your point is well taken and sometimes it does get confusing, the testimony when people are focusing on employment agreements versus what we're discussing here, which is a different situation altogether, which is a collaborative agreement.

Are there any questions? Yes, Representative Srinivasan.

REP. SRINIVASAN: Thank you, Madam Chair. Thank you very much for your testimony and am glad to see you here this evening.

NANETTE ALEXANDER: Nice to see you instead of just talking on the phone.

REP. SRINIVASAN: Thank you. So you clarified a very important point for us the first time discussing that over this discussion we had for a couple of hours.

So an APRN could have in an employment setting is an employment contract, which could say A, B, C and D, whatever the stipulations are. But that's obviously something negotiable and that's agreeable to both parties.

NANETTE ALEXANDER: Right.

REP. SRINIVASAN: But do you also have, along with the employment contract, a collaborative contract with Dr. Rogers or within your practice as well.

NANETTE ALEXANDER: Yes, I do have a written collaborative agreement. It is one page. I believe it's the copy you were provided with, because I wrote it in 1999, when I was here in 1999 with so many other people.

I think the essence of this comes to our health care is changing and nobody's comfortable with change. But how will you vow to take care of all the people that you take care of and how do you explore different models?

Some will work. Some won't. That's already happened. We provide safe care. We're going to continue to provide safe care. We are limited by the models we can do with this current written collaborative agreement.

My employment won't change. I'm too old to change at this point for my employment. My retirement's getting good. I work with great physicians.

But I see the future and it worries me, because if we can't expand different models of healthcare and I can tell you in states like Washington State and Oregon, they have nurse managed centers and unlike Dr. Ardolino who's scared about the old ones retiring and the new ones being lost, they're actually usually university based. They provide nurse practitioner teaching and they're wonderful places for health care, and they're not just for the under-served but for anyone who wants to go.

And if you can get an exemplary health care, it doesn't matter where you go. People don't have to choose a nurse practitioner but they should be able to choose a nurse practitioner.

REP. SRINIVASAN: Thank you very much for the testimony. Good to see you here, and thank you, Madam Chair.

REP. JOHNSON: Thank you. Thank you very much. Okay, the next person on the list is Joanne Iennaco. Welcome. And the next one after that is Janet Carlson. State your name, and thank you.

JOANNE IENNACO: Thank you so much.

REP. JOHNSON: Thank you.

JOANNE IENNACO: My name is Joanne DeSanto Iennaco and I'm an advanced practice registered nurse. My area of clinical practice is psychiatric mental health nursing. I hold a PhD also in epidemiology and I work as a faculty member at the Yale University School of Nursing where I do clinical research and I teach students preparing to be psychiatric nurse practitioners.

My testimony that is on line speaks to several reasons that I support this act and I encourage you to review that evidence in my testimony.

And what I'm going to talk about now are two different models of APRN practice. I'm going to first speak of my own practice because I think that there's really good evidence that approving this change will lead to more cost-effective care and greater access of care in the State of Connecticut.

In my experiences as a psych (inaudible) I have served the severely mentally ill in Connecticut. I worked as a clinician in the Acute Services Department at the Connecticut Mental Health Center in New Haven, Connecticut, which is, I believe a federally qualified health center.

We see our most vulnerable citizens in our area. They are often homeless and have great difficulty accessing healthcare. Many are acutely psychotic, their voice is suicidal and they're very disenfranchised from care.

Without dedicated APRNs and other clinicians that provide care, these patients would have no place to go. I am very proud of the care I provide at CMHC and typically we work with patients to set goals and improve their psychiatric symptoms and their lives.

We help them find housing. We help them engage in health care. It is often very rare that the patients I see even have a primary care provider. And we also stabilize the mental health problems.

The need for services for these citizens has only increased, and as my work exemplifies, APRNs are an important provider of care to these most vulnerable people in many health care settings, not just the CMHC.

I want to compare this now to practice done by one of my colleagues, Dr. Mary Moller. She is a Yale School of Nursing faculty. She is the director of a psych nurse practitioner program she is also, her testimony represents also testimony for the Connecticut Chapter of the APNA.

She worked for over 20 years in the State of Washington, where she practiced independently to the full extent of her education. In Washington, like other states, they are far ahead of us in implementing the 2010 Institute of Medicine Report on the Future of Nursing.

Her testimony reflects how she cannot practice in the State of Connecticut like she did in Washington. In Washington, Mary was the owner of a group practice that included four psych NPs, counselors and a social worker. Collectively they provided between 8,000 and 10,000 patient visits per year and they specialized in caring for these very vulnerable and ill patients.

Her model that they developed in this practice had reduced psychiatric re-hospitalizations in these patients by 93 percent, and it actually saved the State of Washington a lot of money. It helped many patients also get back to work and back to their lives.

So unfortunately in the State of Connecticut, we recruited Mary here from Washington State. Unfortunately, when she came here we were hoping that she in fact would develop a clinic just like she ran in Washington. However, she has been unable to find a physician collaborator.

She has been here now for four years and she still cannot find a physician collaborator who would like to engage with her in this innovative kind of practice, which has actually been repeated in 15 different sites and internationally.

Thank you for your time and I'm happy to answer any questions.

REP. JOHNSON: Thank you so much for your testimony. Much appreciated. Are there any questions? Yes, Senator Bartolomeo.

SENATOR BARTOLOMEO: Thank you, Madam Chair. I think I know the answer to this but I don't ever like to assume.

In a facility such as CMHC or another hospital, you're simply employed as another employee, correct?

JOANNE DESANTO IENNACO: Correct.

SENATOR BARTOLOMEO: You don't need a collaborative physician to sign on?

JOANNE DESANTO IENNACO: Correct. So what happens, there are employment situations like CMHC or if I worked for a hospital setting, where part of that setting includes a policy that has like a contracted agreement that covers us in terms of our ability to provide care.

So that's how, in those employment situations it's very different, and obviously, if this law is removed, those sources aren't going to be running off and starting their own businesses. Many of them are very happy with providing the care where they provide that care.

SENATOR BARTOLOMEO: Okay, so just to clarify and I came in half way through all of this bill, so this is only relevant for people who are trying to do their own practice?

JOANNE DESANTO IENNACO: Well, it's relevant for all of us because in fact, I do still have to have this formal agreement with a physician to be able to practice what I do, even within that setting, yeah.

SENATOR BARTOLOMEO: Okay. So within that setting it's not just you're hired on, do your paperwork and there you are. You have to find a physician within there to collaborate (inaudible).

JOANNE DESANTO IENNACO: Within the setting they would have a physician who would be designated to work with us.

SENATOR BARTOLOMEO: Okay. Thank you very much.

REP. JOHNSON: Thank you so much for your testimony. Any other questions? Thank you. Thank you for being here. Okay, we have someone we're going to need to take out of order, Elaine Kolb because she has a train to catch, so I want to make sure she has a chance to come and provide her testimony, after she's been here all day waiting patiently, but the train will not wait for her.

Thank you so much for being here today and taking the time.

And when you get situated, just state your name for the record, please and then proceed.

ELAINE KOLB: My name is Elaine Kolb. I spent a lot of time thinking about what I might say today and this time is very short. Earlier today I sang a song called Not Dead Yet. I wore the tee shirt. Look it up. Notdeadyet.org. Notdeadyet.org.

But I want to represent someone who couldn't be here today in person, as many of our people could not be here in person, but this particular person, her name is Patty Deke and she died 14 years ago. She died on March 10, 1999.

She was my partner for eleven and a half years. She was born with a disability. From the time she was very young, she was told repeatedly that she wouldn't live long. Do you know what that's like, to be told even as a child that you won't live long.

And then as her life went on, well, a series of things happened. She developed rheumatic fever when she was four. She lost all of her hair and then she was diagnosed with fregretsetaxia, which is a neuro-muscular condition, genetic condition.

I'm going to read a poem that Patty wrote about her aunt who had the same condition.

Anne Krestudis Ode to Nan. The days seem so cold, these days without you. It was just yesterday you were fighting for your life as we watched helplessly from afar, they kept you down with one blow after another. Even though you had a strong, determined will, you got weaker with each defeat and still we could do nothing but fear the worst. Oh, how my heart ached as I watched your independence slip away.

I remember you best as my inspiration. Years of struggling gave you a feisty edge. When others saw you as an impossible, opinionated, angry disabled woman, we saw the real truth, the truth of being a product of growing up disabled.

For most of your life there were no laws to protect you. No rules applied. Freedom was not expected if you were disabled. Our dear, sweet Anne.

And later, you became our mother when mom died from her disability. The years of love and understanding were not wasted on your two disabled nieces. We will always remember the love. Your love will carry us through until we could all be together again.

I know I'm out of time and I just want to say that in the many hospitalizations, for the many crises that Patty went through, and I went through with her, time and time again somebody from the medical system would make the comment, don't you think it's time to let her go?

And my response was no. I think if she's fighting for her life, I'm going to back her up in every way I possibly can, and maybe you're the one who should get off of her case and would be replaced by someone who will help her fight for her life.

Please fight the pain. Don't provide assisted suicide. What happens to people with disabilities is our lives are devalued and so many non-disabled people do not appreciate how much we value our own lives.

Please provide more care, not a way to die.

REP. JOHNSON: Thank you for that very powerful testimony. Are there any questions? Thank you so much. Have a safe trip back.

ELAINE KOLB: Thank you.

REP. JOHNSON: The next person is Janet Carlson, followed by Mary Consoli.

JANET CARLSON: Good evening. My name is Janet Carlson. I'm managing partner of One Eleven Company. I've worked in the pharmaceutical arena for the past 25 years, and I've had the pleasure and privilege to work with many nurse practitioners.

You've got my testimony also on line. I'm just going to cover a little bit of what we've had to deal with.

I am one of the handful of companies that creates online sampling for healthcare professionals, and we've wanted to sample nurse practitioners, but because so many of them require a collaborative agreement, we actually had to change our software, which is fine, we were happy to do it, to allow them to be sampled.

So we actually went to the nurse practitioners, worked with them on a national level to change our software to actually allow them to do it.

The problem is, most pharmaceutical companies don't want to have to deal with that in order to be able to provide samples. This is a shame because a lot of the patients certainly benefit from having samples.

So, you know, I certainly ask you from a business perspective to allow nurse practitioners to get the samples that they need to provide the patients who need it, and by eliminating that one piece of paper. In a lot of cases it is a single piece of paper that can be done much more easily and pharmaceutical support is certainly waiting in the wings.

I can certainly, you know, attest to that. I have plenty of clients who would absolutely love to serve, sample nurse practitioners but feel unable to do so.

And on a personal level, my family and myself have received the very highest levels of care from nurse practitioners and we're very grateful to have them around. Thank you.

REP. JOHNSON: Very good. Thank you so much. Any questions? Thank you so much for taking the time to be with us today. Oh, I think we have, Representative Sayers has a question.

REP. SAYERS: Thank you. Do you do sampling for psychotropic drugs?

JANET CARLSON: We actually do samples for any kind of drugs.

REP. SAYERS: And I know many of our psych outpatient clinics that treat those, many of those patients without insurance, they're so dependent on those samples in order to provide medication for their patients. It's really very difficult. So thank you.

JANET CARLSON: Yes. My pleasure.

REP. JOHNSON: Thank you. Senator Bartolomeo.

SENATOR BARTOLOMEO: Thank you, Madam Chair.

JANET CARLSON: Since I've been here for six hours, I'll answer any question you want.

SENATOR BARTOLOMEO: Can you just elaborate when you say about the, what's the impediment to just pay for, just explain a little bit more why you can't give them samples.

JANET CARLSON: It's not a matter of can't, because as long as you collect that data within the sampling software, you can sample them. A lot of the pharma companies choose not to do that because they just, I guess it's just nervousness or not quite sure, you know. They're getting more and more support.

But we have the software to be able to do the sampling and collect that collaborative agreement. But for the states, what they'll usually tell us is for the states that require collaborative agreements, don't sample them. Just don't offer them. So we're actually, what we do is, we set up our software so it says just for these certain states, we're not going to offer samples. They can't even see the sample offers.

SENATOR BARTOLOMEO: But I guess I'm still not following because they can write prescriptions.

JANET CARLSON: They can write prescriptions but pharmaceutical companies really won't sample them. They just won't offer it to them.

I understand that they can write prescriptions --

SENATOR BARTOLOMEO: Well, I'm just trying to understand why they won't. Can you describe it in any other terms? It's a waste of their time? It's a waste of their product?

JANET CARLSON: I think it's a lack of education, to be honest. I think the pharma companies, if they're not quite true what the deal is, they're really not going to bother with it.

They're also missing out on a huge opportunity, I think to the tune of, I think I did some math on this. It was every brand that actually gave samples to nurse practitioners would gain about $50 million in benefits by doing so.

SENATOR BARTOLOMEO: But I guess, and correct me if I'm wrong, but it seems to me that that's more of problem with educating the pharmaceutical companies as opposed to the way that the current law is.

JANET CARLSON: I think it is a matter of educating the pharmaceutical companies, absolutely. But what I'm saying is, I mean, if this one piece of paper were eliminated, they would have access to much more information, samples. I think that it would just open up a channel of you know, information and you know, supplies to the nurse practitioners who are helping in a lot of cases, indigent patients.

Did I clarify enough?

SENATOR BARTOLOMEO: Oh, no, you absolutely did. I guess I'm still just thinking that it's you know, again, it's the problem lying not with what they're allowed to do, which is what we're looking at changing, but the problem lies with the pharmaceutical companies, so I was just trying to understand in fact, what the impact, what is accurate?

JANET CARLSON: I think it's a multi-pronged issue. I mean, I think certainly, from my understanding of everything about the collaborative agreement it does not seem to impact what they're actually doing.

It was very interesting to hear the testimony today as to those who agreed and disagreed with it, but it doesn't seem that it's actually going to change the way things are done.

I think that they require a lot of education. I've spoken to many pharmaceutical companies but stood up at conventions and spoken very loudly about, you know, being able to actually provide these samples to nurse practitioners and albeit we had to collect a collaborative agreement that it really wasn't a big problem or a big deal.

So I guess I'm partly hoping that you'll just remove that barrier for a myriad of reasons, but also to allow many patients to get the samples that they so desperately need also.

SENATOR BARTOLOMEO: Well, thank you. I do understand what you're saying and I give you credit for taking the time to make the system work better.

I'm not so sure it's kind of a correlation in my mind but I do understand what you're saying and thank you.

JANET CARLSON: My pleasure.

REP. JOHNSON: Thank you so much. Okay. Mary Consoli, followed by Michelle Lopez. And then Karen Lynsted and Mary O'Brien. And if we don't have Mary Consoli, then maybe Michelle Lopez can come to the front. Michelle Lopez? Karen Lynsted? Mary O'Brien? I'm on Senate Bill 1128.

SENATOR GERRATANA: A little technical difficulty here. We're back on track and excuse me, we're now at Senate Bill 1135. Tracy Sullivan, but I think Tony Sicignano and then Tracy Sullivan.

No? Okay. Karen Caturano. Oh, here's someone. I bet it's Tony.

TONY SICIGNANO: Hey. Good evening. Thank you to the Co-Chairs and to the Committee Members. My name is Tony Sicignano. I'm a nuclear medicine technologist. I work at Yale-New Haven Hospital, St. Raphael's campus in New Haven, Connecticut and I'm here in support of Bill 1135 AN ACT CONCERNING NUCLEAR MEDICINE TECHNOLOGISTS.

There's a dual purpose for our seeking licensure or statutory recognition. The main reason is to provide public safety. The legislation provides the public with a safe delivery of healthcare services, medical imaging in the nuclear medicine environment.

This legislation will establish a minimum standard for any person practicing nuclear medicine imaging in the State of Connecticut. It will state the education and certification minimums to be achieved by a nuclear medicine tech.

By establishing these standards, the public will be assured of safe, quality services, reduced healthcare costs by rolling the number of repeated procedures due to poor technique and will be confident that the technologist performing their diagnostic imaging and therapeutic services has been licensed or been part of the statutory recognition for the process.

The second purpose is to develop the appropriate language to allow nuclear medicine technologists the opportunity to operate our hybrid imaging systems, which have been developed over the past few years, namely PET, CT and now more recently developed PET MRI.

We agree, I'm sorry, we would welcome the opportunity to work with this Committee in developing the appropriate language and to work with any other interested parties.

And lastly, we're fortunate enough to go through the scope of practice process, which started last August and during that process we had the opportunity to speak frankly with the Department of Public Health about the possibilities of licensure as opposed to statutory recognition.

And we agree with, our committee was thoroughly convinced that at this point in time because of budgetary constraints, licensure would not be a logical step to take, so therefore, we would be much, we would think that the solution of statutory recognition would be a more possible avenue at this point. Thank you.

SENATOR GERRATANA: Thank you very much for your testimony on that. Oh, I thought maybe someone had a question. I guess not. But we do appreciate that, but I could not find your testimony on line. Did you send that?

TONY SICIGNANO: No, I did not.

SENATOR GERRATANA: Okay. Could you do so?

TONY SICIGNANO: Sure.

SENATOR GERRATANA: Is that possible?

TONY SICIGNANO: Yes.

SENATOR GERRATANA: And our staff is right here at this desk. Thank you so much.

REP. JOHNSON: While we're waiting for the next announcement, I just want to announce one more time that the cafeteria will be open until 7:00 o'clock, so if you have a chance and you need to have some food, please help yourself.

SENATOR GERRATANA: You have to pay for it, though. But it would be nice if we could help ourselves. But do partake. Well, that's what it sounded like. Next is Tracy Sullivan, followed by Karen Caturano.

TRACY SULLIVAN: Hello.

SENATOR GERRATANA: Hello.

TRACY SULLIVAN: Thank you, Representative Johnson and Senator Gerratana and Committee Members. I'm here in support of Raised Senate Bill 1135 AN ACT CONCERNING NUCLEAR MEDICINE TECHNOLOGIST. My name is Tracy Sullivan and I also work at Yale-New Haven Hospital.

As you know, the Department of Health recently completed a scope of practice review for nuke med techs in accordance with PA 11-209. In order to have safe delivery of healthcare services, statutory recognition ensures a minimum standard of education in Connecticut.

The agreed on scope of practice reflects the required didactic requirements in nuclear medicine schools today. The schools are accredited by the Joint Review Committee on Educational Programs and Nuclear Medicine.

This licensure, which we hope to get some day when the state has funding for that, but the statutory recognition ensures that all nuclear medicine technologists in the State of Connecticut have to go to a school that is accredited by the Joint Review Committee.

This assures, as Tony said, said quality services, reduced healthcare costs by lowering repeated exams due to inaccurate experienced technologists.

Another reason for the statutory recognition will be to allow nuke med techs to fully utilize the hybrid equipment being produced in this age of rapidly advancing technology.

There is additional schooling that is in place that will allow the technologist to operate this machinery. They would have to take additional boards also. All of that is already in place. Thank you very much for hearing my testimony. If anybody has any questions.

SENATOR GERRATANA: Thank you very much. I don't think so. Thanks for coming. Next is Karen Caturano. Here she is.

KAREN CATURANO: Thank you, Madam Chair and Members of the Public Health Committee. My name is, that's it?

SENATOR GERRATANA: Thank you for coming. No, you can proceed. Great testimony.

KAREN CATURANO: You know, I have to say, I don't know what is worse, standing on my feet all day or sitting all day?

SENATOR GERRATANA: Sitting. Sitting.

KAREN CATURANO: Oh, absolutely. I couldn't stand after that. But anyway, my name is Karen Caturano. I am a certified nuclear medicine technologist. I work at Middlesex Hospital.

I am here to support the Senate Bill Number 1135, the act concerning a nuclear med tech in the State of Connecticut in getting statutory recognition or hopefully, when the funds come available, licensing.

It is our hope that through getting statutory recognition, this will ensure the safety to the public through the practice of safe and effective use of radio-pharmaceuticals and it will offer an assurance to the public that the regulated individual is competent to promote services in a safe and effective manner.

Currently, 37 states are licensed, some of which include Rhode Island, Massachusetts and New York. Thank you for hearing my testimony.

SENATOR GERRATANA: And thank you very much for presenting it. I don't think there are any questions.

KAREN CATURANO: Thank you.

SENATOR GERRATANA: Thank you for coming today. Next we go on to Senate Bill 1136 and the first person to testify is Barry Kasden. Barry's not here. Jan Van Tassel. I don't see Jan. Sara Frankel? I don't see Sara either. And Abby Anderson. They all went to dinner together, I guess. Okay.

Next is House Bill 6589 and the first person to testify is Marcia Corentzen.

MARCIA LORENTZEN: Lorentzen.

SENATOR GERRATANA: Oh, that's an L. Sorry. Lorentzen.

MARCIA LORENTZEN: Good afternoon, Senator Terry Gerratana, Representative Susan Johnson and the Members of the Public Health Committee. I'm very pleased to be here today to speak in opposition to House Bill 6589 AN ACT TO ESTABLISH A TASK FORCE TO STUDY THE SCOPE OF PRACTICE FOR DENTAL HYGIENISTS.

The reason I'm opposing this bill is because it is time to establish the mid-level provider. It has been studied. It is currently in operation in Minnesota as an advanced dental therapist.

It was previously studied in the 1940s and between 1965 and 1977 as recorded in this book The Forsythe Experiment. It was conducted at the Forsythe School for Dental Hygienists and it had shown at that time that dental hygienists were equally able to perform the cutting and filling of teeth for adults.

A study was also conducted in 1978 and recorded in the Journal of American Dental Association. This study was done at the University of Iowa and the results of that study showed that dental hygienists and dental students could also perform equally at the scope of practice of restoration.

I'm a Dean at the Fones School of Dental Hygiene and we are ready to run a program for the mid-level provider. Our master's degree program in dental hygiene has been approved by the State of Connecticut Department of Education as well as the New England Association of Schools and Colleges.

We have four (inaudible) that were approved. We currently run two of them through an online program. We have the curriculum ready to go for the mid-level provider.

We already had a scope of practice review through the Department of Public Health last year. They have submitted a 159 page report to the General Assembly on the advanced dental hygiene practitioner in February 2, 2012.

In that report they raised some questions that I would like to address in my testimony. One question regards, was regarding the fact that the mid-level provider was not an established professional. Yes, that is true, but since 2009 it has been established in the State of Minnesota and they are finding that it is exceeding their expectations. The care that they are able to provide for their citizens, 50 percent of which are on Medicaid has been outstanding.

The Minnesota advanced dental therapy curriculum is very similar to the advanced dental hygiene practitioner. May I continue? I'll try to be brief.

SENATOR GERRATANA: You certainly may summarize.

MARCIA LORENTZEN: Thank you. The curriculum that has been established will meet the needs of the CODA accreditation that is now under review submitted by the Commission on Dental Accreditation.

And also, I just want to reiterate that the fact that the mid-level provider has been passed by legislation in other states so it is not something that is in the process of being studied but is in existence right now.

Dental hygiene celebrates 100 years in the year of 2013, this year. It is time for expanded practice. We are not the same that we were 100 years ago. It is time not to study but to have action as it's been done in Minnesota.

SENATOR GERRATANA: Thank you very much for your testimony. I don't think there are any questions. Thank you for giving that today.

MARCIA LORENTZEN: Thank you.

SENATOR GERRATANA: Next is Dr. John Mooney.

JOHN MOONEY: Good evening, Senator Gerratana, Representative Johnson, Members of the Public Health Committee. My name is Dr. John Mooney. I practice dentistry in the Town of Putnam since 1989.

I am the Chair of the CSDA Access to Care Committee. I'm a HUSKY provider for over 700 children and adults. I have participated with generations in an FQHC, in a private practice partnership. I serve on the Connecticut Dental Health Partnership Provider Relations Board, and I'm also a member of the Connecticut Mission of Mercy Steering Committee.

I thank you for the opportunity to provide testimony to you in opposition to House Bill 6589 AN ACT ESTABLISHING A TASK FORCE TO STUDY THE SCOPE OF PRACTICE FOR DENTAL HYGIENISTS.

You know, as Chair of the CSCA's Access to Care Committee, I charged that Committee, when we looked at solutions we were to look in the best interest of patients, not the profession. We were not about turf protection.

And based on this approach, we were able to go through a series of economic assessments and other pathways and we found that the easiest way to impact access in Connecticut was to maximize the current dental workforce that existed already.

Thankfully, there was a lawsuit that was happening that would eventually raise the fees modestly and streamline the dental claims process.

Our committee also studied extensively all the workforce permutations that exist not only in the United States but worldwide.

What has transpired since the settlement of the dental Medicaid lawsuit in our state is nothing short of spectacular. It has become a national model for the Center of Medicaid Services. We have a copy of the recent Connecticut Health Foundation Report. We also have the DPH Report of what's happening. Really important stuff.

First, the utilization rates are almost equal to what private insurances, and what's really cool is when you look at the amount of restorative services beginning in the lawsuit and where they are today, the restorative services and the basic planning services are now almost equal.

Not only that, the other thing that's happened is even with an increase in the Medicaid population, the amount of expenditures have been capped at about $120 million for the past two years.

This is a unique experience in the United States Medicaid system. It just doesn't happen. That data, based on the fact that 70 percent, at least 70 percent of the dentists practicing in Connecticut, are general practitioners, makes this study and the study of any additional provider unnecessary at this point.

You also have the results of what you had last year from the spill through review process.

I understand that new Committee Members here might have wanted to study to fully understand the issue. I hope, you know, as you hear the evidence, you'll see that most of what you've asked for has already been done.

Furthermore, what you asked us in professional dentistry to due after the lawsuit was settled, is and has been done, and continues to be done for the Medicaid population.

I strongly urge that you oppose this bill and also reject any attempt to put any other workforce addition on to another bill. The patients in Connecticut deserve no less. Thank you.

SENATOR GERRATANA: Thank you. Are there any questions? Senator Welch.

SENATOR WELCH: Thank you, Madam Chair. I guess I'm gleaning from what your testimony is so far, that you're not in favor of additional or broad scope for dental hygienists, but I'm not sure why, so maybe you can elaborate on that.

JOHN MOONEY: Well, the ADHP model was a model developed actually in the Commonwealth Nation back post World War II and the issue to that was because those Commonwealth Nations didn't have enough dentists. There was a shortage of dentists.

That shortage doesn't exist here in this state. In fact, this state continues to be in the top five annual in the dentist to population ratio, number one.

And number two, the dentists like I said are general practitioners. We're not specialists. We're here to handle everything. So exactly whom is this designed to serve other than basically a scope increase?

SENATOR WELCH: If I may, through you, Madam Chair. Now, this exists in Minnesota. Is that correct?

JOHN MOONEY: I'm sorry.

SENATOR WELCH: In Minnesota, there is a model there? Is that --

JOHN MOONEY: It's, they're trying to make a comparison, and this is part of the problem. What exists in one part of the United States from a workforce standpoint is not what's being proposed in this state. It's a completely different animal.

The Minnesota animal, or workforce model, was developed because Minnesota has specific wants and needs. They don't have an adequate provider base in Minnesota. They don't, the needed to expand functions in order to get care.

Now what's interesting is after the model had been passed by law, and it was a compromise sort of thing, right now there's only one practicing advanced dental therapist, okay, with very stringent collaborative agreement.

Now you've seen how much fun you've had in the previous four to five hours here, okay? Now, trying to get that definition of the Minnesota model into what is being proposed here, completely different animal.

What's proposed here is almost the entire scope of a dentist, okay? Well, not proposed, but the ADHP model. In Minnesota, it's a tightly controlled, well supervised, okay, with very stringent limitations where and how it can practice.

And, here's the important thing about Minnesota. The jury's still out. It will come up for sunset review within the next three years, and before we jump in and create a whole new thing here, all right, let's wait and see what happens in Minnesota.

Has it really impacted access to care? The biggest barrier to access and this is very important, understand this, besides cultural issues and adequate providers, is the cost of services.

If I'm a poor person in Minnesota right now and I go to see one of the six practicing dental therapists, whether they be not advanced or advanced, okay, I do not get a discounted fee for seeing that therapist. I get charged the same amount of money as if I had seen a dentist. Okay?

So like, our approach from an access (inaudible) is how do you reduce the cost of care? Okay. Or, do you have adequate provider base for the Medicaid population to deliver care.

I don't know if I got you confused a little bit but the bottom line is, if it costs me $100 for a filling delivered by a dentist in Minnesota and it cost me $100 for the filling delivered by the dental therapist in Minnesota. So cost is keeping me away from accessing the dentist or dental therapist.

You haven't addressed that, much less all the other cultural issues associated with access.

And I will tell you from a dental provider board relations and serving on that, our issue in Connecticut is trying to understand why the people who have access, Medicaid access don't use it. We're in a completely opposite situation.

SENATOR WELCH: And if I may, I guess, I seem to recall in the past when we had these conversations that dentists were actually supportive of certain things like interim therapeutic restoration and having hygienists.

Is that something that you guys are still --

JOHN MOONEY: We did, the CSDA Access Committee and the CSDA board through its legislative counsel, did submit a bill to allow dental hygienists with proper education and training to deliver interim therapeutic restoration.

Now, this is a tried and well technique that is used all over the world, number one, and came into its own during the Gulf War, the first Gulf War which was fought, because the primary injury, battle injury in the Gulf War was when an explosion would happen. The soldiers would drop to their legs really quickly and they'd get down, and the thing that used to happen in the Gulf War was their front teeth would fracture, and the military developed materials so that those soldiers could be repaired in the field and stay battle ready.

This training and these techniques are available today and we still support that. And that's about as far on the hygiene end that we're, I think the CSDA is willing to go.

For the motivated student who really wants to do all the service as outlined by ADHP, pass a law and get these kids into UConn Dental and get them a full dental education. It's different. The qualifications are different. The testing is different. The code of approval is different.

But the cost, it's not, if you go to Fones for six years and you go to UConn Dental School, I'm sorry. I'm going on.

SENATOR WELCH: No, that's fine. Thank you. Thank you, Madam Chair.

SENATOR GERRATANA: Thank you. Are there any other questions? If not, thank you for your testimony. Next is Dr. Shelley Nathan or Natlin? Not here? Okay. Dr. John Davis. So you were it, Dr. Mooney? No, I meant for the Connecticut State Dental Association. John Mooney, Shelley Nathan or Natlin and Dr. John Davis. That's all I have here.

At the end of the, if you haven't signed up, you certainly can sign up with our staff people if someone needs to testify, but I will call Vickie Nardello at this time.

VICKIE NARDELLO: Good evening, Senator Gerratana, Representative Johnson and Members of the Public Health Committee. My name is Vickie Nardello. I am a practicing dental hygienist and I should say, I have been a practicing dental hygienist for 39 years both in the public and private sector, and I was also a Member of the Public Health Committee for the past 18 years.

I'm here speaking in opposition to House Bill 6589 and the reason for that is that this issue does not need further study. I can't say that any more strongly.

It has been already studied in 2006 and 2011 by the Department of Public Health and I attached two previous bills' testimony, some of that from 2006 and we do have the information from 2011.

There's been extensive study on mid-level practitioners conducted by the Pew Center for the State and the Kellogg Foundation. Both the need for a mid-level dental provider and the safety of the care provided has been documented by these groups in addition to the Department of Public Health who clearly testified that there were no safety issues not to go forward with it.

In my experience, sitting in your chairs, I might add, the only way that we do contentious scope of practice issues is through the Public Health Committee itself. What we've done is, we've actually had to put two people in a room, or a series of people in a room and facilitate negotiation process. That's usually what's worked the best over the years.

The opposition to the advanced dental hygiene practitioner is centered on founded fears and to perceive loss of control by the dental profession. It's interesting that the dental profession supports clear laddering and an expanded function dental assistant, which is under the complete supervision of a dentist, yet opposes the career laddering for the dental hygienist but increases access and provides cost-effective care that works collaborative with the dentist.

The issue of the two-tier system has been raised as a concern because the advanced dental hygiene practitioners propose only for public health facilities. Having worked in both private and public sector, I can tell you that the quality control was rigorous in the public sector because the clinics are licensed, they're inspected and they have internal quality review protocols.

The issue of the length of the educational process has been raised as well. Hygienists with bachelor's degrees already exist in the system and it will only take two additional years to become an advanced practitioner.

The Committee needs to advance both models, the advanced dental hygiene practitioner and the expanded function dental assistant because they address different workforce needs.

The advanced dental hygiene practitioner improves access and addresses unmet needs, treatment needs, while the expanded function dental assistant increases productivity.

For eight years we have debated this issue, and I will begin to summarize. While we debate, countless people with dental needs continue to go untreated.

I ask the Committee to support the fair and equitable solution of combining those proposals into one bill as we did last year in House Bill 5541 and to bring the needed parties into the room to craft a solution. Thank you.

SENATOR GERRATANA: Thank you, Madam. I do have some questions, though, for you. I'm on the Minnesota website in their statutes and reading about and apparently both Minnesota and Alaska referred to advanced practice, if you will --

VICKIE NARDELLO: Correct.

SENATOR GERRATANA: -- to dental therapists, which seems to be the mid-level provider. That's the key here it seems, it appears to me. But both states have designated a dental therapist as a mid-level provider. Is that correct?

VICKIE NARDELLO: That is correct. Those are both, yes, they're dental therapists. And look --

SENATOR GERRATANA: Oh, no --

VICKIE NARDELLO: I'm sorry. Go ahead.

SENATOR GERRATANA: Looking at the description, at least in Minnesota, I haven't looked in Alaska, but it looks like there's a collaborative management agreement that is entered into for certain procedures, if you will, for the dental therapist and then there's also a list of indirect supervision that is, and then a list of those protocols, if you will, or modalities in which there would be indirect supervision.

So my question to you is, that does not seem to me to be the same as perhaps what advanced practice dental hygienists would like to do, but I just wanted your comments on that.

VICKIE NARDELLO: No, actually, they're quite similar. If you look at Bill 5541 from last year, it was also in collaborative practice. It spells it out very, very clearly that it's a written collaborative agreement and it's not to practice independently.

So I would refer you to Section 6 of that bill from last year.

SENATOR GERRATANA: Okay, and that's 55 --

VICKIE NARDELLO: 41.

SENATOR GERRATANA: Okay, I'll look it up. Thank you. Are there any other questions or comments? If not, oh, Representative Srinivasan.

REP. SRINIVASAN: Thank you, Madam Chair. Thank you for being here and for your testimony. So that I understand where we are on the subject matter, you are opposing the creation of a task force because that's already been done and DPH has already given us those recommendations from the task force on dental hygienists.

What I didn't understand is, the adding on this mid-level dental professionals into that. That's the part that I'm having difficulty understanding. Has that scope of practice been done and do we have the report from the DPH or is that something that's pending?

VICKIE NARDELLO: No. Actually that was conducted both in 2006 and 2011, so we do have information from both of those years.

And what I am suggesting to the Committee is that we had a bill that came forth after the scope of practice review in 2011 that put forth the two models of the expanded function dental assistant and the advanced dental hygiene practitioner, and I'm asking the Committee to reconsider that proposal since both models are needed for the general workforce of today.

REP. SRINIVASAN: So you're requesting us to look at the previous reports from the DPH that already came out. As far as the bill that we're discussing right now, 5589, you're opposing creating another task force.

VICKIE NARDELLO: That's correct, Representative. I'm opposing another task force because I feel it's unnecessary. We have already language that actually went through this Committee last year and actually died on a tie vote, so you can see that there are two opposing viewpoints.

But the language has already been created. It's already there. It's just a matter of bringing that language back.

REP. SRINIVASAN: Thank you. Thank you for the clarification.

And just one point that you had made, once again, combining these two bills and the task force. I'm looking at the task force. That's a little bit confusing about the previous things that you're bringing up. Thank you for your clarification.

You had talked about the cost of healthcare, of being better served when we have this mid-level professionals, you know, performing those duties, but that is not what we heard from the previous testimony, where it said that in the Minnesota model the cost that was seen by the dentist for a mid-level provider was essentially the same. Could you, do you have any idea about that, or could you tell us about that.

VICKIE NARDELLO: Yes. Actually, I would point to the Pew Center for the State study who actually they have studied this and actually shown that it's cost effective.

And I have attached to my again, my testimony, the executive summary of Kellogg and Pew so that you can refer to that. But the Pew Center for the State has a specific study that looked at the cost effectiveness and has determined that it is a cost-effective model.

And I could only speak to you also from my experience in the school-based dental clinic that I was in for 25 years. We paid the dentists approximately $110,000 a year, still much less than they get in private practice, I might add.

If we were to hire a dental hygiene practitioner, we would expect that that person would probably get somewhere between $70,000 and $80,000.

Now again, when you're in a public health system where every dollar counts, that's going to make a difference, so I do believe it will provide cost-effective care.

And if you would just give me the leeway just to digress for one minute, I do have a letter from the Minnesota Board of Dentistry and they've issued 25 dental therapy licenses at the present time and expect them to become advanced dental therapists, and I just wanted to enter that into the record and I thank you for your indulgence on that.

REP. SRINIVASAN: And my final question, through you, Madam Chair. So if this, if these mid-level providers were allowed to practice, you know, as you're proposing, would we be restricting them only to the public health settings or it does not matter where they practice?

VICKIE NARDELLO: We are restricting them only to the public health settings because we believe that's where the issue, that's where the access

issue exists.

It's a matter of not only access, but you have to understand that there are disparities in treatment, there are disparities among the age group, so we've made improvements in certain areas.

If you look at the teen years, particularly even in HUSKY, teenagers in the 14, 15 and 16-year-old range are not getting the number of visits that they should. There are other areas where treatment needs aren't being met.

There are some areas that we're doing very well in, but we do believe that the addition of that mid-level practitioner will help meet a health center, school-based health clinics, be able to have a cost-effective provider who will provide most of the, we call the most simplest of cases, simplest treatment.

Those that are more complex would of course be referred to a dentist.

And I do want to say also that I think that most professionals nowadays would not risk their license by taking more than they should in a practice. I think they are generally very cognizant of that and with proper oversight and education, we need to educate the workforce of the 21st century to be able to, again, meet treatment needs that aren't being met.

REP. SRINIVASAN: It is my understanding that you heard from the testimonies today and what we heard the last time on the same subject matter if I recall, that the access was not an issue and these patients that had to be seen in a private setting are being seen. That is, you seem to feel that there's an access issue for these patients?

VICKIE NARDELLO: I would disagree with that. While I believe that we have improved, and we have, okay? We still have a number of people who never get a dental visit. We have a cohort of uninsured people, particularly in the community health centers that are simply not being seen by anyone.

We have the under-insured. We have various, if you look at, it's call the CMS 416 you'll see it stratified and it will look at the various groups and what care they're getting, and it is different among the various groups.

So is there room for improvement and is there a need? I believe there is, and I believe that if you talk to any of the community health centers they would tell you that they would welcome the addition of an advanced dental hygiene therapist.

REP. SRINIVASAN: Thank you very much for your testimony. Thank you, Madam Chair.

SENATOR GERRATANA: Thank you. Vickie, last year's bill has the word diagnose in it. I cannot find that in the Minnesota statutes that there's the ability for an advanced dental therapist to diagnose.

There are parameters for treatment and so forth, so I guess what I'm trying to say to you is that I'm just having a little difficulty to understand exactly what it is that advanced dental hygienists would like to do.

VICKIE NARDELLO: The advanced dental hygiene practitioner would be responsible for the simple restoration. Eighty percent of the individuals coming to any community health clinic need simple treatment. Twenty percent need very complex treatment, having been there, and so therefore they would take care of the simple restorations.

I will give you an example. When I worked in the clinic as a regular dental hygienist, okay, and a child came down with a very, very loose tooth, I was not able to take that tooth out, even though you would as a parent be able to do that.

I would literally give them a gauze square and I would say to them, you need to wiggle your tooth out because I'm not allowed by law to do that.

So they would be able to do that kind of work and they would again, be able to do the simple restorations. The complex procedures would be done by the dentist.

By the way, there's no extraction of permanent teeth, or any of that.

SENATOR GERRATANA: Got you. Okay, well thank you. Are there any other questions? Senator Bartolomeo.

SENATOR BARTOLOMEO: Thank you and it's very nice to see you.

VICKIE NARDELLO: Nice to see you as well.

SENATOR BARTOLOMEO: I'm just, so you were looking for substitute language for this bill that basically advances advanced dental hygienist.

VICKIE NARDELLO: The Committee is considering two bills. One we hard on last Friday and I got to testify at 2:30 in the morning. It was fun, and that was for the expanded function dental assistant, and we did consider both of these proposals last year in House Bill 5541.

So what I'm asking you is to act upon these two, bring them together. They're the best models. They both do different things and then finally end this debate. It's time. People are out there. They're needing treatment, particularly adults in community health centers. We really have issues with adults, by the way and we can take care of them.

SENATOR BARTOLOMEO: And can you explain why you prefer to see them, why you would prefer to see these bills combined as opposed to stand alone?

VICKIE NARDELLO: The reason I would prefer to see the bills combined is because I believe they are both necessary to meet healthcare workforce needs. One shouldn't take precedent over the other.

The expanded function dental assistant is a clear letter of a dental assistant. The advanced practice dental hygienist is a career ladder for dental hygienists.

In the dental assistant what you've got is, you're increasing the dentist productivity. I understand that.

In the advanced hygiene practitioner, what you're doing is, you're increasing access, addressing health disparities and addressing the actual cost of treatment.

So they do two different things. They're both needed. They need to be linked together. It's the fair and equitable solution since you're providing career laddering in both of those areas.

SENATOR GERRATANA: Thank you. I don't think there are any other questions, so thank you so much for coming and testifying.

VICKIE NARDELLO: Thank you for having me and I'd be happy to discuss any of this in the future as the Committee considers its deliberations.

SENATOR GERRATANA: Sure. Great. Let's see. We have a special consideration for Merrily Kaplan to be followed by Mark Derosiers. Here she comes. Welcome, Madam. If you would please state your name into the microphone for us.

LILLIAN KAPLAN: My name is Lillian Kaplan.

SENATOR GERRATANA: Oh, Lillian Kaplan. Welcome.

LILLIAN KAPLAN: I am the mother-in-law of Merrily Lee, who is testifying here today.

SENATOR GERRATANA: Oh, I see.

LILLIAN KAPLAN: But I thought about this and I --

SENATOR GERRATANA: Did you sign up to testify, Lillian?

LILLIAN KAPLAN: I did not.

SENATOR GERRATANA: You did not.

LILLIAN KAPLAN: I'm honest. I hoped to do it but didn't have the courage to.

SENATOR GERRATANA: Okay, before you leave today would you just give your name. Actually, I'll do that for you, that you are Lillian Kaplan but you did not sign up. I'll tell my staff to put you on the list. Okay. Please proceed.

LILLIAN KAPLAN: As I say, I'm the mother-in-law of Merrily Kaplan, who I love dearly and I want to read a letter that her husband gave to the entire family and he said, hello Dad, Desmond, Margie, Anne, Bruce, he went through a whole list of his family.

I hope you are all well. I am writing to tell you that I have decided to end my life soon by my own hand. I have made this decision after much careful thought on my own because of the only way to avoid much more devastating suffering for myself and for Merrily.

I am sorry if this is shocking or upsetting to you. We are now about to hire a part-time aide to supplement the four hours of aide time we get from Medicare, but before long I will need full-time professional care. Right now, Merrily wakes up in the middle of the night and turns me. Before long, I will need more attention than she can ever give me at any night.

Eating is becoming very difficult because my right arm is weakening and the left is far worse than the right. Many other every day activities are impossible or nearly so for me to do alone.

As you know, it's precarious of me to stand, let along take a step. I am severely fatigued all the time and often intensely anxious. At times it's hard for me to open my left eye and that will worsen. Worst of all, breathing is surely becoming more difficult.

It is not only these basic manual things that I can't do. I don't really have a creative life because creativity takes energy and my energy level is so low I need to nap and rest constantly. I can't get out easily and participate in the world. It takes a caregiver enormous amounts of time and preparation to do so.

I have become strangely anxious when anything fast moves or loud or bright or sudden happens, it's a process of shutting down.

SENATOR GERRATANA: Miss Kaplan, can you please summarize for us.

LILLIAN KAPLAN: Yes.

SENATOR GERRATANA: Thank you.

LILLIAN KAPLAN: I'll say this. It is not only these basic, oh, I told you that. I can't have a creative life and I think I have stayed this long because I have the disease, because I love seeing all of you and I love life, here is nothing very compelling that I can do and life is becoming diminished day by day.

With ALS for me it's necessary to pick a point that is enough, because it is possible to be kept alive, locked in a motionless body, unable to communicate in meaningful ways. There's just one more paragraph.

In fact, I have had a fabulous life and done nearly everything I could want to do, gone nearly everywhere I would want to go and had nearly as many wonderful people in my life as I could expect to have.

I have found a way to end my life and prefer to do so with Merrily at my side if she wishes. It requires just a little strength and dexterity, about the amount I still have.

I may want friends nearby to help guard for visitors and to help afterward.

I am writing to you so that you will not have to wonder, and Merrily won't have the burden of explaining what happened why I'm not asking for your approval. Every one of you has given me great gifts of caring and comfort and love during this illness and I have gotten more kindness and compassion from friends than I could possibly have.

SENATOR GERRATANA: Miss Kaplan, thank you so much for coming here today. Now, I don't want to embarrass you, but would you care to share your age with the Committee?

LILLIAN KAPLAN: Well, I happen to be a very old lady.

SENATOR GERRATANA: I like that. Enough said. Enough said.

LILLIAN KAPLAN: And I went to pizza the other day with a couple of my grandchildren and I realized that I'm ten years older than Peppi's Pizza.

SENATOR GERRATANA: I guess we'll have to do the math on that.

LILLIAN KAPLAN: You don't have to do the math.

SENATOR GERRATANA: You know, it's wonderful that you came here and that you gave your testimony because I think after listening to what you had to say, and also being here, I understand your passion and I understand your commitment and we here in the Committee are very appreciative t hat you have come, despite the fact that you're ten years older than Peppi's Pizza.

Are you from New Haven?

LILLIAN KAPLAN: I was born in New Haven.

SENATOR GERRATANA: I kind of guessed that.

LILLIAN KAPLAN: And in a year and a half I'll be a hundred if I live that long.

SENATOR GERRATANA: There you go, folks. Round of applause.

(APPLAUSE.)

Now, if you can be patient for just a minute, I want to ask anyone on the Committee if they have a question for you. No? I guess not. So we thank you for coming today and we look forward, is Merrily going to stay to testify, too.

LILLIAN KAPLAN: Yeah, she's going to testify.

SENATOR GERRATANA: Okay.

LILLIAN KAPLAN: I just got this idea --

SENATOR GERRATANA: Thank you. Now, one other thing before you go, Mrs. Kaplan, can we have a copy of that? Okay. And our Clerk will certainly take it, our (inaudible). Thank you.

LILLIAN KAPLAN: Thank you all.

SENATOR GERRATANA: And may you live another hundred years. You know what we say in Polish, sto lat! Where's Representative Tercyak when you need him? Okay. Sto lot, sto lot. I know the song.

Next is Mark Derosiers. She should go to the Met.

MARK DEROSIERS: That's going to be a tough act to follow.

SENATOR GERRATANA: Yes, indeed.

MARK DEROSIERS: Good evening. Senator Gerratana, Representative Johnson, and Members of the Public Health Committee. My name is Mark Derosiers. I'm a practicing dentist. I practiced in Connecticut since 1988 in the Towns of Putnam, Glastonbury and West Hartford.

This evening I'm here representing the Connecticut State Dental Association as the President-elect of that organization. I'm here to testify in opposition to House Bill 6589 AN ACT ESTABLISHING A TASK FORCE TO STUDY THE SCOPE OF PRACTICE FOR DENTAL HYGIENISTS.

Back in 2002 a Connecticut State Dental Association Committee was formed to improve access to care for people with limited means. This culminated in a newer vision of the Dental Practice Act.

Since that time, there have been many bills related to scope of practice for allied dental personnel, all with the stated purpose of increasing access to care.

About three years ago, the Connecticut Dental Health Partnership, formerly known as HUSKY, increased dental rates to bring them into the realm of the private sector. I am very happy to report that with the help of the Connecticut State Dental Association, number one, 2011 utilization rates for children's dental care of the under-served has increased 20 points from 36.7 percent in 2008 to 57 percent in 2011.

The national average is 42 percent.

Number two, Connecticut, along with two other states, received an A grade from the Pew Center oral health report. More good news.

Number three. There are more than 1,600 dental providers, up from approximately 400 back in 2008.

Any child can obtain a routine dental appointment within eight days. An emergency appointment can be had within 24 hours.

Ninety-five percent of the formerly under-served sector can now find care within 10 miles radius of their home.

Many participating dentists, and I think this is a key point that currently take Medicaid patients are actually requesting more referrals from the Department of Social Services. Seventy-five percent of this care is actually currently given in private offices.

This information is available to you and was sent to you. You've heard much today, numbers, this and that. I would encourage you to read the background information so that you can really get the true information.

In closing, it seems to me that the access issue we've all been talking about is being well addressed. This new scope of practice proposal will complicate the dental delivery system, which is working in Connecticut.

The best dental delivery system is one in which all the caregivers work collaboratively in caring for our patients, something that we try to do with the assistance this past Saturday morning I guess it was.

And we look forward to working with the others so that we can increase the care of our patients. I would like to sincerely thank you for your time and I am in hopes that you will oppose this bill and any effort to amend the advanced dental hygiene practitioner language to any other bill. Thank you.

SENATOR GERRATANA: Thank you. Thank you, sir. And thank you for your testimony.

Next we go on to Senate Bill 1137 and Jessie White Frese is the first person to testify. Jessie here? Then Joann Eaccarino. No, I don't see her either. Well, here's, that's not Joanne.

JOANN EACCARINO: Jessie was unable to make it, so Senator Gerratana --

SENATOR GERRATANA: Okay, thank you.

JOANN EACCARINO: Representative Johnson, Members of the Committee, my name is Joann Eaccarino and I'm President of the Board of Directors of the Connecticut Association of School-Based Health Centers, the official voice of school-based health centers in Connecticut.

Testimony that Jessie has presented on line described our response to Bill 1137 in general. I would like to respond to Section 5 of the bill.

It has been very advantageous over the years to have a school-based health center advisory committee comprised of the Departments of Children and Families, Mental Health and Addiction Services, Social Services and Education, in addition to the Department of Public Health and representatives from the Association. Together we have worked on issues of access, services, reimbursement, funding opportunities and collaboration with school support services.

The Department of Public Health has the major role in establishing standards, including reporting requirements. They license the school based health centers, determine the data needed to support results-based accountability, ensure standards of care are being provided, require local advisory boards to support community collaboration and determine the level of licensing required of providers, and they fund us.

To include the Department of Education as the co-manager in the basic decisions about uniform standards, staffing ratios, third party reimbursement and reporting requirements would not be helpful and could lead to conflict in the day-to-day operations of the Center.

In the 25 plus years of the school based centers in Connecticut, the universal practice has been to offer registration in the health center to every student in the school with their parent or guardian's permission. We believe that this constitutes informed consent for a service that would otherwise be provided in a private healthcare provider's office, a community health center, child guidance clinic or emergency room, all of which require parental permission to treat.

This is an advanced practice beyond that which the school nurse or school social worker provides. In that permission, the school-based health center obtains information about the student's health history, allergies, medications, community providers and information about insurance.

In my personal experience with the health centers that I manage, approximately five percent of parents respond to an annual form with a statement that they do not want their child receiving services from the school-based health center. They are always welcome to reverse that decision but getting active permission from them is not only a Connecticut requirement, but a practice supported by the National Assembly on School-Based Health Care.

We therefore oppose a passive, or opt out mechanism for enrollment in the school based health center as stated in Section 5, Number 4.

Thank you for allowing me to present this and I'm happy to answer any questions about this or about the Section 1 that Jessie was going to be presenting on.

SENATOR GERRATANA: Good. I'm going to read his testimony. Are there any questions? If not, thank you. Oh, I'm sorry. Senator Welch.

SENATOR WELCH: Thank you, Madam Chair. I just, I thought I heard you say you were opposed to an opt out, so you would prefer it to be opt in?

JOANN EACCARINO: Yes.

SENATOR WELCH: Okay.

JOANN EACCARINO: We want parents to be on board fully knowledgeable, give informed consent and sign the permission.

SENATOR WELCH: I appreciate that. Thank you. Thank you, Madam Chair.

SENATOR GERRATANA: Thank you. Next is House Bill 6594. Kay Williams. Is Kay here? There you go.

KAY WILLIAMS: Senator Gerratana, Representative Johnson and Members of the Committee. My name is Kay Williams. I'm an attorney with Cooney, Scully and Dowling and I represent Catholic Charities. I'm speaking in support of Section 40 of Bill 6594 for the reason that it provides the necessary clarification in the definition of medical review committee.

The statute currently defines medical review committee as applying to committees of any health care institution. However, health care institution is not defined in the statute.

The bill seeks to change the term health care institution to health care provider, a term that is expressly defined in the statute. The change is significant in that it removes the ambiguity in the current statute and confirms that licensed health care providers such as Catholic Charities, an organization that provides mental health, substance abuse and counseling services to thousands of clients each year, are covered by the statute.

By substituting the term healthcare provider for health care institution, the statute will become clear and cohesive. Of course, the statute that I'm referring to is Section 19a-17b, the peer review statute.

The medical profession developed peer review as a means to evaluate and improve the quality of health care and has become the principal method of evaluating the quality of patient care. The main objectives of the medical peer review process are the promotion of high-quality health care and patient safety.

The peer review system therefore acts in the interest of public health by affectively policing the procedures and health care providers that may pose a risk to patients, serving an important public policy role for health care.

The free exchange of information and opinions during the peer review process can only occur in a protected setting. Therefore, the confidentiality afforded to medical review committee proceedings, is critical to the peer review process.

The immunities provided in the peer review statute are necessary to obtain participation of medical review committees as well as to encourage individuals to speak freely about past events and share their thoughts on future improvements or safeguards to enhance patient care.

Protections for peer reviews conducted by medical review committees established by health care providers are essential to ensuring high standards for medical care, resulting in better treatment and better outcomes for patients.

In conclusion, the legislation under consideration affirmatively established the inability of healthcare providers to create medical review committees to conduct peer reviews protected by statutory immunity provisions is a necessary step in ensuring quality health care for patients of all medical care providers.

SENATOR GERRATANA: Thank you, Miss Williams. Would you do me a favor? I don't see your testimony on line. Oh, wait a minute. There is a Lois Nesci.

KAY WILLIAMS: Yes. There is testimony provided by Catholic Charities on line.

SENATOR GERRATANA: Okay, and is that the testimony that you gave?

KAY WILLIAMS: My testimony tracks very closely. I didn't want to repeat what was already filed on line, but it is very similar.

SENATOR GERRATANA: Good. I just wanted to make sure we had something in writing. Okay. Thank you so much. Are there any questions? No. Thank you for coming today --

KAY WILLIAMS: Thank you.

SENATOR GERRATANA: -- waiting and giving your testimony.

KAY WILLIAMS: Thank you.

SENATOR GERRATANA: Next is Elaine Cole.

ELAINE COLE: Senator Gerratana, Representative Johnson and Members of the Public Health Committee, on behalf of the Connecticut

Association of Residential Care Homes, I would like to offer testimony in support of House Bill 6594 AN ACT CONCERNING RESIDENTIAL CARE HOMES AND DEFINITIONS OF NURSING HOME FACIITY AND MEDICAL REVIEW COMMITTEE.

The proposed legislation would create a definition of residential care homes separate from nursing home facilities. The legislation does not change the intent or application of any current statute. All currently applicable statutes would apply to residential care homes by adding residential care homes to those statutes that use the term, nursing home facility.

Connecticut has about 100 residential care homes in the state, with approximately 2,700 that, residential care homes provide a special combination of housing, personalized supportive services and care designed to respond to the individual needs of those who require a little more help with their activities of daily living, but who do not need the skilled medical or nursing care provided in a nursing home.

Residents include some of the state's most venerable people, most vulnerable people, excuse me. About 60 percent, actually at least 60 percent of residents have mental disabilities while the remaining residents are elderly.

The proposed legislation would clarify the legislative statutes by establishing a definition of residential care home separate from nursing home.

Under Connecticut General Statute Section 19a-521, residential care homes are included in the definition of nursing home facility with chronic and convalescent nursing homes and rest homes that provide nursing supervision.

House Bill 6594 would provide a unique definition to residential care home by defining a residential care home as an establishment that furnishes in single or multiple facilities, food and shelter to two or more persons unrelated to the proprietor and in addition provide services that meet a need beyond the basic provisions of food, shelter and laundry.

Since residential care facilities are not medical facilities, they should be treated differently than nursing homes. Unlike nursing homes, which are paid through Medicaid, residential care homes are paid through the Aid to the Aged, Blind and Disabled.

SENATOR GERRATANA: Thank you, Miss Cole. Can you summarize?

ELAINE COLE: Yes.

SENATOR GERRATANA: Thank you.

ELAINE COLE: So ultimately, this legislation would provide legislators with the ability to distinguish between residential care homes and other facilities like nursing homes when appropriate.

We thank you for raising this current bill and urge the Committee to support same.

SENATOR GERRATANA: Thank you very much. I did not see your testimony on line, so I would ask that you submit it if you haven't done so already.

ELAINE COLE: This was done yesterday, but after 3:00 o'clock.

SENATOR GERRATANA: No problem.

ELAINE COLE: Okay.

SENATOR GERRATANA: Thank you, so we can refer to it. And just for the record, could you tell me what CARCH is?

ELAINE COLE: That is Connecticut Association of Residential Care Homes.

SENATOR GERRATANA: Of course. Thank you.

ELAINE COLE: Okay. Thank you.

SENATOR GERRATANA: Next is Senate Bill 1064, Karen Chatterton? Gatterton? She left. Okay. Yvette Dobruck? She left, too. Dennis Cleary. A familiar face.

DENNIS CLEARY: Madam.

SENATOR GERRATANA: Oh, sign up.

DENNIS CLEARY: Just anybody?

SENATOR GERRATANA: Just anybody.

DENNIS CLEARY: There are a few former colleague still here and awake. Thank you, Madam Chairman and Members of the Committee for being here and listening to the testimony on this bill in regard to a medication being given by certified nursing assistants with additional training for nursing homes.

Continually and dynamically changing makeup of our health care teams, there are many other bills on your agenda changing scopes of practice in the way medicine is practiced in the State of Connecticut. I ask you to vote out Senate Bill 1064.

History is as long on this issue as our changing health care system. I believe this bill, combined with DPH's support and regulations to be written for the proper training, will improve quality of care in long-term care facilities.

Licensed staff have competing priorities on their time and many status with med techs have seen a reduction, many states with med techs have seen a reduction in med errors as their only responsibility is med administration.

Just for your reference, there's actually a Public Health Committee bill that reported out of this Committee in 2002. It was Substitute House Bill 5684, File Number 333 that had attempted to craft legislation that set all the parameters for both training and safety within this program.

It also was specific as to the supervision, where it would be a one-on-one supervision and the potential hours of training. Those are things I think in this bill that can be addressed by the Department of Health through the regulatory process and would love to answer any questions on either the history of this issue or the future of it. Thank you, Madam Chairman.

SENATOR GERRATANA: Thank you. Are there any questions? If not, thank you for your patience and we appreciate your testimony.

DENNIS CLEARY: Thank you.

SENATOR GERRATANA: Next is Michelle Costa.

MICHELLE COSTA: Good evening, Senator Gerratana, Representative Johnson and Members of the Public Health Committee.

SENATOR GERRATANA: Good evening.

MICHELLE COSTA: My name is Michelle Costa, and I have been a licensed registered nurse since 1986 and I also hold the position of Vice-President of Clinical Operations at Genesis Health Care.

Genesis Health Care is a long-standing provider of nursing home care in several Connecticut communities. I am here this evening to ask the Human Service Committee to support Senate Bill 1064 AN ACT CONCERNING THE ADMINISTRATIN OF MEDICATION IN NURSING HOMES BY CERTAIN NURSE'S AIDS.

This legislation authorizes Connecticut's skilled nursing facilities and rehabilitation centers to employ certified nurse's aides with additional training and experience as prescribed by the Department of Public Health to administer medication to nursing home residents.

This proposed authority is similar to the authority provided to home care, home health aides in the 2012 Session of the Connecticut General Assembly.

The specific certification requirements, including training and experience requirements will be set forth in regulations promulgated by the Department of Public Health according to the bill as drafted.

Authorizing CNAs to administer medications, except those administered by injection, in the close, supervised nursing home environment is a cost-effective approach to the safe administration of medications.

Under Senate Bill 1064 a prescribing practitioner will have the clear authority to specify that a medication shall only be administered by a licensed nurse.

Adoption of Senate Bill 1064 will provide the quality of care Connecticut nursing home residents receive. I, personally, have had the privilege to work with certified medication aides since 1992 when I entered long-term care in the State of Rhode Island.

The certified medication aide allows me as a registered nurse, to spend more time with my residents, to provide comprehensive assessments, develop plans of care, round with physicians and provide resident and family education.

The certified medication aide was an enhancement to my nursing department, not a replacement for licensed nurses. The certified medication aide is trained and educated on medication administration, therefore his or her focus is on the safe administration of medication to our residents.

I know there's been an issue also regarding questions of medication errors, and when I did look at research within my own organization, most of our mediation errors are related to transcriptions and transcription of medication is not in the scope of practice of a medication aide, so few errors are made with the medication administration.

Again, I want to thank you for your opportunity to testify and would be happy to answer any questions at this time.

SENATOR GERRATANA: Thank you. Representative Cook.

REP. COOK: Thank you, Madam Chair. I have a really quick question. Thank you for your testimony.

Under the, in the legislation it says medication administration. That would be the certification that you would receive?

MICHELLE COSTA: Yes, ma'am.

REP. COOK: Is that the same certification as, so I was med certified at the Connecticut Junior Republic to be able to administer medication during off hours if the nurse wasn't there.

Would that be, and it was called a med certification course. Are we talking about the same thing, or would this be probably more in depth?

MICHELLE COSTA: It would be more in depth. It's another class that I don't even think that they have even developed yet. We're looking for the bill to pass and for classes and training to be developed at local colleges under the jurisdiction of the Department of Public Health.

REP. COOK: Thank you very much for your clarification. Thank you, Madam Chair.

SENATOR GERRATANA: Thank you. Excuse me, Representative Johnson would like to ask you a question.

REP. JOHNSON: Just quickly. Are you familiar with the Institute of Living psychiatric aides that administer medication?

MICHELLE COSTA: I am not.

REP. JOHNSON: Okay, thank you.

SENATOR GERRATANA: Thank you. Senator Welch.

SENATOR WELCH: Sorry.

MICHELLE COSTA: My vision's not that great, so I can't --

SENATOR GERRATANA: Now don't leave until I tell you.

MICHELLE COSTA: All right. As you can see, I'm squinting.

SENATOR GERRATANA: Okay. Senator Welch.

SENATOR WELCH: Excuse me. So, as I understand it the State of Rhode Island currently has this kind of certification.

MICHELLE COSTA: Yes. Currently the State of Rhode Island, Maine and New Hampshire.

SENATOR WELCH: And in the absence of this kind of certification, is it an LPN that would administer?

MICHELLE COSTA: Currently right now in the nursing home industry either an RN or LPN administers medications. Medication passed in the nursing home industry is extremely time consuming, so the nurses are then taken away from other responsibilities that we went to school to be nurses for, which is assessing, educating, developing plans of care.

So the medication aides would be focused solely on the medication pass and it would allow nurses to do other nursing responsibilities and duties throughout their shifts.

SENATOR WELCH: And what is the difference in pay between an LPN and a nurse's aide?

MICHELLE COSTA: You know, there is a difference. I can tell you the difference between, in Rhode Island, because I can only speak for the difference between a CAN's rate of pay and a med tech's rate of pay is probably a $2 an hour difference.

SENATOR WELCH: Thank you. Thank you, Madam Chair.

SENATOR GERRATANA: Certainly enough to (inaudible). Anyone else have any questions? Okay, now you can leave. Thank you so much. Next is Jennifer Smith, followed by Martin Sbriglio.

JENNIFER SMITH: Good evening. Thank you all for staying so late tonight. I know you're only half way through.

SENATOR GERRATANA: Oh, we're not even half way down.

JENNIFER SMITH: On the unglamorous side of becoming an elected official so thank you so much for all of you being here and paying so much attention asking so many questions today. We appreciate it.

My name is Jennifer Smith. I'm the Legislative Director at District 1199, SEIU Health Care. We represent over 26,000 health care workers and that includes 6,000 both nurses and CNAs in Connecticut nursing homes.

So I'm here to offer a little bit of a different perspective. I don't think the testimony that we e-mailed in has appeared on line yet so I'm going to --

SENATOR GERRATANA: That's correct, Jennifer. I'm just looking.

JENNIFER SMITH: Okay, yeah. We submitted it last night, but so I'm going to just highlight five reasons why we at District 1199 oppose Senate Bill 1064 regarding the administration of medication by certain CNAs.

One, nursing home residents these days are older, sicker and more frail than in the past. As Connecticut's population continues to age and as we're moving out those healthier nursing home residents into home care, moving into the future, that trend is only going to get worse, meaning that in the nursing home, residents are going to need more medical attention and care, not less.

Two, geriatric nurses who are working in nursing home spend most of their time nowadays actually doing paperwork and charting and so passing meds, although I do understand it can be time consuming, the preparation, this is actually one of the few times that nurses get face-to-face time with nursing home residents, not like what we imagine in the old days where nurses were really hands on providing care. So this is one of the few times when they can do visual, physical inspection of the patient to really complement what the CNAs are already seeing.

Three, already under current state regulations, CNAs are responsible for more than a dozen residents during the day shift and at night that number goes up. The regulations actually have not been updated since early 1980s, and so adding yet another responsibility onto CNAs, which in the reading of the bill as it's written now, is adding on to CNAs, not creating a different classification of people who would only be responsible just for passing meds, when there's already 12 other residents pushing call buttons, needing to be taken to the restroom, et cetera, is really asking for trouble.

Lastly, just to wrap up, this does seem like a way to continue to cut corners in health care rather than really figuring out what is the best kind of care that we can provide in our nursing homes, especially as the industry and the types of residents that we're serving in nursing homes is really going to be changing dramatically into the future.

SENATOR GERRATANA: Thank you very much. Are there any questions? If not, thank you for giving your testimony this evening.

JENNIFER SMITH: Thank you all.

SENATOR GERRATANA: Take care. Next is Martin Sbriglio.

MARTIN SBRIGLIO: Senator Gerratana, Representative Johnson, Committee Members, thank you for staying late. I'm here to support Senate, of course, I'm Martin Sbriglio, as you said earlier and I'm CEO of Ryder's Health Management. I'm here to support Senate Bill 1064 medication administration by certain CNAs.

I strongly support the bill. I am a nurse. I've done med passes and I can tell you that the quality of care will improve with the medical technicians (inaudible) definition.

CNAs that are trained specially, frankly, have in the proposed training program, would have more training, pharmacology training than a licensed practical nurse, so the skill set they would have, and they would be focused on strictly passing meds. They would not be providing direct patient care.

We would not dilute that. The whole point, as a nurse, when you pass meds, you're interrupted by physicians. You're interrupted by patient's families, annoying administrators like myself, and many other interruptions.

If your total focus is passing meds, you will not be distracted and make medication errors.

Some patients have as many as 20 meds, one patient. And many cases when you're doing a med pass, you'll have 30 patients you're passing meds to. There is, it's very difficult for a nurse to pass meds without interruptions.

They're answering phones, portable phones, as I said. Doctors are calling and every time a doctor calls you have to lock up your med car, go answer the phone, frankly, the physician is usually upset because you didn't get to the phone right away. You take the physician's orders, go back to the med cart, unlock the cart. It's a very difficult procedure.

The whole point of a medical specially trained CAN is to improve care, not save money, and I think there's some confusion on that.

It's also from the standpoint of a CAN who doesn't want to or can't become a nurse, it's a career path. It's something that's very good and encouraging and it's good for motivation for the team.

As studies in Rhode Island have proven, that medication errors are reduced.

And I'm very happy to hear the Department of Public Health is now in support of this.

SENATOR GERRATANA: Thank you. I don't see any testimony from the Department on our website, but maybe they submitted something.

MARTIN SBRIGLIO: Okay.

SENATOR GERRATANA: Representative Srinivasan, did you have a question?

REP. SRINIVASAN: Thank you, Madam Chair. Good evening and thank you for your testimony this evening. So that we understand clearly, this person, the CAN technician who is going to do the med pass, their responsibility, his or hers, is only to administer medications to the patient --

MARTIN SBRIGLIO: Correct.

REP. SRINIVASAN: -- or would it also include all the other conventional things they're expected to do?

MARTIN SBRIGLIO: No. Absolutely not. There would be totally no point to this, then. The whole idea is to get, as you heard earlier testimony, is to get the nurses back to the patient, doing patient care, doing what an RN would normally do, a full assessment.

When a doctor calls and wants to know what the patient's condition is, if you're only given 10 seconds to give the med, go to the next room, you're not really going to be able to do a full assessment.

It just makes complete sense to have them totally focused on that med pass. They have no other responsibilities.

REP. SRINIVASAN: Thank you for the clarification. But from the previous testimony the impression we got was this was an added on responsibility and so they're responding to all the buttons during the daytime, and increased load in the night.

So what you're saying is, this person's sole responsibility is med pass.

MARTIN SBRIGLIO: Correct. As much as I respect Jennifer, that was incorrect. That's not what the industry is looking to do. We are purely looking to improve care and streamline the process.

REP. SRINIVASAN: Thank you for the clarification. Thank you, Madam Chair.

SENATOR GERRATANA: Certainly. Representative Tercyak.

REP. TERCYAK: Thank you, Madam Chair. Forgive me for asking a question. I know there are many people waiting.

Did I hear you, sir, say that these aides who would be giving meds would be better trained that licensed staff at giving medication?

MARTIN SBRIGLIO: That's not what I said at all.

REP. TERCYAK: Thank you. You did compare them to licensed staff?

MARTIN SBRIGLIO: I compared the pharmacology component only, the medication administration only to a licensed practical nurse.

REP. TERCYAK: Okay. So the pharmacology component, the licensed medication administration component only --

MARTIN SBRIGLIO: Yes.

REP. TERCYAK: -- you believe will be more comprehensive with an aide than with a nursing student in college?

MARTIN SBRIGLIO: No. A licensed practical nurse. I'm not suggesting an RN. I am an RN and my pharmacology experience was, I don't know what the exact hours were, but 75 hours of training is what I believe is proposed, or 74 hours, approximately, a pharmacology study and that is a pretty intensive program.

When it comes to assessing, no. That's exactly why we only want the medical CAN to be trained specifically for med pass, not for assessing patient condition, not for blood pressure test taking or pulse or respirations or diagnosing, none of that.

REP. TERCYAK: Do you have trouble recruiting LPNs to work in nursing facility?

MARTIN SBRIGLIO: I have to ask around. I can't answer that.

REP. TERCYAK: Because we still have programs that graduate LPNs every year.

MARTIN SBRIGLIO: Yes, and they're very good.

REP. TERCYAK: General hospitals don't hire them. Doctors offices aren't hiring them as much as they used to be. As a matter of fact, the nursing homes are like maybe the number one place for an LPN to get a job. So I'm surprised to hear that you would like us to allow non-nurses to pass medication.

I question why families coming in would alone among everybody they ever see in a convalescent home magically somehow know not to bother the aide who's passing medication. I can't imagine why they should know that. I can't imagine any sign that would be big enough that would make somebody would ignore somebody nearby, and I would think that we would want people passing medications to take the opportunity to do some assessment of a patient and the idea that it's not necessary is frankly alarming.

Thank you very much, Madam Chair. Thank you, sir for your testimony.

SENATOR GERRATANA: Thank you, sir. Any other questions? Representative Johnson.

REP. JOHNSON: Just quickly. I was wondering, who would supervise the aide who is doing the medications? They're pouring the medications and then they're administering them as well?

MARTIN SBRIGLIO: Not all the medications, just certain types, but there's, we're --

REP. JOHNSON: How would you divide the labor there?

MARTIN SBRIGLIO: Pardon me?

REP. JOHNSON: How would you divide the labor and who would supervise the aide?

MARTIN SBRIGLIO: That's still to be determined by the Department of Public Health. That would be structured. The bill does have some descriptions, but we're not looking to replace LPNs. We're not looking to get rid of LPNs. We admire and love all of our LPNs. So the LPNs would certainly be involved in the monitoring, but an RN has to be on the floor. We have RNs in our facilities 24 hours a day, 7 days a week, unlike other parts of the health care continuum.

REP. JOHNSON: Thank you. Thank you, Madam Chair.

SENATOR GERRATANA: Thank you. Thank you. Next to testify is Denise Parent followed by Susan Boritz.

DENISE PARENT: Good evening, Senator Gerratana, Representative Johnson and Members of the Public Health Committee. My name is Denise Parent and I'm the President-Elect of the Connecticut Association for Marriage and Family Therapy.

We wanted to thank you for raising Bill 6646. It addresses a technical fix in our accreditation process that is duplicative and redundant so that is the first purpose of this bill.

The second purpose is that we would like to ask you to add the language regarding an associate license for our marital and family therapists. This license adds structure to the period after graduation and before they're licensed to work independently and can help them obtain employment and also create some regulation for that period while they are in that gray area where they're still needing supervision.

This does not at all change the scope of practice but adds an additional layer of accountability for this period of time. Thank you.

SENATOR GERRATANA: Thank you, and you did attach that to your testimony?

DENISE PARENT: Yes, I did.

SENATOR GERRATANA: Great. Very good. Any questions or comments? Senator Welch.

SENATOR WELCH: Thank you, Madam Chair. So very quickly, with respect to the changes that deal with accreditation --

DENISE PARENT: Yes.

SENATOR WELCH: -- are there any institutions that will no longer be able to have their graduates obtain this designation, or is it purely technical?

DENISE PARENT: No, this is really from 30 years ago when marriage and family therapists were trained by other marriage and family therapists and they were not housed in accredited universities and colleges, so it really just updates and adds that extra, it removes that extra layer of duplication where the Commission on Accreditation has to receive, submit their paperwork to the U.S. Department of Education and our national association has asked us to correct this across the board in all states.

SENATOR WELCH: Okay, thank you. Thank you, Madam Chair.

SENATOR GERRATANA: You're welcome. That's it. Susan Boritz.

SUSAN BORITZ: Hello, Senator Gerratana, Representative Johnson and Members of the Committee. My name is Susan Boritz and I'm a licensed marriage and family therapist and a licensed alcohol and drug counselor currently in independent private practice in Sandy Hook. I'm the Legislative Liaison of the CTAMFT Board and I'm here to make the case that the current regulations are in need of a few small tweaks in order to bring them up to date and make them more (inaudible) for our membership, the agencies and entities in which we work and most importantly, the public in need of the services we provide. So thank you for taking up this bill.

I want to say a little bit more about the associate license. I'll tell you why it's so important right now to address this.

There are some practical problems in the current pathway to licensure for MFTs. Under the current provision, the candidate must complete the following, must graduate from a regionally accredited clinical training program in MFT, pass a national exam, amass 1,000 hours doing therapy with clients, that's direct client contact, and document 100 hours of supervision by an MFT.

So the associate license would address the period of time between completing steps one and two so if you have a graduate degree from an accredited program, you are an MA or an MD, and step three and four.

Steps three and four can take a candidate a considerable amount of time. A thousand hours can amount to two years. A hundred hours of supervision is one hour a week for two years. So it's in that period of time that members, our young MFTs are in a bit of a trap.

It can be like these people don't have credentials at all. Currently, they cannot serve in many roles in agencies where a license is required to perform certain functions. As things are, they can't get reimbursed by third party payers. The net result of those limitations is that it's difficult to get hired by agencies or to work in private practices, where they can actually get the hours and supervision they need to get licensed.

With an associate license they could be more readily hired by agencies or work in private practices if that's the work they're best suited for.

This is also something that social workers have lobbied for. So I just want to conclude. We're not proposing any change in requirements for licensure. There is not anything that's going to change in the scope of practice. There is no cost to the state other than in the initial implementation. These candidates will be paying a fee.

What we're doing is proposing removing a real world obstacle for MFTs on their path to licensure and by so doing, allowing agencies and private practices to have greater flexibility in hiring and using staff in roles for which they are best prepared (inaudible).

SENATOR GERRATANA: Thank you, Miss Boritz. Can you summarize or are you through?

SUSAN BORITZ: That's it. I'm done.

SENATOR GERRATANA: That's it. Now, I did look on line. I don't see your testimony there. Did you submit it?

SUSAN BORITZ: I submitted it yesterday, so it should be there.

SENATOR GERRATANA: Good. Good. Okay. So long as we have access to it. Thank you so much. I don't think there are any questions. Thank you.

We now go on to Senate Bill 1065 and the first person to testify is Steve Karp, followed by Susan Campion.

STEPHEN KARP: Good evening. I'm Stephen Karp. I am the Vice-President of the Connecticut Certification Board. Some of you know me from my position as NESW Executive Director, but I'm here tonight on behalf of the CCD.

From the late 1990s, when the license alcohol drug counselor statute was put in place, it was very stringent requirements in order to qualify. Those requirements included demonstrating competency in alcohol and drug counseling by completing the counseling relating master's degree, 300 hours of supervised practicum, 3 years of supervised work experience, 360 hours of education with no less than 240 hours in alcohol and drug counseling education and passing a written exam.

In 2012, at the end of the Session, some of those requirements were changed and we believe dramatically weakens the LADC.

In terms of the 240 hours of education alcohol and drug counseling education, the drug and alcohol counseling education was removed, so basically you now have the 360 hours of education, but there's no requirement that any of that education be necessarily specific to drug and alcohol counseling.

The other section that was removed was having a master's degree in a counseling related field, so now you have a master's degree but that master's degree could be anything. So you could have a master's in architecture and then get 18 hours of counseling training, 18 hours a semester of training and then meet the other requirements and then sit for the LADC.

What this bill does is, very simply, it returns the requirements to the initial, to the original language in terms of the education, in terms of the 240 hours of alcohol and drug counselor education.

What we are asking is that you actually amend this bill by also returning the language of having a master's degree in a related, a counseling related master's degree. That would then put it back to where we were when this bill first passed, and as I said, it was really until last year at the end of the Session, you know, we looked at the history of the bill. We're not sure what exactly the reason was for changing it, but we suspect that whatever the cause was has been resolved.

And at this point we would like to see it going back to our original language, and that's really the essence of this bill.

I do want to also say that, I just want to say very quickly on behalf of the NESW that we very strongly support SB 1136, particularly the section, this is the mental health services bill, the section that deals with setting up a regionalized system of consultation for pediatricians.

It's wonderful. It's terrific. My counterpart in Massachusetts says it's fabulous. We think it's one of the better ideas we've seen in mental health services.

SENATOR GERRATANA: Well thank you.

STEPHEN KARP: I wanted to throw that in.

SENATOR GERRATANA: Good. And thank you for your testimony, too. Actually, my Co-Chair and I were just discussing it. I said I think that was an adjustment made last year to the alcohol and drug counselors for whatever reason, and of course, I think the right thing to do is to restore it to the way it was.

So we thank you for your testimony. Are there any questions? If not, thank you for coming this evening.

STEPHEN KARP: Thank you.

SENATOR GERRATANA: Next is Susan Campion, followed by Bobbi Foy.

SUSAN CAMPION: Thanks to Senator Gerratana and Chairperson Johnson and all Committees Members for your valued service to us residents of Connecticut staying so late.

SENATOR GERRATANA: Thank you, ma'am.

SUSAN CAMPION: I'd like to introduce myself. My name is Susan Campion. I am a licensed alcohol and drug abuse counselor and I'm a licensed marriage and family therapist with about 30 years of experience in administrative and consulting work.

Before I testify to make things a little bit clearer, we have two documents. I believe they're on your website.

SENATOR GERRATANA: Yes. We have, there's you're here twice.

SUSAN CAMPION: Just shows how much I want this bill to go through. But in any event, I will get tongue-tied trying to read the requirements.

I would just say, as my colleague from Connecticut Social Workers, just a few words have the power to literally crash our profession or help and sustain our profession.

First of all, again, thank you, thank you, Public Health Committee for raising this bill and letting us have a voice. You also were kind enough to restore the substance abuse training.

We are asking for an additional consideration and that is outlined in your visual. To have a master's degree in a behavioral field such as counseling, psychology, social work, human services or related mental health field from an accredited institution of higher education with a minimum of 18 graduate semester hours in counseling or counseling related.

This is so critical because it will carry on the strong tradition of the licensure bill but move it one step forward. So although we were stunned by 2012's legislation, we now feel it was a blessing in disguise. Oops.

I just would like to tell you from my perspective --

SENATOR GERRATANA: You can. I just want to be clear what you attached because I have to read it upside down or sideways, I guess. Is that the language that you wanted to include, the master's certification.

SUSAN CAMPION: Yes.

SENATOR GERRATANA: Okay.

SUSAN CAMPION: And the other piece that I would want you to refer to is the template model we use, which is from the Department of Public Health's licensed professional counseling. That's exactly the same education --

SENATOR GERRATANA: I see. I see.

SUSAN CAMPION: So we have parity.

SENATOR GERRATANA: Okay.

SUSAN CAMPION: Quickly. If this bill is not passed, unfortunately it will allow for flawed license lacking statutory regulation for best practice requirements in the provision of substance abuse treatment.

It will also cause erosion of the quality of a workforce people by addiction specialists and most importantly, it will lose our position as a profession in the state and as we move forward in the behavioral and health network and the Affordable Care Act.

What will happen to these substance abusing clients? This has been my vocation. This is my passion. If we do not get this license, Connecticut residents will no longer be guaranteed of the highest quality of treatment by statutory regulations and that going forward would cause innumerable problems that all of you on this Committee are aware of.

SENATOR GERRATANA: Yes, I think we are.

SUSAN CAMPION: I would just again say, this is both for the profession and most importantly for the sick and suffering addicts, and I hope you will consider and pass this bill so that we can get on with the very important business of our profession.

SENATOR GERRATANA: Thank you. Thank you. We'll do our very best. I don't think there are any questions, though. Thank you. Next is Bobbi Foy, to be followed by Daniel O'Keefe.

BOBBI FOX: Hello, Senator Gerratana, Representative Johnson and Members of the Committee. Just for the record the name is Bobbi Fox.

SENATOR GERRATANA: It says f-o-y here. Oh, I see, the other part of the, I see, Fox. Thank you.

BOBBI FOX; Formally, it's Barbara Fox and I'm the immediate past vice-president for the Northeast Region of NAADAC, the National Association for Addiction Professionals. I am currently the Vice-President for the Connecticut Association for Addiction Professionals, better known as CAAP. I am also a professor and the program coordinator for the Drug and Alcohol Recovery Council Program at Manchester Community College.

Last year the 13-year-old licensing law for addiction counselors was revised and two very important components of the original law were either changed or removed in Section 20-74f, Section 19 (d) and (e) (3) of our General Statutes. The master's degree requirement was changed and the requirement for education in addiction-specific education was removed.

These changes have dramatically transformed our licensing law for addiction counselors. Someone with no training or education in addiction-specific areas and a master's degree outside of behavioral health, could, with 18 graduate credit hours and counseling, eventually be deemed eligible to obtain a license to practice addiction counseling in Connecticut.

We, as a profession, locally and nationally, have been working to bring our profession into alignment with other behavioral health care professionals like social workers and licensed professional counselors.

Currently, there are approximately 30 states with either licensing laws on the books or waiting to introduce such legislation. It can be said that this is a national movement to have addiction professionals join the ranks of other behavioral health specialists.

Addiction counseling is seen as a unique specialty among health care providers and we, the advocates for the addiction professionals work continually to make sure we are seen as a separate and vital profession within the health care community.

To this end, we have in place national scopes of practice and a career ladder for substance use disorders along with an accrediting body for addiction study programs in colleges and universities.

Lastly, in the Affordable Care Act, the Health Care Workforce Section 5002, there's a definition for mental health service professional and it includes a graduate or post-graduate degree from an accredited institution of higher ed in psychiatry, psychology and other areas like social work, substance abuse disorder prevention and treatment and professional counseling.

I'd like to thank you at this time for all listening to me. Thank you.

SENATOR GERRATANA: And thank you very much for bringing your testimony to the Committee.

BOBBI FOX: Thank you. Any questions?

SENATOR GERRATANA: Yes, Representative Ziobron.

REP. ZIOBRON: Thank you, Madam Chair. So are you saying that normally or in the future, most counselors are going to have graduate degrees, if that's what the legislation on the federal level is putting forward?

BOBBI FOX: Yes.

REP. ZIOBRON: Is that what you're suggesting?

BOBBI FOX: Yeah, on a federal level to work in and get Medicare and Medicare reimbursement, they're going to be looking for licensed professionals. That's coming with the Affordable Care Act.

REP. ZIOBRON: And will that, do you believe in your opinion, cause a shortage of these folks to help people with substance abuse?

BOBBI FOX: There already is a shortage. It exists now.

REP. ZIOBRON: Thank you very much. Thank you, Madam Chair.

SENATOR GERRATANA: Absolutely. Thank you. Next is Daniel O'Keefe to be followed by Roby Rowe.

DANIEL O'KEEFE: Good evening, Senator Gerratana, Representative Johnson, Members of the Public Health Committee. To expedite this testimony and avoid sounding like the department of redundancy, I will omit the details of this matter and move directly to my vehement support of the passing of Bill 1065.

The entry into the addiction counseling field should not be a mere post-graduate afterthought requiring only a semester's work of addiction counseling, or counseling, education in counseling, excuse me.

A student or professional deciding to enter this field must not only demonstrate their prowess as a potential licensed drug and alcohol recovery counselor, they must show a dedication to the educational specificity required.

This must require an education practicum, which marries all facets of the professional's pursued behavioral health education directly to the drug and alcohol counseling field.

The bill passed in June, 2012, which allowed professionals and students to all but circumvent this vital requirement is tantamount to allowing an individual with a master's in anthropology to become a licensed alcohol and drug counselor by simply completing six classes on counseling at the graduate level.

Our credibility as professionals, the safety of our clients and the welfare of our community's health as a whole are all at stake today.

I trust this Committee will see the importance of the passing of this bill.

SENATOR GERRATANA: Thank you, Mr. O'Keefe. Absolutely appropriate. We do appreciate it. Are there any questions? I don't believe so. Thank you for giving your testimony.

Next is Roby Rowe.

ROBY ROWE: Good evening.

SENATOR GERRATANA: Good evening.

ROBY ROWE: I'm Roby Rowe --

SENATOR GERRATANA: Roby.

ROBY ROWE: -- Public Policy Chair for the Connecticut Association of Addiction Professionals. I'm here to testify in favor of SB 1065 and to clarify some additions we are requesting to the bill.

I want to begin by thanking the Committee and the Co-Chairs Representative Johnson and Senator Gerratana. My comments will primarily focus on the need to require a master's degree in the behavioral science field as a prerequisite for being granted an LADC.

But I will point out that you have received this grid and were looking for the language that is the right column on the first page. The second page is already taken care of in the bill.

SENATOR GERRATANA: Yes. I don't see your testimony on line. Did you submit it?

ROBY ROWE: This morning.

SENATOR GERRATANA: I'm sorry? Oh, this morning, okay.

ROBY ROWE: At around (inaudible) this morning.

SENATOR GERRATANA: Okay, very good.

ROBY ROWE: You're undoubtedly aware that substance abuse is one of the primary, if not the primary public health issue our state and nation face, having a workforce with the highest preparation to address these complex issues is critical.

I'm going to skip some things in deference to the time limit.

There's a lot of difference between a planned comprehensive course of study in a behavioral health science field and a degree in any other field of study and a planned program provides a comprehensive view of a profession and would include a lot of courses related to (inaudible) psychology, multi-cultural issues and other things that I've named in the written testimony.

SENATOR GERRATANA: Thank you. Can you summarize for us please?

ROBY ROWE: There's an ever-increasing emphasis on best evidence-based practices, those with, backed by research and an increasing emphasis on faster implementation of research back practices, and these will be much better addressed with higher qualifications.

I respectfully trust that you will protect Connecticut's reputation for high standards (inaudible) and pass 1065 with the inclusion of language requiring master's degree in the behavioral health field from a regionally accredited body approving degrees of higher education.

SENATOR GERRATANA: Right.

ROBY ROWE: The regionally allows for the transferability of credits with other institutes of higher education in the area.

SENATOR GERRATANA: Good. Thank you very much. I don't think there are any questions.

ROBY ROWE: Thank you.

SENATOR GERRATANA: And I'll look forward to seeing your testimony on line. Next to testify is Dr. John Foley.

MICHAEL DARREN: Thank you very much. I'm not Dr. Foley. Unfortunately, he was unable to be here --

SENATOR GERRATANA: You're not?

MICHAEL DARREN: -- due to a family emergency. He would very much have liked to be here and given this testimony as he feels very passionate about it.

My name is Dr. Michael Darren. I'm a thoracic

surgeon from New London. Dr. Foley is President of the Connecticut State Medical Society. I'm the past president of this society, past Speaker of the House, past Chairman of the Board of Trustees.

And thank you for the opportunity to speak. Senator Gerratana, Representative Johnson and the Members of the Public Health Committee, on behalf of the almost 7,000 physicians and physicians in training in the Connecticut State Medical Society, I'm here today to provide testimony in strong opposition to House Bill 6644 AN ACT CONCERNING COMPASSIONATE AID IN DYING FOR TERMINALLY ILL PATIENTS.

The Green physician, I can't believe it, call back. Terribly sorry, but we have somebody who's covering for me and has probably, but I'm sure it's not a problem.

The ancient Greek physician Hypocrites, known as the father of modern medicine prescribed specific ethics and guidelines for physicians. Thousands of years later, his Hippocratic oath is still taken by physicians as they enter the practice of medicine.

As part of this physician's pledge to devote themselves to healing and to life, and they speak the words "I will give no deadly medicine to anyone if asked nor suggest any such counsel."

As the bedrock of physician ethics the Hippocratic oath is fundamentally inconsistent with the concept of physician assisted suicide. Laws sanctioning the use of assisted suicide undermining the foundation of the physician/patient relationship, which is grounded in trust in the knowledge that the physician is working wholeheartedly for the patient's well being.

The American Medical Association has come down strongly against physician assisted suicide and in their ethical opinion states, allowing physicians to participate in assisted suicide would cause more harm than good.

Assisted suicide is fundamentally, incompatible with the physician's role as healer and would be difficult or impossible to control and would pose serious societal risks.

I'd be happy later to tell you how that comes about but that's not done by a committee. It comes through the House of Delegates, which represents 500 physicians having to vote on this and a whole process.

I think it might be a little bit easier to pass a law through this Legislature than it is to pass it through the House of Delegates of the AMA. It's a very long and laborious process.

SENATOR GERRATANA: Thank you, sir. Can you summarize for us?

MICHAEL DARREN: Yes. I think the legalization of suicide would also place tremendous social and economic pressure on physicians and patients. We would also have to ask, where would it stop legally? Would it spread to the disabled, to those who are not terminally ill and it would be against every fiber of that obligation of a physician and on the basis of that, I ask you to oppose this legislation.

SENATOR GERRATANA: Thank you very much. Are there any questions? Senator Welch.

SENATOR WELCH: Thank you, Madam Chair. Have you, I'm assuming doctors from Oregon and Washington had input into the AMA's position with respect to this.

MICHAEL DARREN: Correct.

SENATOR WELCH: Have you heard from them? Did they have any testimony with regard to the operations in those states?

MICHAEL DARREN: This position on assisted suicide is probably, I don't know, I would have to go back maybe seven years, eight years or nine years. I'm not even sure what the policy was or what the law was in either of those two states. But I'm sure, however, there were people who gave all sides of this testimony.

SENATOR GERRATANA: Thank you. Representative Ziobron.

REP. ZIOBRON: Thank you very much for your testimony. Thank you, Madam Chair. I have a question.

So if a patient refuses their medicine, as a doctor and as the oath as you just described, what would be a response from the AMA if you had a patient who was refusing the medication and refusing food. Would you abide by their wishes?

MICHAEL DARREN: Yes. The patient ultimately is the final arbiter and they are free to make whatever decisions they want to make, and so that's, we would try to discuss that with them, talk with them about it, give them the options, give them the alternatives and the implications of their decision.

Ultimately, it's the patient that is in control with the physician there to work on that decision, whatever that decision may be.

REP. ZIOBRON: So, for instance you have somebody who has congestive heart failure, diabetes, they refuse their medication, they refuse to eat, you would in no way force feed them or try and change their mind? You just explain the facts? Is that what I'm understanding?

MICHAEL DARREN: I think we would not force feed them. We wouldn't force that. But, I think we would discuss that with them and explain to them that congestive heart failure is easily treated in many cases.

Of course, there comes a time when we support life. We want to make life better, but there's, all of us have a fatal prognosis. Everyone in this room has a fatal prognosis. We will all pass away at one time. We have to accept that and there are times when that is inevitable, in which case the physician still has a role of assisting that patient in their final chapter of their life, along with their family, making them comfortable and being sure that they have a dignified passage.

REP. ZIOBRON: Thank you. Thank you, Madam Chair.

SENATOR GERRATANA: Thank you, Representative. I don't think there are any other questions, are there? No.

MICHAEL DARREN: Thank you very much.

SENATOR GERRATANA: Thank you, sir. Next is Tracy Wodatch.

TRACY WODATCH: Good evening, Senator Gerratana --

REP. SRINIVASAN: Good evening.

TRACY WODATCH: -- and Members of the Public Health Committee. My name is Tracy Wodatch. I'm Vice-President of Clinical and Regulatory Services for the Connecticut Association for Health Care at Home. I'm also an RN with 30 years experience in home health, hospice, long-term and acute care.

The Connecticut Association for Health Care at Home is the united voice for Connecticut's hospice and palliative care providers. We oppose Bill Number 6645 AN ACT CONCERNING COMPASSIONATE AID IN DYING FOR TERMINALLY ILL PATIENTS.

For the remainder of the testimony, I'll refer to it as physician assisted suicide or PAS, which is the common acronym.

On behalf of the Association and its members, I testified before your Committee last week in support of two bills, a MOLST pilot and a Palliative Care Advisory Council.

Both emphasize the importance of best practice for hospice and palliative care services, consumer education and conversations between the patient and the primary care provider regarding available services, goals of care and quality end of life care.

PAS is not an option that promotes quality end of life care. Connecticut currently ranks last or 51st in the country, including Washington, D. C. in hospice length of stay. This translates into last minute hospice referrals, last minute end of life care.

The provider continuum is not doing a good enough job to promote hospice and palliative care services resulting in late referrals and poorly informed consumers regarding their end of life options. Perhaps this is why some feel a bill on PAS is needed.

Instead of considering legalizing PAS, let's instead focus our efforts now on the essence of hospice care, which is to allow patients to make the most of their remaining time. Hospice values people's lives until their natural end, making their death a true death with dignity.

The general public still thinks hospice is a place to go to die, only to be used in final days of life. Our hospice and palliative care providers can be very effective in helping people die with dignity.

They offer expert, compassionate relief of pain and suffering. They strive to help patients and families deal with the important physical, psycho-social and spiritual needs as they end their lives, as their lives come to an end, I should say, promote opportunities for meaningful experiences, personal and spiritual growth. They assist patients and families to cope with the loss and grief and they support patients' rights to participate in all decisions regarding their care.

SENATOR GERRATANA: Thank you, Miss Wodatch. Can you summarize for us, please?

TRACY WODATCH: The Connecticut Association for Health Care at home is committed to the hospice philosophy, cherishing life until its natural end while reinforcing dignity, quality and comfort.

We afford the highest regard for person-centered choice and self determination. However, we do not support the legalization of physician assisted suicide.

SENATOR GERRATANA: Thank you, ma'am. Are there any questions? Representative Demicco.

REP. DEMICCO: Thank you, Madam Chair. Thank you for testifying. I just had a question for you about hospice and palliative care. I'm certainly appreciative of the hospice and palliative care, my question is.

I have been told that in some extreme cases palliative care is not sufficient to relieve the pain and the suffering of some patients, and I was just wondering if you could comment on that?

TRACY WODATCH: I'd like to first take a moment to define the difference between palliative care and hospice care, and I believe the definition that is used within the bill needs to be clarified.

It does state palliative care is for terminal illness and it's not for terminal illness. Palliative care is holistic care along with serious illness. So somebody could be receiving curative treatment, lung cancer, getting chemo-therapy, radiation, but they have symptoms of pain. They have symptoms of unable to eat, unable to breathe, things like that.

Palliative care is supplemental care being given while someone is being treated aggressively still. They also get the psycho-social, spiritual, all of the holistic pieces that come along with hospice.

Hospice is for people with a prognosis of less than six months to live. Okay?

So I think in the language of the bill it says it's for terminal illness and it's not. Palliative is for serious, those with serious illness. Eventually, they may become in need of hospice care, okay?

So, are there cases where people may not be made comfortable, I think what you had asked, and I will tell you that in most case our hospice and palliative care providers are able to provide the comfort of the pain and suffering that can come along with end of life care in most cases.

REP. DEMICCO: Well, you opened the door to my next question, then. How about those, you know, few cases, let's say where that is not able to happen. What's the solution?

TRACY WODATCH: We continue to work very closely with the patient, with their family, with the physician and we try to find a formula that does help them be comfortable. There's an awful lot out there right now in best practice for pain and comfort and our providers are extremely successful in helping that happen.

REP. DEMICCO: If I could, Madam Chair, just one other question. I imagine that in some cases there are side effects to some of the drugs that might be used, you know, in this very serious situation and I was just wondering if you could describe what might be some of the problems there.

TRACY WODATCH: In pain medication people can get drowsy. They can become very constipated, but we give counter medications to try to combat those side effects.

And usually when someone is in pain, the drowsiness doesn't have as much of an impact. When we find the right medication to give them, they're very functional.

REP. DEMICCO: Okay. That's what I was curious to hear, so they are functional and --

TRACY WODATCH: Until they become actively dying, then they're going to go into an actively dying stage.

REP. DEMICCO: Okay. All right. So, just so I'm clear. As far as you're concerned, there are, there is a means to ameliorate whatever pain is present in such situations, which would make what this bill proposes unnecessary, as far as you're concerned.

TRACY WODATCH: Yes. We do believe that as hospice and palliative care providers. I think also the key here is that what I was trying to explain in my testimony is that we don't utilize hospice and palliative care enough, so I think that people don't realize the services that are there for them and sometimes they have a feeling that there's no other way.

REP. DEMICCO: I see.

TRACY WODATCH: We're looking for trying to increase awareness and helping, you know, the physician that also spoke about the importance of having those care discussions, and I think that's the thing that is missing the most in people who are suffering from serious illness, what are their options?

REP. DEMICCO: Okay. Thank you. Thank you, Madam Chair.

SENATOR GERRATANA: Thank you. Representative Ziobron.

REP. ZIOBRON: Thank you, Madam Chair and I'm curious through your work with hospice, specifically, you see people probably at their best and maybe even sometimes at their worst in those situations, and I'm curious if part of your opposition to this bill.

Are you concerned about the possible abuse with your experience in hospice, with other family members, with pressure to make those sort of decisions? Are you concerned about that at all, or is your opposition just clearly from what you stated earlier?

TRACY WODATCH: From the statements that hospital philosophy is cherishing life until a natural end.

REP. ZIOBRON: Thank you, Madam Chair.

SENATOR GERRATANA: Thank you. I think that's all for now, and thank you for coming to testify. Next is Lenore Snowden, Dr. Lenore Snowden. Is Lenore Snowden here? She left. I wasn't sure if it was that woman. The next is Barbara Coombs Lee.

BARBARA COOMBS LEE: Hello.

SENATOR GERRATANA: Good evening.

BARBARA COOMBS LEE: Good evening, Chairwoman Gerratana and Chairwoman Johnson, Members of the Committee. Thank you so much for allowing me to be here and testify before you.

My name is Barbara Coombs Lee. I'm a nurse, a physician assistant, an attorney, and President of the national advocacy organization, Compassion and Choices. I'm also an author and defender of the Oregon Death with Dignity Act over the last 19 years.

I'm here to talk about the many patients who suffer, even with the very best care and pain management. I want to dispel people of the idea that somehow Oregon Death with Dignity aid in dying and hospice are two mutually exclusive modalities.

Fully, 97 percent of the people in Oregon who avail themselves of the Oregon Death with Dignity Act last year were already in hospice. They were receiving what we consider the gold standard of end of life care.

It's not an either or situation. People want good pain and palliative care, and if that fails, they want a safety net. They want an insurance policy. They want a way to escape unbearable suffering. It does not displace hospice.

I have four points very quickly that I want to make. First is that aid in dying is an emerging practice, acceptable and integrated into the standard care in the United States.

It's based on a simple premise. People should be free, particularly at the end of their lives, they should be free to manifest their own beliefs and values. People in Connecticut have no less right to be free than the people in Oregon, Washington and Montana.

That freedom is based on two understandings. One is that aid in dying is absolutely voluntary. It is a self-determined option. It begins with the patient. It ends with the patient. The patient maintains choice in the control from beginning to end.

The second is that the choice of aid in dying is fundamentally different from suicide. Suicide arises from disordered thinking, mental illness. Aid in dying is a rational decision. A dying person who cannot make the choice to live can only make the choice about what that feels like to them and what it looks like to their surviving loved ones who will witness it.

It is fundamentally different from suicide. It is as different from suicide as stabbing is from surgery.

A second point is that Connecticut citizens support end in dying. We have survey results here. We've polled and the support crosses all demographic segments. It crosses all religions.

The third point is that Connecticut stands in a place of rich, scientific knowledge about what aid in dying is about and what happens when a state adopts aid in dying.

SENATOR GERRATANA: Miss Coombs Lee, if you would summarize. I know you have four points to make.

BARBARA COOMBS LEE: Yes. We do not have to resort to speculation. We have data. We have data from a variety of scientific sources. It does not impair, it does not abuse or put at risk vulnerable populations, does not impair the physician/patient relationship, hospice or society.

And finally my fourth point is that yes, the AMA does oppose aid in dying. It has opposed aid in dying for 20 years. It has not changed that position for 20 years. That is not a position that is informed by the scientific data coming out of Oregon.

Other professional societies, including the American Medical Women's Association, American Public Health Association, American College of Legal Medicine and the American Medical Student Association, all support it. Thank you very much.

SENATOR GERRATANA: Thank you very much and thank you for giving your testimony this evening. Does anyone have any questions? No. Thank you so much. Thank you for your patience.

BARBARA COOMBS LEE: Thank you so much.

SENATOR GERRATANA: Next to testify is Dr. Gary Blick, followed by Gloria Blick.

GARY BLICK: Good evening, Madam Chair. It's been a long, long night.

SENATOR GERRATANA: Good evening.

GARY BLICK: May I make a request first, before I start with my time. Senator John McKinney texted me and said you might not mind if I read his mother's testimony into the record.

As you know, Lucy McKinney is the widow of one of our most respected Congressmen Stewart B. McKinney. So with your permission, I could probably do it in 90 seconds.

SENATOR GERRATANA: So you would like to read her statement rather than give your testimony?

GARY BLICK: No, I would rather read hers as a segue into mine.

SENATOR GERRATANA: Well, you have three minutes.

GARY BLICK: Well, then I can't do hers. I just wanted to do this out of the --

SENATOR GERRATANA: You could certainly, it would be appreciated if you submit anything. You know, anyone here today that doesn't get enough time to say everything they'd like to, just so that everyone knows that if you submit your written testimony, or a written statement, we get to read it. It will be scanned and electronically put on line so everyone will, everyone in the world will be able to see it. So thank you, sir. Please proceed.

GARY BLICK: I did submit ten copies of it already, so.

SENATOR GERRATANA: Great.

GARY BLICK: Okay, please start my clock all over again, please.

SENATOR GERRATANA: Okay.

GARY BLICK: Madam Chair, Members of the Public Health Committee. I'm Dr. Gary Blick and I am the Chief Medical Officer of a nonprofit that I co-founded called World Health Clinicians. We have CIRCLE CARE Center in Norwalk, Connecticut and we're proud to be Connecticut's only center for excellence for HIV and AIDS.

I've been an HIV AIDS specialist for 26 years, have been actually seeing AIDS patients for approximately 30 years and have taken care of well over 2,000 patients seeing hundreds die many different types of death.

So I'm here to testify not only on their behalf, but on behalf of the 500 HIV AIDS patients I currently take care of, many who are facing terminal illness right now plus my general internal medicine patients who many are facing terminal illness with cancer and so on and so forth.

A representative this morning said this was not the legislative consideration. You may remember Blick v. Connecticut that is myself. We came in front of Superior Court Judge Aurigemma back in 2010 to argue the state's 1969 manslaughter statute should not apply to physicians who provide compassionate aid in dying via prescription medication.

It was Judge Aurigemma who said we should take it to the Legislature and that's why we're here today, three years later.

I'd like to go into the oaths also. The Hippocratic oath that was just read to you was from 2000 years ago. The current Hippocratic oath does not say we can't dispense medications in the way we're talking about right here, and I can submit that if you need to see that for your own edification.

But 29 years ago, I took my own oath, and it was the oath of Maimonides and I agreed to never see in the patient anything but a fellow creature in pain. I acknowledged "Oh God, Though has appointed me to watch over the life and death of Thy creatures". Today, many can discover its errors of yesterday and tomorrow he can obtain a new light on what he thinks himself sure of today.

So what I want to talk about is, I'm a major hospice supporter. I've been putting patients in hospice obviously for the last 26 years, but many of the hospice patients who I certify to live less than six months, outlive my declaration by sometimes six months, twelve months or more.

And remembering that I took the oath to watch over the death of my patients, I was tormented that dozens of these deaths were horrific, agonizing, tortuous and in my mind, frankly, unnecessary.

So after an enormous amount of soul searching, I discovered over time that watching these patients die in this manner was one of my personal errors of yesterday and as my spoken words from the oath of Maimonides tomorrow I obtained a new life, a new perspective and a new point of view on what I thought myself sure of at that time. I discovered that for a select few, terminally ill patients, their only chance to die with dignity, while retaining some control of their remaining lives --

SENATOR GERRATANA: Dr. Blick, can you summarize for us.

GARY BLICK: And I'm going to say it right now.

SENATOR GERRATANA: I do have a question for you.

GARY BLICK: I'll take the questions, gladly. Their only opportunity to take this dignity in dying remains in this Committee right now.

So this is not a bill for the disabled. This is not a bill for the elderly, like my 91-year-old mother is about to testify. This is a bill only for those select few who are facing a terminal illness where hospice is not for them.

SENATOR GERRATANA: Thank you, sir. Actually, my question goes to this. It's very obvious that you have been treating very, very ill patients, would I would consider to be at the end of life.

Have they asked you for an option such as this? Have they ever?

GARY BLICK: Many, many, many times. And that's what Mrs. McKinney's testimony will say because as the Stewart B. McKinney Foundation in setting up housing for homeless with HIV and AIDS, she had that request so many times, came to me as a physician, and I could not, you know, break the law and do that.

SENATOR GERRATANA: I see.

GARY BLICK: And I'd also like to say, I'm a big supporter of hospice, but it's not a natural death to be on an intravenous morphine drip.

And you guys, you said this, you asked the questions before, you know. Morphine can be horrific. It could be wonderful for 90 percent of the patients, but for 10 percent or less patients, it can be horrific and agonizing and --

SENATOR GERRATANA: How long does one stay on a morphine drip?

GARY BLICK: Well, you know, once again, it does speed up death, so when you go on a morphine drip and you know you're terminally ill, it can mean anywhere from one to three weeks. If you stop eating and stop drinking, then somewhere within one to three weeks you will die.

But I've certified these patients and sometimes they've gone six months or more and it's been horrific and that's why we bring this bill to your attention today.

It's just for those select few patients where hospice might not be the option of choice.

SENATOR GERRATANA: Thank you, sir.

GARY BLICK: You're welcome.

SENATOR GERRATANA: Are there any other questions? Senator Welch.

SENATOR WELCH: Kind of unrelated, but you look very familiar. Did you testify on?

GARY BLICK: We were here at 8:30 doing medical marijuana before the Judicial Committee, yes. I think almost exactly this time one year ago.

SENATOR WELCH: All right.

A VOICE: Exactly.

GARY BLICK: And just remember, you guys, we're progressive here. I applaud you guys for medical marijuana. I applaud you guys for same sex marriage, and I hope we will applaud you today for being very forward thinking enough, because I love hospice. It is one of my first choices for my patients, but it's not initially the choice for every patient.

SENATOR GERRATANA: Thank you. Representative Srinivasan.

REP. SRINIVASAN: Thank you, Madam Chair. Thank you very much for your testimony this evening. Could you enlarge on the morphine drip alternative, which I know exists and it's legal, obviously. It's my understanding that the morphine drip can be titrated up or down and when it is done to a certain extent it automatically ends up with the inevitable.

GARY BLICK: Right.

REP. SRINIVASAN: So is that a kind of physician assisted, I always, you know, have questions about the morphine drip.

GARY BLICK: To my mind, morphine is an aid in dying, so it definitely takes away pain if you give it the amount it needs to be done, but you know, if you give too much it suppresses respiration and you die automatically.

So a patient who is on a morphine drip is given the opportunity to handle their own drips, they're already doing what we're talking about today and I will testify in front of you that this has been done but illegally, and we would just like to make it legal for those select few patients.

Because if you go on a morphine drip without a doubt, it could render you incoherent, psychotic, completely unaware of your surroundings, strip you of your independence. Yes, it can constipate you, but we just said very minimal symptoms over here. It could do much worse. It affects your whole ability to make rational decisions for yourself and it takes away your last remaining chance to leave this world in a dignified and controlled manner if it doesn't serve the patient's need. Most of the time it does.

But I'm talking about for those select few that do not respond well to morphine drips and do not get that pain control and may not want to go two more, three more, six more months. You always develop a tolerance to your opioid. You always will develop the tolerance to your morphine. You will always need more and more and more to control that pain. That's the way it is.

REP. SRINIVASAN: And in the same train of thought that morphine drip going up or down I know it is under the direction of the physician.

GARY BLICK: Right.

REP. SRINIVASAN: But is it also kind of, you know, the patient helping in which direction to go?

GARY BLICK: Yes. And many times we can give an order to hospice that the patient will have the opportunity to give themselves more if they need it, and we can be pretty flexible on how much they really need to give themselves.

And many times it has, and I will vouch for you, I'm testifying today on the record, they've opened it up and they've died. That is illegal the way the statute is written now. And if I prescribed it, that means I can be convicted of committing manslaughter and go to jail. But it gets done, and I'll vouch for that today.

REP. SRINIVASAN: Thank you for that. Thank you for your testimony. Thank you, Madam Chair.

SENATOR GERRATANA: You're welcome. Representative Johnson.

REP. JOHNSON: Thank you, Madam Chair and thank you for your testimony today.

GARY BLICK: You're welcome.

REP. JOHNSON: Just going over that part where people are taking morphine or some other time of pain relieving medication and perhaps they have a respiratory problem, there's always a balance going on, trying to make sure that the medication isn't the cause but the cause is actually, you know, precipitated by the illness.

GARY BLICK: That's correct.

REP. JOHNSON: And so, that's really what we're talking about in this legislation.

GARY BLICK: Right.

REP. JOHNSON: And I think that you've pretty well highlighted that, but are there any other details about that that you'd like to go into.

GARY BLICK: Yes, because, you know, once again as I said, I'm a strong supporter and advocate for hospice, so please, I'm on the record for that.

But it you don't want to go that way, you know, somebody mentioned potassium chloride. This is not potassium chloride. We're talking about potent barbiturates. What you may have known as, you know, pentabarbitol or secobartitol now, without a doubt the advice can be given to any physician to any patient if they need that, about what dose needs to be taken so they can quietly, calmly, peacefully go to sleep and never wake up again.

And so that's what we're talking about. We're not talking about, you know, any kind of Jack Kevorkian passing chloride drips here, okay? I just want to be clear about this. It's not physician assisted suicide. This is compassionate aid in dying.

REP. JOHNSON: Just one follow up. In terms of I think that there's an implication with suicide that we're, people are taking their life when they have a lot of life left, and this is, that's the other part of the aid in dying and how we're terming this, because it really is when you are at the end of life.

GARY BLICK: You just raised a very good point because that emeritus professor that was here that was bringing this whole thing up, listen, I'm an HIV AIDS specialist. If I have a patient who's dying from progressive multi-focal luquinsephalosophy, a virus that puts holes in their brain, I don't need to send them out for a consult.

That's what I do, and I will know that almost every one of my patients face terminal illness is depressed and I have a licensed clinical social worker in the clinic to help them with their depression as they make these decisions.

So it should be comprehensive care. But we don't always have to send out for a consultation. If it's metastatic stage four prostatic cancer to the bone, I need my oncologist to help me get that diagnosis and decide what the prognosis is and what the therapy's going to be. That's when we'll have the consultants involved.

Like I said, I don't need a psychiatrist or a psychologist because we do have a licensed clinical social worker. We'll soon have two in our clinic and they're very, very functional in helping me and my patients make these kind of decisions.

REP. JOHNSON: Thank you for your testimony.

GARY BLICK: You're welcome.

REP. JOHNSON: Thank you, Madam Chair.

SENATOR GERRATANA: Okay. Representative Conroy.

REP. CONROY: Thank you, Madam Chair. You seem a little knowledgeable on this, so I just.

GARY BLICK: Thank you.

REP. CONROY: It's getting late, so I don't know if this was answered earlier today.

GARY BLICK: I studied before I came.

REP. CONROY: But when it says, you know, what is the medication we're talking about? Is it a one-time dose of something?

GARY BLICK: Yes. Yes.

REP. CONROY: Because earlier I heard some testimony that in the states that do have this it's about 67 percent actually take it. How is it regulated that you're aware of that you prescribe something to me for a lethal dose. I decide not to take it. It's hanging around in my medicine cabinet. Do you know how that works?

GARY BLICK: Well, that is actually very fair and I think you've heard testimony that nine out of ten patients, it's a security blanket. It's an insurance policy, and then they'll make the decision later on.

But the bottom line, there's no pill. So I've heard that referred to, what's the pill? The prescription would be secobarbitol, for instance, 100 milligrams and you might need 90 to 100 of them, nine to ten grams of it. That's the standard dose that say they would give in Oregon.

And once again, we have Compassionate Choices here in Connecticut to advice doctors and advise patients on what should be done, but that would be one prescription, and that's a very, very easy, calm way to go. You know, if we're worried about any kind of possibility of anything else going on, we can give anti-anxiety along with it, say, what you would typically know as alpraslan, or Zanax or Benzodzothine, so all those things can be used in combination.

Well, we're really talking about dispensing one major prescription, and that would be a barbiturate.

REP. CONROY: And just to follow up that other second question I had. The people that don't use it, what happens with that prescription then hanging around?

GARY BLICK: Well, if they're still alive, it just hangs around. If they die, usually the family will come in and gather up all the medications and in our situations, they usually bring them back to our clinic so we can dispose of them properly.

REP. CONROY: Thank you.

SENATOR GERRATANA: Before we go to Representative Cook and then Representative Ziobron, did you say you have to take 90 of these pills?

GARY BLICK: Nine grams, and they're 100 milligrams.

SENATOR GERRATANA: Nine grams.

GARY BLICK: Which is 9,000 milligrams and they're 100 milligram tablets.

SENATOR GERRATANA: I see. Thank you for that clarification. Whew!

GARY BLICK: Yes. It's 90 pills.

SENATOR GERRATANA: It is 90 pills.

GARY BLICK: Nine thousand milligrams, nine grams.

SENATOR GERRATANA: So one would have to take 90 pills, individually.

GARY BLICK: Yes. Ten 100s would make one gram. Ninety 100s would make 9 grams.

SENATOR GERRATANA: Okay. Thank you for that. Representative Cook, followed by Representative Ziobron.

GARY BLICK: Another point. It doesn't have to be that specific prescription. Many patients who are not dying with chronic pain may take something like Oxycodon, which you might know is Percoset and could be in immediate release form, too, so we could use opioids, provided they don't have a dependence on these where they really wouldn't work.

So we have to tailor it to the individual and what would be best for them.

SENATOR GERRATANA: Okay, thank you. Representative Cook.

REP. COOK: Thank you, Madam Chair. Thank you for your very insightful testimony. My question is, and it goes along with Representative Conroy's question about the type of medication that we're talking about or prescription, and the amount that Senator Gerratana had just referred.

What is the history of any, for somebody who has taken this medication thinking that it would end their life and that no has happened? Is there anybody on record for that?

GARY BLICK: Yes, I'm sure there is. I think I've read of cases like that in Oregon where a patient will take their prescription. Maybe they've had a tolerance or something and they've woken up from it.

Now, once again, they still would satisfy the criteria to go back to their physicians and get the next set of prescriptions, and obviously it's going to be more than what you previously prescribed, so they still would satisfy as long as they're mentally competent after everything, but they would just wake up from a long sleep.

REP. COOK: And do we know if there's anybody that has taken the medication and had some type of an adverse effect who had not lost their life at this point, thinking that they would, and then had significant other medical conditions that they've had to treat?

GARY BLICK: No. Once again, these are what you would consider, you know, strong sedatives so for instance, I've had patients take an entire bottle of Zanax thinking that they could, you know, take themselves out that way. They'll wake up five days later from a long sleep saying, what am I? I'm still here.

So that really can happen. But it's very, very, very rare with these doses, but I'm not going to say it never would happen. And I believe patients should be counseled that this should be enough for you but it's happened a couple of times where you might wake up from this and that's why they need to be informed properly.

REP. COOK: Is there a place that we can get the statistics on any type of situations of what I just described and asked questions about?

GARY BLICK: I'm sure we can get that at Compassionate Choices because they're very familiar with the Oregon and Washington experience. I'm sure we can get that.

REP. COOK: I would be interested if somebody could pass that information. Thank you, and thank you for your information.

GARY BLICK: You're welcome.

REP. COOK: Thank you, Madam Chair.

SENATOR GERRATANA: Representative Ziobron, followed by Representative Miller.

REP. ZIOBRON: Thank you, Madam Chair. Representative Conroy actually asked my first question, which was, you know, what is the delivery of the medication?

But my recollection of earlier testimony also spoke to a couple things, and I'd like your opinion on those things.

One is, our current bill doesn't have a waiting period. Do you believe a waiting period should be part of any successful bill in this case?

GARY BLICK: That's an excellent question and just remember, I'm coming from the point of view as an HIV AIDS specialist, so if the patient has that disease I just told you about, for instance PML, that brain condition, that brain virus, they don't have 15 days. If they had to wait 15 days they would probably no longer be mentally coherent at that point. They'd never be able to fulfill the requirements necessary, you know, for aid in dying.

So some of these diseases can go very rapidly where you'll lose your consciousness, your coherency and you would no longer be mentally competent, but it could still take several months to die. Now you're stuck. We certainly could go to hospice. No problem at that point, but trust me, with that kind of disease related to HIV and AIDS, you don't want to die that death and be aware of anything happening. It's a terrible, terrible way to die. It's agonizing.

REP. ZIOBRON: Through you, Madam Chair, I would also say then, if you have somebody with that disease, and obviously in that specific case, I would think they would be contemplating their final days and what they want to do for quite some time.

Wouldn't it be, wouldn't they most likely decide to fulfill a prescription for that medication in advance so that they're prepared for when they're in that situation, so go ahead and ingest it?

GARY BLICK: I think that's what we're referring to, it's just having that security blanket or that insurance policy to know that that bottle of medicine is sitting there in the medicine cabinet should the day start coming and they see that progression.

And they will see that progression because they'll lose the use of a hand, or a leg, they'll become paralyzed on one side. Hopefully, they're still obviously mentally competent at that point, so they'll know what to do.

REP. ZIOBRON: So the situation you're describing is one that is probably a little unusual. It's not necessarily for somebody who's suffering from Lou Gehrig's disease or other things, but unfortunate disease that you're talking about is horrific.

But do you think that for the, when you look at it from the big picture and all the citizens of this state, don't you think they deserve to have a waiting period, so that it's not a one-day decision because of the serious consequences of what they're about to do?

GARY BLICK: I'm personally not against the waiting period, but I want to make sure that we're covering all patients. And so having a waiting period in that situation could be very, very detrimental to the patient, and we are talking about, you know, compassion to our patients at that point. So I gave you one circumstance like that.

REP. ZIOBRON: And through you, Madam Chairman, my last question. You know, I also listened to testimony --

GARY BLICK: I'm sorry. I didn't mean to interrupt you. But I did want to make a point about that earlier, since we brought that up.

When you're getting a patient's diagnosis, there's automatically a waiting period, because it's a shock for patients when you tell them, you've got Stage 4 metastatic, you know, carcinoma. It is. So they've got to go home. They've got to process that.

Usually as I said, you're going to become depressed by that. You're going to want to sit in therapy. I think there's an unspoken waiting period in almost all these situations after a patient gets a diagnosis.

I don't think there would be any situation where, you know, I told the patient they've got this diagnosis and they're going to automatically want to take themselves out that day. It's not going to happen.

Usually, I'm very, we have a very holistic type of health care center where we are, so we always deal with, you know, every need of the patient at that point and that includes their mental torment, their psychological torment as well as their physical and emotional.

REP. ZIOBRON: Thank you for the clarification. Through you, Madam Chair, I'm also reminded of testimony earlier today that spoke of the doctor who would fill out the form for consent, and that in some cases it could be a specialist that may have only seen that patient one or two times, versus a family physician that has a history.

And I'm curious if you have any opinion on the differentiation of those two scenarios and if it makes a difference?

GARY BLICK: I'm not averse to, you know, let's say the person has metastatic Stage 4 cancer and my oncologist gives me that diagnosis on one visit and signs that form. I think that would be very appropriate because the oncologist is fully convinced of that. I may not be the most skilled to make that diagnosis, although I can read a PT scan or an MRI scan and know that, but I would not be averse to my consultant in that situation, you know, signing that form on behalf of my patient.

REP. ZIOBRON: I'm sorry, Madam Chair. That brings me to one, my really last question, then. With your answer, though, that now brings me to the issue of being, you know, judging competency.

So if you've only seen this patient one time, I'm a little concerned now that you may not know that patient well enough to decide whether that's patient competent.

So could you talk to that for a moment, please?

GARY BLICK: Yeah, I think that's an excellent, excellent question to ask, because competency is something that we determine by having a doctor/physician relationship.

You know, if you meet somebody for the first time, you may not know that patient in any other way except they're coming to you for that diagnosis. All right?

So let's talk about that patient that is going from doctor to doctor, because that may happen. You know, a lot of physicians may be uncomfortable prescribing this for whatever, religions reasons, whatever reasons there may be, so a patient may hear that, well Dr. Blick may be comfortable with that, so they come to see me.

But I don't really know that patient. I'm getting them for the first time, and we, you know, we take these oaths to really understand everything about our patient. I'm not going to sign a page one time seeing the patient. I need all those patient's records. I need to consult with that consultant who made that diagnosis.

You need to sit down and really get all the information necessary. So if I see an HIV AIDS patient in my office, I don't believe they have HIV AIDS until I get my own testing done and then bring them back and say yes, I can see it on your viral load. You do have HIV and here's your diagnosis. I've got all the MRIs and so on and so forth.

So you know, I'm not saying it can't happen, you know, because you know, there could be doctors.

I think, you know, Representative Sayers, you mentioned it before. You know, you can't just prescribe these things haphazardly. You know, we have a licensing bureau for this reason.

It's the same thing that we were worried about with medical marijuana with patients, you know, going in and getting a certification for a disease that they may not even have. You go into a doctor's office and say, oh, I've got chronic Lyme arthritic pain. Okay, here, sign this form and now we've given you your medical marijuana card. That's not the way the medical marijuana act should go and that's not the way this act should go, either.

I'm not saying that you can't find a doctor like that, but in my mind, that's malpractice.

REP. ZIOBRAN: Thank you so much for your candor, and thank you, Madam Chair.

SENATOR GERRATANA: Thank you. Representative Miller.

REP. PHIL MILLER: Thank you, Madam Chair. Dr. Blick, it's obvious that this is a topic, which you have thought deeply upon for a long time, probably before you were even an M.D., I suspect.

GARY BLICK: Actually, I went to medical school to do plastic surgery, so I don't believe I was thinking about it at that time.

REP. PHIL MILLER: Okay, sure.

GARY BLICK: It shifted over the decade.

REP. PHIL MILLER: My question so you is, the Hippocratic oath to do no harm. Can you, would you be willing to share some of your thoughts on that and how you reconcile that with your belief in wanting to aid in compassionate dying?

GARY BLICK: Representative Miller, I took the oath of Maimonides, and nowhere in that dose it say that. I read you some passages and how I applied that to my life and my growth and a physician and understanding in this situation and how it relates to aid in dying, so I didn't take the Hippocratic oath. University of Miami Medical School is the oath of Maimonides.

And what I was pointing out to you earlier, is that the Hippocratic oath from 2000 years ago from Hippocrates days is nowhere near the Hippocratic oath we take now.

As a matter of fact, it says nothing about prescribing medications that a patient may use to end their lives. It's taken out of there.

In other words, it's been modernized to fit the times, and that's why we're coming to you today because we're sort of modernizing this thought of compassion and aid in dying and regardless of the oath, we're not doing harm.

For me, putting a patient on a morphine drip that makes them psychotic, that maybe they're laying around in their own, you know, feces, that's doing harm, sometimes. Sometimes. Most of the time it's not. I told you I'm a very big proponent of hospice.

But there are times where you have to shift your thinking that that decision to go on hospice is causing that patient harm, and now we have to make the shift, that they're not going to get better. We know this. We need to give them the medications and let them go peacefully and with dignity.

It's just that select few cases, Representative. It's not for everybody.

I do also want to say, not all patients that are disabled are terminally ill. Most of them are not. I mean, I had a spinal cord injury. I've got spinal stenosis that I got from my father, I slipped a disc into my spinal cord. I don't have any feeling in my feet. I've lost half the feeling in my hands. I'm disabled. I'm not terminally ill.

And for the most part, disabled patients are not terminally ill. We always talked about ALS today. Without a doubt it's a terrible disease. We have no treatments for it, but an ALS patient is not terminally ill until they start getting respiratory complications. Then they're terminally ill.

Then I can certify for hospice that they have six months or less to live, or this bill will, you know, satisfy them at that point. Do you understand?

REP. PHIL MILLER: Yes, and thank you very much, and thank you, Madam Chair.

SENATOR GERRATANA: Certainly. Representative Sayers.

REP. SAYERS: Thank you. And most of the time people on a morphine drip do not become psychotic and incoherent for the most part. If someone is in a lot of pain and receiving a morphine drip it is more of a comfort measure.

Where if someone who was near close to death were to take 90 pills, the chances are they would be vomiting uncontrollably and it would be very, very difficult for them to ingest 90 pills. Most of the people that I (inaudible) they can ingest 90 pills.

So to me, that is much more difficult where I've seen many people on morphine, morphine patches, a number of other, and it does give them a degree of comfort, because of the amount of pain they're in, but does not make them incoherent or psychotic as you indicated, but rather does provide that comfort measure to them for the pain that they are in.

Ten years ago, fifteen years ago, people with HIV AIDS were dying within a very short period of time of their diagnosis. Now we see them living 20, 30 years, and much longer.

So even that has changed, and the horrendous deaths that we saw early on from people suffering from HIV were very, very difficult. We're not seeing that same type of death as early or as often or in the same manner than originally, because we know more about the disease. We have much more medications to better treat the disease and we do treat it much better than we were able to early on.

GARY BLICK: Representative Sayers, I'm assuming you've got a medical background. I don't know you personally, so correct? Because you seem to have a good medical background on this.

REP. SAYERS: Yes, I do.

GARY CLICK: Okay. So I'm not saying at all that all morphine drips will do that to an individual, but you will acknowledge paradoxical reactions.

So we know that, you know, upwards of eight to ten percent of people can have the opposite reaction to a drug that we're giving to give them comfort and they can actually become psychotic. They can hallucinate and they can do that.

That's all I'm referring to. I think for most patients, hospice works beautifully. I'm a big advocate of it. I meant that. I'm testifying, you know, with oath here, so I agree with all that.

REP. SAYERS: And by the way, what I heard from you is that you're not advocating for hospice and I have a real problem with that --

GARY BLICK: Oh, no.

REP. SAYERS: -- because it is a very, very good option for people. We don't often give it enough.

GARY BLICK: Please --

REP. SAYERS: But you indicated that --

GARY BLICK: Please, for the record. I strongly believe in and advocate for hospice. It's not for everybody. All we're trying to do here is give the patients, those select few patients, another choice, another option if hospice is not right for them.

SENATOR GERRATANA: Okay, thank you. I think we're through with our questioning.

GARY BLICK: Also, I think I just wanted to address your taking the 90 pills. Most of the time if they're taking secobarbitol, they're dissolving them in water, and they're drinking it up that way. So they just put all the pills in water and they swallow it.

REP. SAYERS: It's a lot of intake that sometimes makes them extremely nauseous and they will vomit it.

GARY BLICK: Acknowledged.

REP. SAYERS: It's not just 90 pills. It's oral intake.

GARY BLICK: I don't want you to think they're swallowing 90 pills one at a time doing it like that, because it is just dissolved in water.

REP. SAYERS: And it doesn't taste very good by the way, either, so, you know.

GARY BLICK: Right.

SENATOR GERRATANA: Okay, so very much for that, and thank you for your testimony, Dr. Blick.

GARY BLICK: You're welcome.

SENATOR GERRATANA: And I see your mom is here, too, and she's going to, Gloria, you're going testify.

GLORIA BLICK: Yes, I am, and I thank you all. I'm almost speechless. I have heard my son speak a number of times but the pride in me today is overwhelming and I thank you all for the opportunity of sitting in front of a commission, a Committee of this caliber to understand the problems that exist in our health system and in our existing conditions in the world today.

So before I do any of my testimony, I would like to thank you for the evening's experience.

SENATOR GERRATANA: Thank you. Thank you, ma'am. And we do have your testimony on line.

GLORIA BLICK: Okay, thank you. I am 91 years old and can honestly say that I have been most fortunate to have never had a serious illness. Yes, I have had glaucoma. I have glaucoma. I had Lyme disease. I had both my hips replaced and my shoulder surgery was taken care of. But I had a very healthy, normal recovery.

I'm a member of the Stamford Senior Center and was past Chairwoman for two years. Currently, I am on the Board of Directors for the Smith House in Stamford, which is city-owned health care center. I have been on the Advisory Board of the Southwestern Connecticut Agency on Aging for over ten years.

I have been appointed by former Mayor Malloy as Commissioner on the Commissioner of Aging for Stamford, and I'm giving you this information to clearly show you my strong connection to, and my involvement with seniors.

With a background of working with seniors, I have shared many experiences with my friends during their difficult times. I've watched my dear friends have to commit, yes, commit their dear ones to a nursing home due to terminal cancer. I shared my friend's pain that day when she went to visit her husband and he was not aware of who she was, all because he was overly dosed with medication to alleviate his pain.

That made me very, very distressed and having watched all of that, I cried with her when she returned home.

This week I shared the pain of another friend of mine waiting for her husband to receive the critical decision from the physicians that he was overwhelmingly in the last stages of a metastatic cancer. She had watched him suffer so severely over a long period, and with that, we were just so upset until she finally came back and said to me, there's no options for him at this point.

Unless you've had that experience and unless you've lived long enough like I have, to suffer with friends and to have the experience of seeing them, it upsets me to even say the word, to sit with my friends and to watch their terminally ill patients suffer it makes me frightened.

Today, I'd like to you what would be my response if I was suddenly told that I was ill with some serious illness and that my physician and my doctors and my family said, there's nothing more I could do for you.

SENATOR GERRATANA: Could you please summarize for us?

GLORIA BLICK: Yes.

SENATOR GERRATANA: Thank you.

GLORIA BLICK: If I had that decision to be made, I would never in a million years wish to remain alive. If I had to make the choice, my choice would be, please, please help me end my life.

I have been too active. I have been too strong. I have been too well to see myself go down the drain and suffer in that fashion. I don't think I could do that to my children. I have three sons, but this one in particular, I couldn't do it to him. I know his compassion. I just couldn't. He has too much compassion for life and I couldn't do it.

So with that all, I ask you to please consider it. Consider it seriously, and I thank you for the time.

SENATOR GERRATANA: Thank you very much. Thank you. Are there any questions? If not, thank you both for coming and testifying today and for your patience. We like that.

Next is Sara Myers, to be followed by Sidat Balgobin. Sara Myers? She already testified. Sorry, I guess I wasn't here. Sidat Balgobin?

SIDOT BALGOBIN: Good evening, Madam Chairs and Members of the Committee. My name is Reverend Sidat Balgobin. I'm a retired minister of the United Church of Christ, sometimes known as the Congregational Church. I am also a former hospice chaplain and a certified spiritual director. I live in Norwich, Connecticut and I'm here to support this House Bill 6645.

I'm also speaking on my own behalf and I don't represent any institution so this is just my own voice.

Earlier this month I wrote a two-page commentary on this issue, which is attached to my testimony. The title is From Certainty to Compassion.

An abridged version of this was printed in the Norwich Bulletin on March 5th. The day after the op ed piece appeared, about a dozen people reached out to me thanking me for putting words of support to this issue, an issue, which they each cared deeply about.

Many of those were Catholics and some were elderly. All wanted to at least have this choice available to them when the time came when they could be facing a terminal illness themselves.

To me, the two central questions each must ask ourselves are this. What is the compassionate thing to do, and the second is like it, what is the right thing to do?

We are called, I believe to use both our heads and our hearts in this matter. It is ultimately a matter of conscience. People of faith will come out on different sides of this issue. There is no one correct answer in response to our faith and our beliefs. I am here to use all of your wisdom and experience to answer for yourselves what is compassionate and right.

I do not see that we are here to discuss religious beliefs or views. That should not be the issue before a Legislative Committee here, and yet our faith and ethical beliefs, whatever they may be, must inform us. That is precisely the reason I fully support this bill. To me, it is right and compassionate.

This law would give great comfort to those facing a terminal illness whether they choose to use this choice or not.

Having this bill enacted into law will give comfort to everyone simply knowing the choice is available. It will not only relieve physical pain and suffering, but mental anguish and anxiety.

It will allow for emotional, mental and spiritual healing to take place at the end of life by allowing for a more peaceful space in which to reflect, and yet at some point, pain and suffering becomes unendurable.

With the enactment of this law, a life can be celebrated with family and loved ones before passing on. It will allow for a graceful passage and I urge each of you to support this bill. Thank you.

SENATOR GERRATANA: Thank you very much for giving your testimony today. Does anyone have any questions or comments? No. Thank you so much. Next is Hunt Williams, to be followed by Jim Young.

HUNTINGTON WILLIAMS: Good evening. I'm Huntington Williams. I live in West Cornwall. I am speaking in reference to House Bill 6645 AN ACT CONCERNING COMPASSIONATE AID IN DYING FOR THE TERMINALLY ILL.

Madam Chairs and Members of the Committee, I'm testifying in support of the above specified legislation.

On June 11, 2004, I went to the home of a good friend, John Welles, 66, in West Cornwall, to sit with him from 9:00 a.m. to 1:00 p.m. John was dying of cancer and a roster of friends was looking after him in shifts. He had gone from hospital to rehab to home, where he lived alone.

John had been very frank and open with us. He had no intention of becoming dependent on others and losing control of his own life. Instead, he would end his life on his terms. When I arrived there was John and a close friend who had been with him through the night. She was saying her goodbyes and would be at the local restaurant in West Cornwall.

John informed me that this was the morning. It looked like I had drawn the short straw. We visited briefly. He smoked his pipe for the last time and he went to another room where he produced a rusty 38 caliber Smith and Wesson revolver.

Being concerned the gun could malfunction and maim him, I examined it, ran a cleaning rod through the barrel and handed it back to him. John loaded the gun and with the aid of his walker went out into the garden. He laid down and asked about where to aim the gun. We concluded what would be effective and shook hands.

He asked that I leave him and walk the short distance up the driveway. He asked where I was. I told him and started to say God bless you. The gun's report cut the last word short. I returned to John, observed that his suicide had been successful and went into his house and called 9-1-1.

In time, a state trooper arrived and eventually the Western District Crime Squad, Major Crime Squad. At 4:00 p.m., after making a detailed and lengthy statement, I returned home.

I'll repeat, this was June 11, 2004. In January of the next year, 2005, I received a call from the State Police detective at Troop B in Canaan informing me that I was under arrest for second-degree manslaughter. The next day I went to the State Police Barracks, was processed and released.

The judicial process began in Bantam and continued in time to Superior Court in Litchfield. At each court appearance, residents of Cornwall and area supporters overflowed the courtroom and anterooms. The outcome was not a trial, but a one-year accelerated rehabilitation with nothing on my record.

John Welles was of sound mind and very capable of making his end of life decisions. He feared losing control of his life, and being reduced to a vegetative state.

He should have not have been forced to end his life by his own hand. Fortunately, he was capable of doing that on his own unassisted. No one should have to face the end of life alone.

We did what was called for under the circumstances. The eventual process was a relatively long, costly and painful one. It should not have been necessary.

I think that Oregon's track record of some 15 years, I believe, speaks to the effectiveness of that law. I think it certainly contains many points that are good examples.

Connecticut's laws can and should better serve the people. Thank you.

SENATOR GERRATANA: Thank you, sir. Thank you for giving testimony. I think I was a little taken aback with what you had to say. Take care. I don't think anyone has any questions. Thank you, Mr. Williams.

Next will be Jim Young, followed by Josh Pawelek. Jim Young? There he is.

JIM YOUNG: Good evening, Madam Chairs, Honorable Senators and Representatives. My name is Jim Young and I live in Groton. I'm here to speak in favor of House Bill 6645 AN ACT CONCERNING COMPASSIONATE AID IN DYING FOR THE TERMINALLY ILL.

I have practiced law since 1981, since 1987 in southeastern Connecticut and prior to that in Portland, Oregon. I often meet with clients who are signing advanced health care directives and wills and many of them are highly concerned about matters that are before this Committee now.

This bill is fundamentally a bill about personal choice and is another step in a long-evolving trend in the law that recognizes our rights as citizens to control our own bodies, a fundamental human right.

I think at certain earlier points in time today, the discussion here, to me at any rate, seemed to be getting rather theoretical and abstract, and I will even say sidetracked about possible, theoretical problems, frankly, to many people to whom I think this law has no application.

I note that Oregon has had a law very similar to this for 15 years. My question is, where are the problems? Where are the problems in that law? I think the law professor that was here from Ave Maria University in Florida earlier today, who I think it was pointed out was paid to come here, put on a really entertaining show for us earlier today about all of the horrible things that might happen if this law were passed, but I don't recall him talking about any specific factual problems that occurred. Maybe other people do. I don't.

So let's talk about what the real problems are. I think we know what those are. I think the real problems are our loved ones who suffer through final months of excruciating terminal illnesses, and by the way, this business about morphine curing all the pain, I've been there. Okay? It doesn't always work.

Loss of memory, loss of ability to enjoy life and some would say are the very qualities that make us human. It's in many of us. Make life worth living.

What about our loved ones, who's taken their own lives with firearms, or (inaudible) pills and have gone off? Many of us are familiar with these things. This is not some extraordinary, unusual event.

As for the parade of abuses that some claim will arise from this bill, after reviewing the results under the Oregon law in force for 15 years, I don't think there's a reasonable basis to claim that these horrible things are going to happen.

So my question is, why must we continue to be required to endure such pain and suffering? Is it maybe our bad luck to bear and impose upon our families and loved ones an equal or greater measure of pain and suffering by virtue of them standing witness to our suffering? Sometimes is there impoverished?

Why cannot we here in Connecticut have the same rights and choices as those in Oregon and Washington, so we can control how much of that final death march we endure at such time as we feel that we can go no further to say, enough, and leave the field of life with our pride and dignity, after having lived a good life, through a thoughtful and caring process as is set out in this bill.

SENATOR GERRATANA: Thank you, Attorney Young. Could you summarize for us, please.

JIM YOUNG: Gladly.

SENATOR GERRATANA: Thank you.

JIM YOUNG: Might not you or some loved one of yours want to be able to make this choice at some point in the future?

As to the claim that passing the law will lead to abuse, I suggest there's another question to ask. What about the pain and suffering of the many Connecticut citizens that will doubtlessly occur if this law is not passed? I don't think there's any doubt about that.

You have a tremendous opportunity to do something of lasting and material benefit for our citizens that shows courage, true caring humanity and compassion. I ask you to vote for this bill.

SENATOR GERRATANA: Thank you. Are there any questions? If not, thank you for your testimony. Next is Josh Pawelek, followed by Andrew Schneider.

JOSH PAWELEK: Good evening, Senator Gerratana, Representative Johnson and distinguished Members of the Public Health Committee. Thank you for sitting here these long hours. I really appreciate it. My name is Josh Pawelek. I'm the minister at the Unitarian Universalist Society East, in Manchester. I'm also a resident of the 31st District where Representative Srinivasan is my Representative and I'm here to speak in support of Raised Bill 6645 AN ACT CONCERNING COMPASSIONATE AID IN DYING FOR TERMINALLY ILL PATIENTS.

The heart of the matter for me is this, providing aid and dying under the strict conditions contained in this bill preserves human dignity.

Every day there are people who receive news that there are no remaining medical interventions to treat a terminal illness that will inevitably and quickly end their life. Some of those people, not many, but some upon receiving this news and after careful consideration of all the ramifications find in themselves a strong desire to end their life by their own hand rather than let their disease run its course.

Why do they have this desire? They may be in great pain. They may be emotionally and spiritually depleted from fighting their disease. They may be losing their mental capacity and fear becoming a burden to their loved ones. All of these reasons inform their desire to end their life but the primary reason some people seek aid in dying is because it assures them they will maintain their human dignity as their life winds down.

Our dignity lies in our ability to make choices about our destiny. When choice is denied, dignity is denied, and for those who desire to end their life after careful spiritual discernment and after meeting the strict conditions like those outlined in this bill, I think they are seeking death with dignity as they understand it.

Some might argue that simply allowing a disease to take its course without hastening death, to allow a person's life to wind down naturally is also death with dignity. We've heard that suggested here tonight and I agree wholeheartedly with that.

I, too, am a great supporter of hospice. I note, though, that many people choose to die naturally and again, we call those deaths dignified.

As a pastor, I will always first counsel those under my care to strive for a death like that rather than seek aid in dying. However, I also recognize there will always be people who are better able to let their lives end naturally if they have the comfort of knowing they can end their lives by their own hand. And again, having choice figures prominently here.

There's a little more to my testimony, but I heard the bell. I just want to urge you once again to support --

SENATOR GERRATANA: So we do have it on line, too, so thank you.

JOSH PAWELEK: Okay. Please support the bill.

SENATOR GERRATANA: Thank you. I don't think there are any questions, so thank you so much for waiting and testifying tonight.

JOSH PAWELEK: You're welcome. Thank you.

SENATOR GERRATANA: Take care. Next is Andrew Schneider, followed by Eileen Kaplan. Did I, yes, I think she already testified.

ANDREW SCHNEIDER: Senator Gerratana, Representative Johnson and Members of Public Health Committee, I'm Andrew Schneider, Executive Director of the American Civil Liberties Union of Connecticut and I'm here to support House Bill Number 6645 AN ACT CONCERNING COMPASSION AID IN DYING FOR TERMINALLY ILL PATIENTS.

I commend you for taking up this issue, which addresses fundamental constitutional principles of privacy, autonomy and human dignity.

Since 1997, adults in Oregon suffering from advanced terminal illness have had access to voluntary, safe and legal medical assistance in dying under a law that is similar to the legislation before you today.

Washington State has had a very similar law since 2009 and Oregon's long experience with careful record keeping provide us with 15 years of facts and statistics, which clearly show that the law has worked as intended. It's rarely used, but provides a measurable comfort to those who facing the ends of their lives are assured options to preserve their dignity and choose for themselves the level of suffering they will endure.

The Oregon Public Health Division reported that in 2012 physicians prescribed aid in dying medication for 115 terminally ill people in the state and that 77 patients died from taking the medications. Sixty-six received the prescriptions in 2012 and another 11 who had received prescriptions in a previous year.

These statistics tell something about the death with dignity law has done for the people of Oregon for the past 15 years. The statistics can't, however, quantify the amount of pain, suffering and indignity that has been relieved or the peace of mind that has been granted.

We may not be able to understand that fully unless we watch someone we love endure an agonizing death or until we endure it ourselves.

The legislation before you is carefully structured and has been thoroughly tested. It sets out a series of safeguards against abuse. To receive a prescription for aid in dying medication, a patient must be a competent adult who has been diagnosed with a terminal illness and whose prognosis is for no more than six months of life remaining. The patient must make a written request for aid in dying without coercion before witnesses.

Provisions are made for a second medical opinion, counseling when warranted and the right to revoke the request at any time. These are the same safeguards that worked in Oregon and Washington.

I urge you to approve the legislation in the spirit of courage and compassion and out of respect for individual human dignity.

As Dr. Marcia Angell, former Editor in Chief of the New England Journal of Medicine wrote, why should anyone, the state, the medical profession or anyone else presume to tell someone how much suffering they must endure as their life is ending?

We respect people's right to self determination when they're healthy. That shouldn't be denied to them when they're dying. Thank you very much.

SENATOR GERRATANA: Thank you very much, Mr. Schneider. Are there any questions? Representative Ziobron.

REP. ZIOBRON: Thank you, Madam Chair. Thank you for your testimony. I'm a little puzzled. Your mission at the ACLU is, my opinion was to protect the rights of all people, so I'd like you to explain to me how you would determine your support of this bill when you view people who are significantly disabled and do you feel that their circumstances has anything to do with your opinion on this matter?

ANDREW SCHNEIDER: Absolutely. I mean, this is consistent with other rights, the other rights that have been recognized, personal, fundamental personal autonomy that's implicit in the concept of order liberty and that's apprised from the Fourteenth Amendment due process clause.

And while we, you're right, we also take up the issue of disability rights. These are two separate issues. We feel that this law is carefully tailored to protect, to balance those rights and not lead to abuse.

As I mentioned in the statistics from Oregon, the law is used very sparingly, and there's many safeguards in place to make sure that there's no abuse and that people are not harmed by it.

And I think that the law that we're looking at here in Connecticut is modeled after that law and so I feel comfortable that this expands liberty without making it at the price of other people. Thank you.

REP. ZIOBRON: Thank you for the clarification.

ANDREW SCHNEIDER: Sure.

REP. ZIOBRON: Thank you, Madam Chair.

SENATOR GERRATANA: Thank you. I don't believe there are other questions.

ANDREW SCHNEIDER: Thank you very much.

SENATOR GERRATANA: Thank you, sir. Next is Doug Perry, followed by Adam Stillman. I'm sorry? They both had to leave. Okay. Laura Borrelli. I'm looking at you all day, Laura.

LAURA BORRELLI: Yes, you have, haven't you. I, too. Thank you very much for hearing my testimony this evening. Good evening Senator Gerratana, Representative Johnson and Members of the Public Health Committee. My name is Laura Borrelli and I'm the Hospice Director at Franciscan Home Care and Hospice Care out of Meriden, Connecticut.

Franciscan Home Care and Hospice Care is a health care agency that serves the needs of individuals and their families in 32 towns from West Hartford through New Haven in the state.

The hospice program assists those in need of the specialized type of intensive caring with an emphasis on pain control and symptom management.

As an RN with over 28 years of experience predominantly in the home care field with an expertise in hospice, I am knowledgeable about end of life care.

As a resident of Bristol and raising my children there, with our Catholic values, I believe in respecting all life through natural death and as a concerned daughter and health care representative for my elderly parents, my mom's 86 and my dad's 89 and suffers from advanced Alzheimer's disease.

I know what it means to show compassion for individuals during their final stage of life.

I am strongly opposed to Raised Bill Number 6645. To manage all symptoms is the ultimate goal of a hospice team through an interdisciplinary approach. There have been many times in my experience as a hospice provider that patients or their families have expressed a natural fear of the dying process, but with the support of qualified hospice team members, we are able to alleviate the individual and family's fears and provide through and (inaudible) them through a natural dying process. This is called compassionate care at end of life.

Pain relief is one of the foremost objectives of hospice care. Updated discussions with the hospice pharmacists and physicians allows for effective relief of pain with medication orders, not over-medication orders.

My agency currently uses Hospice Pharmacia, a mail order pharmacy for support services that provides emergency medications in the home necessary to obtain adequate symptom relief. We have medications available that provide this relief of pain and suffering as needed. This is called compassionate care at end of life.

We are all physical beings with emotional, spiritual and social needs. The hospice care strives to aid patients and their families in all aspects of their well being. To concentrate only on one area would be to miss the opportunity for fulfilling hopes, dreams and growth in another. In promoting meaning through their activities of daily living, meaning in their life experiences shard and meaning in their evolving feelings and meaning through their naturally dying process, the patient and their families are embraced by the full experience of hospice. And this is called compassionate care at the end of life.

And to conclude, individuals facing their final years, months or days are deserving of dignity through their naturally dying process, dignity to be cared for in a loving, supported manner that values the life they have led. Hospice promotes this level of involvement by focusing on patient-centered goals, allowing the individual and their family to lead the plan of care provides them with the respect and support they have the right to expect.

SENATOR GERRATANA: Miss Borrelli, can you summarize for us please?

LAURA BORRELLI: I will.

SENATOR GERRATANA: Thank you.

LAURA BORRELLI: Death with dignity means listening to and caring for patients, even when it is difficult, when it may become messy, or when there is no one else to do so. This is compassionate care at end of life.

So I encourage you all to please oppose this House Bill 6645.

SENATOR GERRATANA: Thank you so much. Representative Cook has a question.

REP. COOK: Thank you, Madam Chair. Thank you for your testimony and for sitting with us for 12 almost hours.

I just have a really simple question. You know, I respect your views and opinions and thank you for your honesty and your candor.

My question is, if one of your parents and not the one with Alzheimer's. I think that that's a different situation altogether and not what we're talking about, but if one of your parents had asked you within their right mind that they chose to end their life in the type of manner that we're discussing, would you respect their positions or would you step away from that position? And I know that's a difficult question, but I think that that's something that us sitting on this side of the desk, we're really grappling with is to, it's a personal opinion and how you handle that if it's somebody that you immediately care for and that's their personal opinion?

LAURA BORELLI: I'm a little blurry-eyed today.

REP. COOK: I understand. I had about four hours of sleep. I spent until about 1:00 a.m. in the ER with my father-in-law and he's still at Bradley Memorial Hospital as we speak.

In the past year he suffered from prostate cancer, head and neck cancer, lung cancer with metastatic disease outside the lung most recently and Stage CHF and end-stage heart disease.

He's spoken with me honestly and openly just last week before this hospitalization because my mother-in-law couldn't really rouse him yesterday. I'd rather be, I should be in the grave, you know. I'd rather be in the grave right now than to have gone through all the treatments and stuff that I went through and we did have an open discussion about it, but it was only through that open discussion that it came to realize that it was based on some fears, based on not wanting to be that burden to his family and based on realizing that we loved him so and wanted to support him so in whatever his choices were at this point in time, whether it be the hospitalization or the hospice route, whatever he's choosing to do.

Could I support a loved one in killing themselves? No. No, I could not do that.

Could I love my parents and my in-laws or any member of my family and helping them through those natural fears? Yes, in helping them through those natural expressions and concerns, yes, toward the end of life, yes, and that is where most of those concerns and fears, you know, come from.

The fear of the unknown that I've heard expressed. The fear of not knowing what to expect, you know, with those around you, if there will be someone to care for you.

And hospice can and an effective team can support and alleviate those fears in a home environment or whatever environment the patient so chooses without resorting to suicide, without resorting to killing oneself.

You know, what I found through personally and professionally is that most of those questions that come out, again, are just faced on the fear of the unknown and allowing a person to know that they're well supported is the most important thing.

And they usually don't choose that route in the long run. I hope I answered the question.

REP. COOK: You did. Thank you. I grapple with the whole personal choice conversation and this has been a pretty rough day for me, myself, so I'm sorry for the situation that you are going for and I wish you well in that.

And I just, you know, it is one of those conversations that personal choice gets to be a matter of what do we legislate and how are we overstepping which bounds and which way do we go, and do we stand on the right of the person who has the right. What is their right, you know?

Do we have the right to tell them that they have to suffer through the pain and agony of the end of life, or do we have the right to tell them that they have to? That's a difficult choice for us to be on, on this end, one I wish that we could have discussed probably ten hours ago.

LAURA BORRELLI: You and me both.

REP. COOK: But all in all, I think that whatever decision is made out of this Committee, it's not going to be because we haven't given it a whole lot of thought.

LAURA BORRELLI: Yes.

SENATOR GERRATANA: That's for sure.

REP. COOK: And it's not a simple one, and thank you for your honest and your time.

LAURA BORRELLI: Thank you.

SENATOR GERRATANA: Thank you very much. And ditto for me.

LAURA BORRELLI: Thank you.

SENATOR GERRATANA: But I do thank you for being here this evening and giving your heartfelt testimony. Oh, Representative Sayers has a question for you.

REP. SAYERS: Thank you. Earlier we heard testimony that to receive like a morphine drip causes people to become psychotic and it could be devastating to the family, the side effects from the morphine drip and it would be much simpler to take 90 pills, even if they were dissolved in water.

Could you just, as someone who's been there frequently at the end of life and stayed with patients, could you just talk about that and what you've observed.

LAURA BORRELLI: Thank you, yes. I work in home care, all right, and in home care, which is by and large where most individuals say they would like to die, surrounded by their loved ones in their own natural environment and surroundings that they're familiar with.

In those circumstances, I've used a morphine drop on a rarity of occasions. The times I have, it might have been because of ease of access. This individual had had a port put in for chemotherapy, saying we had one there and we were going to transition to using it, we would certainly use it at that moment, but it would probably be more toward the end, the true end of life, the last few days.

I've never had one go on for weeks and weeks on end as far as a morphine drip is concerned. For the most part, we use something called the morphine concentrate, a sublingual medication that effectively controls the pain of individuals in their dying phase of life and it blows my mind when I hear individuals talk in terms of the pain and people being in such pain and such psychotic states. I have not been witness to that at all in my practice.

I have seen individuals that have been comforted and brought to peaceful states, physically and emotionally and lessen their anxiety with medications that we've been able to use within the home that families have been able to easily administer, and again, not over-administer at all, but to administer appropriate doses to control whatever symptoms that we're seeing.

REP. SAYERS: The second part of that was that the comment on, I mean, just to visualize someone at that stage in their life being able to take 90 pills, whether it was dissolved in water, whether they had to swallow them individually or however the manner was. Could you just make a comment?

LAURA BORRELLI: The (inaudible) is something that would prevent the vomiting from occurring, would have to be naturally administered first because there would be vomiting with this amount of liquid ingested or pills ingested and it would be clearly extremely difficult for an individual toward their dying phase or dying process to ingest that amount of fluid without causing undue harm, you know, to them, aside from the natural (inaudible) of causing their death.

REP. SAYERS: Thank you.

SENATOR GERRATANA: Thank you, and thank you again. And please, I hope you can go home and get some sleep and rest easy.

LAURA BORRELLI: This was very important, so thank you all very much.

SENATOR GERRATANA: Thank you. It was my pleasure to see you there all day. Thank you so much. Next is Linda Smith-Criddle, followed by Mary Fran Libassi.

LINDA SMITH-CRIDDLE: I'm not sure whether to say good evening or good night.

SENATOR GERRATANA: Good evening, I guess.

LINDA SMITH-CRIDDLE: My name is Linda Smith-Criddle. I'm a priest in the Episcopal Church. I have a doctorate in theological studies and a master's degree in philosophy with a specialization in ethics.

I served for 20 years in a hospital as chaplain and ethicist and in that position, as you can imagine, I spent a good deal of time with all kinds of patients and innumerable dying persons in particular.

I have continued my interest in this field and it's from this background that I wish to highlight several issues I believe are essential to our fully understanding why legislation could possibly be considered that might provide assistance to ending one's life.

First of all, the legislation that is being considered would limit the assistance to circumstances in which a person is facing an imminent death and suffering is known to her alone. Life is not only biological but also biographical and who knows better than the dying person, if life under these circumstances is bearable or not.

Slippery slope arguments are not defensible in this situation for their intention is to take away the legitimate decision making right from an individual patient when she is capable of doing so.

We need to hold intention to honor both the life of a person and to honor a person's freedom to choose. Yes, life is a gift to celebrate for the most part, but there are circumstances in which a person may find herself in unremitting pain and essentially slowly losing her life.

How long is the suffering required? When will the futility of terminal angst be enough to respond to an intentional fashion?

Some say any intentional act is suicide but the comforting ability in this proposed legislation for a competent individual to indicate such a choice after lengthy efforts to cure have failed, is rather a merciful means of alleviating the no exit conundrum.

I thank you for this opportunity to testify.

SENATOR GERRATANA: And thank you.

LINDA SMITH-CRIDDLE: And I extend to you and especially to all of those who suffer trapped in inexorable decline a peace that is beyond all human understanding.

SENATOR GERRATANA: Thank you. Thank you for your testimony. Next is Mary Fran Libassi, followed by Bill Knight.

MARY FRAN LIBASSI: I'm just going to wave and say hello to you.

SENATOR GERRATANA: Hello.

MARY FRAN LIBASSI: This has been a long day.

SENATOR GERRATANA: Yes, it has.

MARY FRAN LIBASSI: And I feel like you're all friends now. My name is Mary Fran Libassi and I'm a resident of 20 Loffler Road in Bloomfield and I'm testifying in support of House Bill 6645.

I have been on the faculty of the School of Social Work for over 30 years and actually this is my first year in retirement and I don't like it. Anyway. But I'm very honored and kind of excited to have the opportunity to testify on this bill because you won't believe this, but I have believed in this concept ever since I was in my twenties.

And that was because somehow as an individual, a very young individual I believe that everyone has a right to self determination concerning their health care and even their death. So this bill is just what I've been looking for all these years.

Now, there have been some wonderful things that have taken place since I was 20 that have moved us toward self determination and I think you Legislators have been the ones that have helped us to do this, and these are things like living wills and advanced directives, and those have given us some control over our dying.

Here we join with our doctors and we work together to plan what options we want and what we don't want as we are dying. So we can even name a health advocate to act for us if we're not able to and this self determination is honored, respected and supported as we plan our deaths.

So now there is this one step more that is yet to be taken, and that is what I believe this bill provides for us, is this opportunity to really take control of what is going to happen to us at our death.

It was very interesting. I live in a retirement community and I have spent many hours talking to people, especially over at our nursing home and one of the things that they frequently say to me is, what's wrong, Mary Fran, why does it take so long to die? I've lived a very good life and I'm ready to die, and these are people who feel as though the process of living and the ways in which they have lived and the excitement and everything that there's been to life, they don't want to give that up.

They're not so much afraid of the pain. I think there is some fear of the pain that they may encounter as death comes about, but they're really more afraid of what is going to take away who they are as people.

And I think this new bill provides the option that allows them to stay people, the kind of people they want to be for as long as they want to. It means that they can carry on conversations with their friends. It means that they can talk to their grandchildren and spend time with their grandchildren and they can really live until the time of their death.

SENATOR GERRATANA: Thank you, Mary Fran. Can you summarize your testimony?

MARY FRAN LIBASSI: Well, this is just about it.

SENATOR GERRATANA: Oh, good.

MARY FRAN LIBASSI: This is just the option that I believe the compassionate aid in dying is providing for us that people can determine what they want to do when they know about their terminal illness and to do what they want to self fulfill their lives for themselves.

So that's pretty much it, and I hope that you all will vote to support this bill. \

SENATOR GERRATANA: Thank you very much and thank you for giving your testimony this evening. Next is Bill Knight, followed by Michael Culhane, maybe? (Inaudible) Catholic Affairs, Public Affairs after Bill Knight, Connecticut Council on Developmental Disability. Is Bill here? Okay. Michael Culhane. I think it's Culhane. Michael here? Oh, there he is, good.

MICHAEL CULHANE: Senator Gerratana, Representative Johnson and Members of the Public Health Committee, I am the Executive Director of the Connecticut Catholic Public Affairs Conference and for the record, the Catholic Conference is the public policy office of the Catholic Bishops of Connecticut, and I'm here this evening to urge the Members of this Committee to reject House Bill 6645 AN ACT CONCERNING COMPASSIONATE AID IN DYING FOR TERMINALLY ILL PATIENTS.

The Conference opposes this legislation not only because it is an affront to the teachings of the church, but because we join so many other non-religious organizations representing the medical, hospice, elderly and disability communities who have also publicly opposed this bill.

The proponents of this measure to characterize this issue as religious is clearly an effort by them to detract from the many serious problems related to this legislation on assisted suicide.

The Connecticut Legislature should reject the concept of this bill, based on the public policy that it established in 2012 when the repeal of the death penalty was debated and passed.

One of the strongest arguments made in our efforts to abolish this law was that if just one innocent person could be saved, then the repeal would be justified. Even President Obama promoted this view of life in the aftermath of the Newtown tragedy when he stated during a White House remark on January 16th of this year that, and I quote, if there's even one life that can be saved, then we've got an obligation to try to do so.

For the proponents of this bill to talk about end of life issues I would like to make three very, very brief comments.

Doctors admit when asked that the exact end of one's life is unknowable.

Secondly, there are volumes of examples of terminally ill patients who at the end of life have gone into remission and subsequently have lived long, significant and productive lives.

And three, I would also like to speak personally on this subject. In the year 2000 I was diagnosed with Stage 4 kidney cancer and had surgery at Sloan Kettering Memorial Hospital in New York. A year later in 2001, I was diagnosed with pancreatic cancer and had surgery at that same, wonderful hospital and I'm here 12, 13 years later and I have beaten the odds. But for those who are sick and suffering, the efforts of this Committee must be directed at research and programs to enhance palliative and hospice care, not on concentrating on ways and methods to promote physician assisted suicide.

SENATOR GERRATANA: Thank you, Mr. Culhane. Could you summarize, please?

MICHAEL CULHANE: This is it.

SENATOR GERRATANA: Okay.

MICHAEL CULHANE: So my concluding point is simply this. We as a society must emphasize, to quote the President, our obligation to preserve even one life. I believe that this bill is bad public policy. It places the state squarely in the middle of a private matter where the state should not be, and I urge the Committee to reject House Bill 6645.

SENATOR GERRATANA: Thank you.

MICHAEL CULHANE: Thank you.

SENATOR GERRATANA: And thank you for giving your testimony this evening.

Next to testify is Duane Lueders, okay, followed by Dr. Matthew Kenney.

DUANE LUEDERS: Good evening, Madam Chair and Committee Members. My name is Duane Lueders and I live in West Simsbury.

SENATOR GERRATANA: Time's up. No.

DUANE LUEDERS: Shall I summarize?

SENATOR GERRATANA: Please continue, yes.

DUANE LUEDERS; I am in favor of House Bill 6645 AN ACT CONCERNIGN COMPASSIONTE AID IN DYING FOR THE TERMINALLY ILL. I would like to use my time to address two aspects of the debate.

First to respond to the arguments put forth by the opposition and second to clarify as best I can what I consider to be the essence of the bill.

As for the arguments put forth by the opposition, they may appear numerous but they really fall into two categories, those based on belief and those purportedly based on fact.

The arguments based on belief spring primarily from religious teachings. I have nothing against religion per se and respect any person's right to practice his or her beliefs when it comes to his or her own personal life.

However, no group should ever be allowed to impose its religious beliefs on others. It has no place in the debate.

As for the arguments purportedly based on fact, no Legislator can make an informed decision on this bill without first examining the data from the State of Oregon. Simply stated, the bill before us has already been put to the test in Oregon over the last 14 years and the results are clear.

It accomplishes its objectives of relieving the suffering of terminally ill patients without any of the adverse effects that have been claimed by the opposition such as elder abuse, coercion or the slippery slope that so many fear.

It is elementary that any Legislator considering a bill that has, in essence been effort for a decade and a half in another state would examine the data from that other state. The data is not ambiguous and it systematically refutes point by point, argument by argument, everything the opposition has to present under the guise of facts.

Your decision can be based on wild speculation or facts. I suggest facts.

Finally, I would like to give you my thoughts on what I consider to be the essence of the bill. When I asked myself what is this bill really about, or what do these people really want, the answer is obvious. They want to be left alone.

To illustrate the point, I'm going to take a moment to put myself in the shoes of a qualified patient who might be eligible for relief under this bill. If I were such a patient, I would say this to all of you.

I am mentally competent. Two qualified doctors have told me that I have six months to live. I am told I should expect to suffer greatly during that time. I would rather not. I want to obtain medication that will allow me to end my life peacefully when I decide I have had enough.

Given my exceptional circumstances, can any of you think of any reason why I shouldn't be allowed to do that? Given my exceptional circumstances, can any of you think of any reason why the government should interfere with my ability to go home, get in bed, take my pills, go to sleep, never to wake again.

Given my exceptional circumstances, don't I have the right to be left alone?

SENATOR GERRATANA: Thank you, sir. Thank you for your testimony this evening. Representative Srinivasan.

REP. SRINIVASAN: Thank you, Madam Chair. Thank you very much for your testimony. You were very clear, very concise in the way you presented your testimony. We appreciate that.

DUANE LUEDERS: Thank you.

REP. SRINIVASAN: The facts, as you call them, you know, as you said, if you recall much earlier in the day, we had the proponent of the bill himself talk about safeguards that were not there in the bill that we are debating at this point and that this bill needs to be improved by several safeguards that need to be included.

And my impression from your testimony was, you were very happy with the way the bill was and were not too concerned about the safeguards a) that we talked about earlier in the day and b) the proponent of the bill himself felt it would be necessary moving forward.

DUANE LUEDERS; I guess my response would be and again, I don't claim to be an authority on this, but from what I understand from the data collected by the Compassion in Choices folks is, in terms of again, looking at the data in Oregon and looking for those let's say, adverse results or unexpected results or undesired results, I gather many surveys have been done and I'm sure they've got the information, none of which have supported any of the claims that basically the bill has led to adverse results.

And I guess I'm inclined, assuming that information is reliable, which I assume it will, is if the bill accomplishes its objectives without any of the adverse results, I don't know what more improvement any bill or any type of legislation could possibly ask for.

And again, I understand it's big decision and if additional protections are put in place, I don't think I would object to them. I think it's more important that the bill get passed but given the track record in Oregon, I would just wonder why the need for tweaking the bill or changing it would arise in the first place.

REP. SRINIVASAN: Thank you. Thank you, Madam Chair.

SENATOR GERRATANA: Certainly. Senator Welch.

SENATOR WELCH: Thank you, Madam Chair. I just walked into the end of the question, so I apologize if I get this wrong.

So you were talking about potential adverse results?

DUANE LUEDERS: Yes.

SENATOR WELCH: And I guess you were comparing this bill to Oregon's bill?

DUANE LUEDERS: I am.

SENATOR WELCH: Okay. So you see this bill as the same as Oregon's bill?

DUANE LUEDERS: I'm not going to say I've compared them line by line. My understanding is that this bill is based in great part on that bill.

SENATOR WELCH: I would say it is based in great part, but I would also say that there's some pretty substantial differences, which I guess we haven't focused on. We focused on earlier in the morning, but not lately.

And then I guess with respect to adverse impacts, you know, one of the things that I've read about in the testimony but I haven't heard much about tonight and maybe I will, maybe I won't. I don't know, but it seems to be that the suicide rate in Oregon has gone up and that also includes when you take out those that have opted for physician assisted suicide and you move that set out, you still see an increase in suicides in the State of Oregon.

The last number I think I saw was 41 percent greater than the national average. I guess I would kind of look at that as an adverse result. I know that's not looking at the individual who is requesting this, but it's looking at a societal impact as a whole and I don't know if you would see that as an adverse result.

DUANE LUEDERS: I'm not familiar with the data. I guess the only question I would have if I were in your shoes is whether or not that's a correlation as opposed to causation.

SENATOR WELCH: Sure. Absolutely. All right. Thank you, Madam Chair.

SENATOR GERRATANA: Thank you. (Inaudible). Next is Dr. Matthew Kenney followed by Deacon Tom Davis. This is Dr. Kenney?

MATTHEW KENNEY: Yes.

SENATOR GERRATANA: Thank you.

MATTHEW KENNEY: Thank you, and my compliments to all of you on your fortitude. My name is Dr. Matthew Kenney. I'm a Clinical Ethics Consultant at Saint Francis Hospital in Hartford, and also a professor of bioethics at a number of universities.

The Shakespearean question, what is in a name aptly applies here. This bill has been termed AN ACT CONCERNING COMPASSIONATE AID IN DYING FOR TERMINALLY ILL PATIENTS when in fact it is neither compassionate nor of aid to those who are most vulnerable within our society.

Let's not skirt the issue. This is a physician assisted suicide bill. In fact, it fits almost verbatim the definition of physician assisted suicide, which the AMA provides.

As such, it violates the tenets and codes of medical and nursing ethics and is prohibited by the ethical and religious directives for Catholic Health Care Services, which all Catholic hospitals are obliged to uphold.

Most significantly, the bill does not accomplish the goals it purports to attain, mainly promotion of patient autonomy, lessening a sense of burden upon society and loved ones, alleviation of pain and a loss of self.

And contrary to what Dr. Blick says, the Hippocratic oath still does contain the line that I will not give a lethal drug to anyone if I am asked. There are different versions that are out there that are taken and new doesn't always mean better.

The American Medical Association Code of Ethics states, and I quote, that physician assisted suicide is fundamentally incompatible with the physician's role as a healer. It would be difficult or impossible to control and would pose serious societal risks.

They go on to say, instead of participating in assisted suicide, physicians must aggressively respond to the needs of patients at the end of life. Patients should not be abandoned once it is determined that cure is impossible.

Patients near the end of life must continue to receive emotional support, comfort care, adequate pain control, respect for patient autonomy and good communication. End quote.

As a Catholic, I'm concerned that this bill violates essential tenets of Judeo-Christian tradition, namely the sanctity of live and the promotion of the dignity of a human person.

As a bioethicist, I'm concerned that this bill violates central tenets of ethics. My work and research has evidence that physician assisted suicide does not accomplish the goals that it says that it will attain.

In fact, if often undermines proper care for the terminally ill by short circuiting the continuum of care that we owe our dying patients. I apologize for going over.

This bill does try to put safeguards in place to avoid a slippery slope but they're often associated with physician assisted suicide and although people have said that is not an issue, these safeguards are flawed and insufficient.

The bill itself cautions against coercion and the risk of undue influence by medical professionals, family members and society is significant and no policy will be able to completely mitigate against this.

Historically, this has proven to be the case in the Netherlands where the Dutch government's own study reports incidents with patients who have expressly said they don't want physician assisted suicide and were euthanized, and among this population was an increasing disproportionate number of vulnerable populations, especially the elderly, the handicapped and the disabled.

SENATOR GERRATANA: Thank you, Dr. Kenney. Can you summarize please for us?

MATTHEW KENNEY: Yes, I just want to in response to a question, even the State of Oregon as you were asking, reports that only 6.2 percent of all patients who received life-ending medication were referred for psychiatric evaluation, even though assessment of decision-making capacity, possible depression and emotional stability is the key component of the act.

Lastly, I'll conclude by saying, I was asked to submit this testimony to the Committee on behalf of Saint Francis Medical Center, the largest Catholic hospital in New England, and as a professional bioethicist and educator.

However, and most perhaps most primarily, I write as a widower who accompanied his wife through chronic and terminal illness and joined with her as she struggled to maintain her sense of worth, dignity and autonomy.

I was with her as she lay dying in my arms. I gave her CPR myself. More importantly, I was with her as she struggled to live. Fundamentally providing compassionate aid in dying as the aid is called means helping the terminally ill to see that they are not disposable. The dying have a lot to teach us about living if we only stopped to listen.

We promote passionate care for the most vulnerable among us when we affirm their existence, listen to and acknowledge their fears, aggressively treat their pain and help them alleviate their spiritual and existential suffering, not by assisting them with suicide. Thank you.

I do also, I know there were a number of --

SENATOR GERRATANA: Thank you. I'm sorry. Did you have something to add.

MATTHEW KENNEY: There were a number of questions that were asked that were not able to be answered and I do have some insight, particularly for a couple of questions that were asked by Representative Ziobron and also Representative Cook, but I will yield time if needed.

SENATOR GERRATANA: Well, Representative Ziobron wants to hear what you have to say.

MATTHEW KENNEY: Representative Ziobron, you had asked before of the attorney who was testifying regarding the difference between allowing a patient to refuse treatment and this particular bill, if I recall.

I wanted to point out to this body that the U.S. Jurisprudence on that is very clear. Compassionate Dying v. Washington and Zacco v. Quill on appeal to the Supreme Court affirmed the right of patients to refuse medically futile and extraordinary treatment and even on other surrogates to refuse that on behalf of them.

But they also said that that's fundamentally different than a constitutional right to physician aid in dying and they recognize legitimate states interest in prohibiting physician aid in dying.

So those ruling promote patient autonomy through refusing those types of treatments and recognizing the right of competent patients to refuse any treatment, but they did note that it was fundamentally different than physician assisted suicide.

The other point that you had asked is, if the bill fails to meet the needs of patients subscribed, then what is necessary in the bill to do it?

I think what's necessary for us to do well what we already have in place, to use advanced directives, to use appropriate and aggressive palliative care and to respond to the needs of the whole person, the spiritual, existential and social needs of the patient. We don't need a physician assisted suicide bill to do that. We just need to do what we're called to do and do it well.

REP. ZIOBRON: If I may, Madam Chair?

SENATOR GERRATANA: Yes, please.

REP. ZIOBRON: Thank you. Then to follow up on that, you know, and my questions are because I'm very interested by the way on both sides of this discussion and I hope that comes through with my line of questioning.

So on the flip side of that, I would submit to you, so if you have someone who's suffering and we don't have to describe the illness. They're suffering, they've been suffering for a long time. There's no hope. How do we deny them the opportunity for them to end their suffering with a clear conscious decision if that they can't obtain that through stopping their medication, stopping eating and everything else. What alternative do they have?

MATTHEW KENNEY: Well, first I would like to clarify. My doctoral dissertation on this subject was entitled, Toward the Reestablishment of Hope, a holistic approach to caring for the terminally ill as an alternative to physician assisted suicide.

So I think there are ways in which we are called to responsibility help particularly those who are terminally ill, or even critically ill, to find meaning in the context of their suffering, to find a sense that they are not (inaudible).

There's a beautiful phrase from the (inaudible) the fact of the other calls them to responsibility, and I'm already guilty for not having responded.

The, you know, and Representative Cook asked the question, well, what if this was your family member, and unfortunately, I was in that circumstance, and what I told my wife every day. We're going to love each other through it, and her fear was a sense of being a burden to me, a sense of, you know, loss of purpose, and in talking with her and listening to her narrative and her story, I was able to help her find the fact that she's not a burden. It was a privilege for me to accompany her on this journey, and also to find meaning in the context in the dignity with which she faced what life threw her way.

In terms of the you know, what do we say to someone in that situation? The first response is one that I'm so sorry that you're in this situation. I'm so sorry that you're going through this and I want to accompany you on that journey.

But I think there's a fundamental difference between, and the courts agree, on withholding and withdrawing futile medical treatment and then also looking for physician aid in dying.

And I would add that physical pain is not the most, nor is it even at the top of the list as to factors for requests for physician aid in dying. It's those other factors that, those existential and spiritual factors that I brought up.

And helping to someone to see their continued value and worth, and that they're not alone goes a long way to alleviating those requests.

REP. ZIOBRON: Thank you very much for your thoughtful answer. Thank you, Madam Chair.

SENATOR GERRATANA: Thank you. Senator Welch.

SENATOR WELCH: Thank you, Madam Chair. So it sounds like you spent a lot of time studying and writing and researching on this issue and I guess my question, my first question would be to what extent have you examined the Oregon experience?

MATTHEW KENNEY: I looked at the annual reports from Oregon, which if Representative Cook were here, I would suggest that she check that report as opposed to the Compassionate Choice's version of the Oregon referendum because that annual report is published by the state so it would be effective.

I looked at those Oregon reports. I've not spent a tremendous amount of time line by line comparing them. I'm aware of some of the concerns that are raised with that issue.

I'm also aware of some of the positives that have been connected with that bill, especially the ability of physicians to talk more openly about end of life issues with their patients and their willingness to discuss appropriate and aggressive palliative care.

I suggest that those are not inherently and de facto connected with the bill. We should be doing that anyway. That's good care, and you know, the point was raised is it a cause or a correlation, I think in response to your questions.

I think yes, good care for the dying and we're a different state than Oregon. We are not going to repeat what Oregon happens. We're a different constituency and it is a different bill. We don't have all those safeguards in that they have.

But fundamentally, we address that this bill tries to address by providing better care for the dying using the mechanisms we already have in place.

SENATOR WELCH: I don't know if you know the answer to this question, but does the report or does any information coming out of Oregon talk about how many doctors are actually prescribing what --

MATTHEW KENNEY: Yes. I don't want to quote an exact number. It's a small proportion of doctors within Oregon and as a matter of fact, there's a small number of people that avail themselves on this bill as I think most sides have said, last year was 77 patients actually availed themselves of the prescription and ended their lives through use of aids.

You know, so it's a small number who are actively involved in this.

If you go to the annual report it has a spread sheet that does, you know a number of incidents, the disease and the physicians that were involved.

SENATOR WELCH: Thank you. Thank you, Madam Chair.

SENATOR GERRATANA: Thank you. Thank you for coming this evening. Next to testify is Deacon Tom Davis, followed by Rachael Payne.

TOM DAVIS: Good evening.

SENATOR GERRATANA: Good evening.

TOM DAVIS: I am Deacon Tom Davis. I'm an Associate Director of the Pope John Paul II Bioethics Center at Holy Apostles College and Seminary in Cromwell, Connecticut and an adjunct member of the faculty where I've taught bioethics and law.

I'm also a Deacon in the Melkite Greek Catholic Church, which is one of the eastern rites of the Catholic Church and I'm here to speak in behalf of the Bioethics Center and the Melkite Catholic Church in opposition to HB 6645.

I have submitted written testimony and I won't read that to repeat it, but I would like to emphasize and modify one part of my written remarks.

I mention that modern palliative care modalities have revolutionized end of life care since 1960s but it's not just that. It's also revolutionized the spiritual communion between health care providers and dying patients based on on a fundamental principle known as non-abandonment.

And this principle was developed primarily by Dr. Michael Brescia at Calvary Hospital in the Bronx. Dr. Brescia was going to be here today. I made reference to him in my written remarks, but this morning he advised he wouldn't be able to make it. I since communicated with him and he's asked me to echo a couple of comments he and I share.

The developments, Dr. Brescia, first of all so you understand who he is. He invented the Brescia-Cimino fistula, which is the means by which dialysis is delivered to tens of millions of people, tens of millions of people who would otherwise have died. He developed that in 1960s, and next to antibiotics and perhaps internal body imaging, is arguable one of the three great developments of medicine in the 20th century. So he's a man of considerable stature in the medical community.

What he and his team at Calvary Hospital did, was they committed to this principal of non-abandonment to a patient and as an institution and as caregivers, they developed all the new modalities of palliative care we know today, inpatient care, pain management and family counseling and spiritual care and home-based hospice and outpatient clinic care.

If he were here today, he would tell you, and he's affirmed this to me in an e-mail today, that no one need suffer excessive pain. The modalities exist that no one need suffer excessive pain in the dying process.

I'd also like to just briefly comment, and I'll wrap up that we heard today from Dr. Blick and his mother and others about various ideas of human dignity. We heard from a pastor of another denomination that dignity is about the ability to make choices, about a vigor in life.

That's a view that I don't share. I know many don't share. We believe human dignity is inherent and it doesn't really matter what your level of vigor is. It's that you are a member of the human family and your dignity therefore is not dependent on these changing circumstances.

Dr. Blick mentioned that 90 pills, 90 pills would be the dosage for assisted suicide. That's 90 pills.

SENATOR GERRATANA: Thank you. Could you please summarize your testimony?

TOM DAVIS: Sure.

SENATOR GERRATANA: Thank you.

TOM DAVIS: The last thing I would say is, Attorney Schneider from the ACLU told you that the bill embodies the ordered liberty concepts of freedom in the due process clause in the Fourteenth Amendment.

Like Attorney Schneider, actually like the professor you've heard earlier, I've had a long career in the practice of law as a government lawyer here in Connecticut.

What Attorney Schneider didn't tell you is that the Supreme Court has held definitively that the Fourteenth Amendment does not provide a constitutional right to physician assisted suicide. They rejected that unanimously in Washington v. (inaudible). Thank you.

SENATOR GERRATANA: Thank you, and thank you for your testimony. Next is Rachael Payne, followed by Stephen Mahalchik, I think. Oh, he already testified, sorry. So it's Rachael Payne followed by Stephen Mendelsohn.

RACHAEL PAYNE: Good evening.

SENATOR GERRATANA: Good evening.

RACHAEL PAYNE: Madam Chairs and Members of the Committee, my name is Rachael Payne as you know, and I am speaking today on behalf of the Connecticut Coalition of Secular Organizations and we have over 1,000 members here in Connecticut and we are in support of HB 6645 AN ACT CONCERNING COMPASSIONATE AID IN DYING FOR TERMINALLY ILL PATIENTS.

The Coalition is in favor of this legislation for two reasons. First, it provides mentally competent terminally ill patients the right to control how they face death at the final stages of their illness increasing their autonomy and alleviating their fears about end of life suffering.

Second, the requirements outlined in the bill prevent abuse and ensure that a decision to request end of life medication will be the patient's decision alone.

I'd like to share Nancy Niedzielski's experience with the committee, which is reported in the documentary film by Peter Richardson, How to Die in Oregon.

Nancy's husband Randy suffered from a terminal case of brain and spinal cancer. During the final stage of his cancer, the tumors in his brain grew so large that it forced his eyeballs outward to the point that he could no longer physically close his eyelids. He frequently screamed out from the pain and described his suffering as worse than death.

Before he died, Randy asked Nancy to promise him that she would fight to enact the legislation for end of life in Washington.

It is with the torment of those like Randy in mind that it becomes crystal clear that end of life legislation can bring autonomy, dignity and peace of mind to terminally ill patients. Surely, it is not for everyone, but that is precisely the point of the law.

To provide patients with as many compassionate options as possible, to give them the authority to make their own decisions. Opponents of end of life proposal frequently argue that this type of legislation is a slippery slope that will inevitably lead to the abuse of the elderly, disabled and mentally competent.

However, 15 years of data collected as a result of the Oregon law have proven that those fears, although sincere, were prevented by the thoughtful and meticulous protections contained in the law.

The Oregon act mandates a rigorous reporting requirement and according to the Oregon Public Health Division, the agency charged with collecting data and reporting on the law, there have been no cases of abuse, and nine independent studies corroborate the finding.

Further, by making this choice legal, I'm almost done, is it all right if I finish?

SENATOR GERRATANA: Yes, please summarize.

RACHAEL PAYNE: I will. By making this choice legal, we are protecting those who would seek it out on their own anyway, from abuse. The Connecticut bill does mirror the protections and requirements of the Oregon law. If you'd like me to identify where there are some deviations, I would be happy to do that, and we'd like to emphasize that there is no argument against this bill that is supported by the available facts and evidence.

It comes down to a matter of imposing personal opinion and belief on the (inaudible). The facts and evidence is clear. It does not lead to abuse. It is giving choice to a very small number of qualified people, who in many cases don't even choose to use this. Thank you for your time.

SENATOR GERRATANA: Thank you, Rachael. I don't see your testimony on line.

RACHAEL PAYNE: I submitted the 10 copies this morning.

SENATOR GERRATANA: You did. Okay, and I just have one quick question. The, some people had testified that the suicide rate in Oregon had risen by a certain percentage. Do you know where I would find those facts or statistics?

RACHAEL PAYNE: You know, I have not seen that the suicide rate has risen, but I would certainly be happy to look into that and provide the Committee with that.

SENATOR GERRATANA: Thank you. I would appreciate it. Thank you. Representative Demicco.

REP. DEMICCO: Thank you, Madam Chair. Thank you for your testimony. Since you offered, I would ask you, could you just briefly describe for us the differences between the Oregon law and what's proposed here?

RACHAEL PAYNE: Yeah, and I want to emphasize that as others have said, I haven't gone through line by line but I've spoken with some people who are very well informed in addition to my own research, and it's my understanding that in Oregon there is what is called the waiting period, which is initiated by the oral request to the doctor, separated, they wait 15 days to make a second oral request.

The other thing is, here we are saying they need the primary physician or the physician for the terminal illness, the primary physician in that illness, and a consulting physician, we have an exception. In Oregon there's no exception. There's always a two doctor requirement.

And I wanted to say one thing about the pills. There's been a lot of misinformation spread about that today and if it's okay, I'd like to clarify that.

In Oregon it's capsules that break apart and there's powder. They all are emptied into a small glass of water, what I would call small to medium glass of water about this big, and it's consumed very easily. It does not result in vomiting. It does not, it's not something that's difficult to consume. I just wanted to clarify that information.

REP. DEMICCO: Madam Chair, may I? I noticed that in the proposed bill that there is no prescribed method and I presume that there's no prescribed method in Oregon as well?

RACHAEL PAYNE: Prescribed method of how to self administer?

REP. DEMICCO: Correct.

RACHAEL PAYNE: That is my understanding, although I do know that there are (inaudible) that take it upon themselves to fill out and educate people (inaudible) on this but that's certainly something that could be added to the bill.

REP. DEMICCO: I notice, I don't see any reference in this proposed legislation any specific reference to pills and --

RACHAEL PAYNE: You're right. There's not.

REP. DEMICCO: -- and I presume there's no specific reference to pills in the Oregon law either.

RACHAEL PAYNE: That's correct.

REP. DEMICCO: So that's why I'm confused, but --

RACHAEL PAYNE: Because typically there are certain drugs that are used and as Dr. Blick testified earlier, it's commonly dispensed in 90 pills and their capsules emptied into maybe applesauce, a small glass of water and it's taken that way. That's the common experience.

But you're correct that there is not a reference to a precise drug or type of (inaudible).

REP. DEMICCO: Thank you. Thank you, Madam Chair.

RACHAEL PAYNE: Thank you.

SENATOR GERRATANA: Thank you very much for your testimony. Next is Stephen Mendelsohn, followed by Karen Laski.

STEPHEN MENDELSOHN: Senator Gerratana, Representative Johnson, Members of the Public Health Committee, my name is Stephen Mendelsohn. I'm an adult on the autism spectrum and one of the leaders, along with Kathy Ludlum and others of Second Thoughts Connecticut, an advocacy organization led by people with disabilities opposing the legalization of assisted suicide.

All of us are here today in vigorous and unconditional opposition to the Orwellian titled House Bill 6645 AN ACT CONCERNING COMPASSIONATE AID IN DYING FOR TERMINALLY ILL PATIENTS.

House Bill 6645 is a radical and dangerous bill without even the pretense of safeguards. It will needlessly shorten the lives of elders and people with disabilities perhaps including my own.

Let us first correctly understand the act of the core of this bill is assisted suicide. We must not use euphemisms like compassionate aid in dying to justify the unjustifiable.

Back in 1942 at the height of the Holocaust, when German and French psychiatrists and pediatricians were murdering over 300,000 people with disabilities in institutions like Hadamar, the American Journal of Psychiatry published an unsigned editorial titled Euthanasia.

This shocking editorial supported the views of neurologist Foster Kennedy who advocated that all five-year-old children in the U.S. with severe intellectual disabilities be killed. What is pertinent here are the euphemisms used by the editors of the American Journal of Psychiatry to describe their plans for medical murder.

As I have written in The Disability Rag and Dr. Peter Breggin has written elsewhere, the editors of the official journal of the American Psychiatric Association never use the words murder or kill. Instead, they speak of "disposal by euthanasia", "merciful passage from life", "a method of disposal" and even "a lethal finis to the painful chapter", and also suggest a psychiatric campaign to alleviate parents of the guilt over the murder of their children.

The repeated references to the euphemism "aid in dying" and the attempt in Section 15 and elsewhere to proclaim that a doctor prescribing a lethal overdose of barbiturates does not constitute assisting a suicide hearkens to this dark chapter in psychiatry.

The term aid in dying is also an attempt to put suicide assistance under what Dr. Breggin has called the medical umbrella, just as the medical umbrella of German doctors in the late 1930s enabled the psychiatrists to develop the gas chambers, crematories and even the extraction of gold from the teeth of the dead, later to be used --

SENATOR GERRATANA: Thank you, Mr. Mendelsohn. Could you summarize for us?

STEPHEN MENDELSOHN: I'll try to summarize. Let me just quickly --

SENATOR GERRATANA: I wanted to ask. Did you submit your testimony?

STEPHEN MENDELSOHN: I did submit my testimony. Kathy Ludlum submitted hers, but it's not on line. I want to make sure hers gets too.

SENATOR GERRATANA: Okay. I just wanted to make sure so we could read it. Could you summarize for us.

STEPHEN MENDELSOHN: I just want to make something very clear. I am Jewish and I'm very sensitive about making any comparisons to the Shoah. The lack of safeguards, the lack of even pretense to safeguards can only lead to the conclusion that compassionate choices is seeking to put the death of old, ill and disabled people under the same medical umbrella.

When final exit network scares people to suicide outside the medical umbrella, they are widely perceived as rogues, when compassionate choices does the same thing under the medical umbrella, this act is now compassionate aid in dying.

The medical umbrella inures us to this medical killing just as it did 70 years ago, and I noted again, with Barbara Wagner and Randy Stroup, they did not choose. I noted in my testimony at least eight different ways, and there are many others cited how this endangers the lives of people with disabilities and some of them are not present in the Oregon law and let me get to the end.

SENATOR GERRATANA: Thank you.

STEPHEN MENDELSOHN: As somebody on the autism spectrum, this endangers people with my disability, too. Please give this bill the assisted death it so richly deserves. Thank you very much.

SENATOR GERRATANA: Thank you. Thank you for your testimony. Have a good evening.

STEPHEN MENDELSOHN: Okay, you're welcome.

SENATOR GERRATANA: Okay. Next is Karen Laski followed by, I think it's Christopher Walsh. Hi, Karen.

KAREN LASKI: Hi. My name is Karen Laski. I'm here in support of 6645. Please excuse that this testimony may be disjoined. When I wrote down my thoughts I was wrought with memories and had a difficult time crafting many years into minutes.

I think of this bill as an opportunity to reverse a mandate that demands that the terminally ill accept dying according to the state statutes. Both my parents were sick for many years. When they were approaching death, I felt as though I had abandoned them, that the whole world had abandoned them. They had no choice but to endure more pain every day and it wasn't just pain, it was a constant struggle to be still, to sleep.

My father was nauseous and barely able to move, a feeling he always hated and dreaded. Both of my parents feared not being able to breathe. That struggle and the accompanying sounds were terrifying for them.

This bill was created to enhance the peaceful transition into passing away, the timing to be determined by the person involved.

I want to determine how I pass. Hearing the details of an uncontrollable death takes time away from me now during the living years. This is the time I appreciate life, not when I'm struggling with pain and the terror of more pain and perhaps gasping for air. There was no meaning for my parents in this condition. They endured a living hell.

I support hospice. They do as much as they can to relieve pain and give comfort to the dying. For 15 years I cared for my parents and was grateful for hospice when the time came. I had hoped that hospice could protect my parents and ease them into a comfortable death, like going to sleep. That didn't happen despite the wonderful care and medications and oxygen.

What my parents both feared, what I feared, happened. They both had terminal conditions, no quality of life but their hearts continued to beat. They saw no merit in this. Their bodies were ravaged and destroyed. Every moment was unbearable.

My mother weighed 55 pounds and every part of her body hurt. It hurt to pee. It hurt to breathe. My father's respiratory system started shutting down. He struggled. I needed to change the way the world looked at this struggle and couldn't.

There was no peaceful goodbye. There was just raw suffering. I'm almost finished.

Looking back at my parents' living years, I remember them both telling me that when there was no hope to let them go. They didn't want to suffer. We were aware of how difficult that would be. We weren't aware of how difficult that would be, how long a person can suffer in agony.

They both had signed advanced directives before either had become ill, but those directives were only instructions for others. My parents would still not be allowed to decided how much they could take when the passing would be unbearable for them.

Please let's do this. Let's give people who are pleading for mercy the option of a peaceful passing, allow them to decide what is right for them so that they need not fear the abyss of endless suffering and the panic of unceasing pain and struggle. Please give them the comfort of knowing that in the face of death, they have the support they need to leave on their own terms.

SENATOR GERRATANA: Thank you, Karen. Thank you for your testimony. Does anyone have any questions? No. Thank you. Have a good evening.

REP. JOHNSON: Christopher Walsh, followed by Dr. Sandra Coors? Dr. John Connelly. Helen Conroy. Lisa Honkanen.

LISA HONKANEN: Good evening.

REP. JOHNSON: Welcome, yes.

LISA HONKANEN: Good evening, surviving Members of the Committee. This is almost worse than residency. My name is Lisa Honkanen. I may be a little disjointed because it's been a very long day.

I'm a physician of geriatric medicine. I come from the State of New York, so I have a long drive back, but I have an active practice of taking care of homebound elderly patients, so I'm here to oppose HB 6645 and I don't want to repeat too much of what's been said already by my colleagues who oppose the bill but there are a few things that I do want to mention.

I did submit my testimony, so you can refer to most of that there.

But first I think it's important to bring attention to the word compassion. The root of that is to suffer with and what I want to point out is that it is never acceptable, it is never an acceptable choice to end the suffering by ending the sufferer, which is the ultimate abandonment when we assist somebody to die, to help them die.

In regard to the reasons why the patients request a physician assisted suicide, it should be noted that less than 20 percent request it because of pain and there are many modalities now available besides just morphine, so that as Dr. Brescia commented, even though he's not been here as was mentioned before, there are virtually no reasons why people have to resort to suicide to end, the other reasons which are mostly loss of autonomy, independence, you know, and depression.

It should be noted that in one study of terminally ill cancer patients who were receiving aggressive palliative care, depressed patients were four times more likely to desire hastened death, yet screening is not required for those seeking physician assisted suicide in Oregon, or it seems like in this bill.

But in fact, two percent of the patients requesting physician assisted suicide in Oregon get mental health counseling, even though we know the doctors of patients suffering or being diagnosed with a terminal disease are those at most risk for depression.

Furthermore, it was mentioned earlier multiple times about how normalizing suicide increases the incidents in the general population. I do actually have a reference for that. In my testimony it's Reference Number 14. It's an article by Shen, so you can refer to that where 35 percent increase in suicide in the general population.

I guess there's not really much more time to talk about the evidence that is there about the abuses that have been recorded in Europe and in Oregon, so I won't go through that. It's in my testimony, but I just want to conclude by saying physician assisted suicide is not an answer to a solution that is really more about unaddressed suffering and rather we need to focus our resources on real caring and support for the sick and dying.

Again, otherwise we're really abandoning patients at their time of greatest need.

And one last point is that by opposing this, we're not taking away freedoms from people because there are actually ways that people can do this without (inaudible) the art of medicine and requiring physicians to be the conduit for making this happen.

You know, legalizing physician assisted suicide would open this all up to abuses for those who do not share the beliefs of those undecided (inaudible).

REP. JOHNSON: Thank you so much for your testimony and your long wait. Are there any questions? Yes, Senator Welch.

SENATOR WELCH: Thank you, Madam Chair. Thank you for your testimony and I just actually pulled it up. I do have a few questions about what you cite in there on Page 3. You talk about, you say that since PAS took effect in Oregon, suicide has become the leading cause of injury death. What is the category of injury death? What does that encompass?

LISA HONKANEN: Oh, you know, if somebody has an accident. If they, in the case of (inaudible) committing suicide, cancer, you know, heart disease, so those are the different categories.

So when we break them up like that, suicide comes into another one. I will mention that when doctors fill out the death certificate for patients that have, you know, expired due to physician assisted suicide, suicide is not listed on the death certificate, so the record, or the statistics compiled for physician assisted suicide do not include the statistics of those undergoing this process.

SENATOR WELCH: All right. I'm sorry. I'm still not clear. So what is an injury death?

LISA HONKANEN: Oh, an injury death would like be in a car accident. Oh, you mean, what encompasses an injury?

SENATOR WELCH: Right.

LISA HONKANEN: So if somebody has fallen, if there's an accidental shooting or things like that, other injuries. But of all of those, I don't know all of the different types of, if you're asking me how people commit suicide.

SENATOR WELCH: No, no. I mean, you make a statement that it's a leading cause of injury death and so I'm trying to understand what is the universal injury death that suicide is now the leading cause of, or the second leading cause, rather. I'm sorry, the leading cause of.

LISA HONKANEN: I guess of all injuries, suicide, you know, somebody injuring themselves, of all the deaths called by injuries, you know, injuries of car accidents, of all of those, I don't know which is the top one, but say like car injuries, car accidents would be number one. Injury caused by self-inflicted suicide would be second, then following from there.

SENATOR WELCH: And you also say it's the second leading cause of death in Oregonians 15 to 34 years old. And you make a statement since PAS took effect, was that, was it not the second leading cause of death prior to PAS?

LISA HONKANEN: I can't tell you all of those statistics.

SENATOR WELCH: Okay. That's all right.

LISA HONKANEN: I don't know off the top of my heard because it's been (inaudible) putting all this together.

SENATOR WELCH: Okay, great. Thank you.

LISA HONKANEN: Yeah, but the reference is there, so --

SENATOR WELCH: All right. Appreciate that. Thank you Madam Chair.

REP. JOHNSON: Thank you. Are there, yes, Representative Ziobron.

REP. ZIOBRON: Yes, thank you, Madam Chair. I'm curious why you would make the effort to come and testify in Connecticut on a law that does not affect you as you're a resident of the State of New York?

LISA HONKANEN: It doesn't affect me as a physician practicing in New York but it's something that I feel very strongly against and I know that it's a domino effect. We already have it in Oregon, in Washington. Then Montana has not made it a statutory thing, it has a domino effect and there are six states right now that are putting this forth, you know.

I think it's really important that the disingenuous presentations about how there is no slippery slope I think need to be dispelled. I hope I had more time to discuss it in a forum here but that's why I did try to do it in a more comprehensive way in my testimony, so that there is evidence from other places there who have experience, that there is a slippery slope, that there are many, while recidivism in the European experience, there were many very explicit safeguards, that despite that, there are 1,000 people a year that are involuntary euthanized despite explicit safeguards that it should be voluntary and it should be you know, terminal.

There's lots of policy definitions. Even here today we've heard contradictions and inconsistencies and loopholes that, you know, can result in abuse and the sad thing is, it's the victims of this abuse are conveniently dead.

So I think that it's very important to, you know, to make that representation here because, you know, if this should pass in Connecticut, it's only a matter of time before we see the same thing in New York.

REP. ZIOBRON: Thank you for your testimony. Thank you, Madam Chair.

REP. JOHNSON: Thank you. Any additional questions? Thank you so much for taking the time. Okay. The next person on the list is James Dowling, followed by Janet Roberts. Welcome. Please state your name for the record and proceed.

JAMES DOWLING: Thank you, yes. James Dowling. Madam Chair, Health Care, Health Committee Members, Bill 6745 is a proposed answer to alleviate human suffering.

Today we've heard much testimony, many stories, stories that tear at the heart. This past Saturday my friend buried his daughter after three years' struggle with cancer.

This proposal is not the answer. It is not appropriate to end suffering by ending a human life. Human life, for reasons unknown, God has not yet called.

Human life is a gift from God to be taken by no one but God, the giver of live. Thank you.

REP. JOHNSON: Thank you, sir. Thank you for taking the time to be here today. Are there any questions? Thank you so much and have a good evening.

JAMES DOWLING: Good evening to you.

REP. JOHNSON: Next, Janet Roberts, followed by Merrily Kaplan. Welcome, and please indicate your name and proceed.

JANET ROBERTS: Okay, good evening. I'm Janet Roberts. I'm urging you to vote no on HB 6645 and any similar legislation on assisted suicide or assisted death.

It is imperative to stop this medical and psychological madness now. The mere fact that this horrific legislation is being considered provides the evidence of the brain washing process has begun in our State Legislature. To simply call it compassionate aid is unconscionable.

To allow such would be an atrocity. To further cover up, I mean, a further cover up in the language of this bill is the word terminally. This broad-based term is a vague expression that leaves room for excessive violations well beyond thoughtful imagination.

Furthermore, this open-ended bill is nothing short of a cover for future ending of life measures. Eventually, every single person could be affected directly or indirectly by this legislation. Those targeted could later include individuals deemed onerous to society at all ages.

Parents, children and guardians would be coaxed into accepting end of life measures for those under their care and close to them.

It is everyone's God-given duty to help the innocent to live, not to help them die. To do otherwise in and out of government is aiding and abetting criminal activity, of which the most defenseless citizens are targeted.

Plainly and simply put, this legislation represents incomprehensible evil activity against the weak and hurting.

I hope you take a strong look at the destructive ramifications that HB 6645 provides. It furthers a grotesque trend of devaluing individual worth in our state. To promote any of such activity would be a terrifying injustice of the immense proportions, leading to acts of violence.

Since we are in the process of trying to prevent massacres here in Connecticut, I suggest reaffirming passionate care for the innocent so-called terminally ill patients at all ages who are valued assets to our society in ways we may not even see.

As ridiculous as it may sound, it would make much more sense to give a death sentence to terminally incarcerated criminals. After all, to aid in the death of an innocent individual is to participate in their sentence of death.

I would like to add that this bill is evil. Sandy Hook would be (inaudible). There were 26 victims. The victims of this bill will be much greater, that's why I'm using such strong language here. It's disturbing legislation. The weapon is medications and the bottom line is anyone can commit suicide today without this legislation.

REP. JOHNSON: Thank you so much for your testimony. Are there any questions? Thank you for taking the time. Much appreciated. Okay, Merrily Kaplan, followed by Tim Appleton and then Eva Cestari. Welcome, and please state your name for the record.

MERRILY KAPLAN: Hi, everybody. My name is Merrily Kaplan from Hamden. I'm here to offer my testimony in support of 6645. Today's my birthday and I didn't have to figure out anything else to do because I've been here all day.

A VOICE: Happy birthday.

MERRILY KAPLAN: Thank you. And it's 10 years and 13 days since my husband Steven Kahn ended his life. In a sense, this is also Steven's testimony.

You got a sense of his clarity of mind, his strong spirit and his loving kindness in the letter that my mother-in-law read earlier.

Steven had LAS, a devastating terminal illness. He fought hard, even participating in some experimental treatment to stay alive because of his fierce love of live, and he hoped by staying alive he might benefit from research in stem cell or gene therapy, but this was not to be so.

Steven was faced with the stark certainty of being locked into his body without speech, without movement, and he desperately looked for help so that he could choose to end his life when he was ready.

A lot of people talked about we shouldn't abandon people at the end, and that giving them some kind of medication is a way of abandoning them, but let me tell you, Steven had so many friends and relatives and doctors. He had a neurologist, a pulmonologist, social workers, hospice workers and he couldn't talk to anyone about this need that could help him, and so he really did feel abandoned.

I mean, he talked to me, but I couldn't help him with that, and so it was, it added, I can't think of the word, more pain and distress to an illness he already had because he didn't have peace of mind about being able to choose not to get locked in at some point, and he needed, he felt for him, that he needed to find a way to end his life before he would get locked in and then wouldn't be able to.

And finally, he was able to get in contact with the Hemlock Society and it was only there that we found compassionate caring, people that were willing to listen to him, even when he was, you know, typing on his computer with one finger, and offered support and no coercion at all, and that's when he did not feel abandoned.

In summary, Steven was well aware of the laws in Oregon and he was a strong believer in those and he wished that they had been happening in Connecticut, and if he were here today he'd be here. Thank you very much.

REP. JOHNSON: Thank you for sharing your story. Very much appreciated. The next person on the list is Tim Appleton and then Eva Cestari and Mary Pollock.

TIM APPLETON: Madam Chairs, Vice-Chairs, Ranking Members and Members of the Committee, my name is Tim Appleton. I'm the Connecticut organizer for Compassion in Choices and I've lived in South Windsor with my family for 10 years.

Thanks for this opportunity to speak before you tonight. I'd like to take a moment to offer some facts into the record this evening.

This is the Oregon Department of Health study published every year regarding Oregon's Death with Dignity Act and we will be happy to make it available on line for the Committee this evening.

In the report, it reflects that 97 percent of patients who took medication to end their life did so under the care of hospice. Earlier today there were also some questions regarding patients who took end of life medication and did not die. According to this report, only six patients in 15 years regained consciousness.

Further, in 15 years of medical practice, only 673 patients have hastened their life under this law, representing a mere .24 percent of those that died in Oregon.

Sixty-four percent of patients prescribed medication hastened the end of their life, while thirty-six percent did not take the medication. Eighty-one percent of those patients had cancer and in 2012, last year, sixty-one physicians wrote 115 prescriptions and seventy-seven patients took that medication.

Finally, the Independent Oregon Protection and Advocacy Organization for those with Disabilities is on the record stating there has not been a single case of misuse or abuse as does this report from the Oregon Department of Mental Health.

Thank you for affording me the opportunity to testify this evening. Please vote in favor of House Bill 6645 AN ACT CONCERNING COMPASSIONATE AID IN DYING FOR THE TERMINALLY ILL.

REP. JOHNSON: Thanks so much for your testimony. Are there any questions? Yes, Senator Welch.

SENATOR WELCH: Thank you, Madam Chair. I notice on your website that you've got a list of kind of FAQs when it comes to counseling and end of life questions, and one of them is that if you live in a state with no law protecting even dying should I move to Oregon or Washington and the answer is no, there are many available options to people across the nation.

What other options are there, other than moving to Washington or Oregon?

TIM APPLETON: Senator Welch, thank you for the questions. As I stated at the beginning of my testimony, I am an organizer for Compassionate Choices and certainly not an end of life counselor nor do I have a background and I think it would be appropriate to follow up with you later with that answer.

SENATOR WELCH: Okay. Thank you, Madam.

REP. JOHNSON: Okay. Any other questions? Thank you so much for taking the time and being here this evening. Much appreciated.

TIM APPLETON: Thank you very much.

REP. JOHNSON: Okay, the next person is Eva Cestari and then Mary Pollock and then John Pollock.

EVA CESTARI: Hi. My name is Eva Cestari and I am here to weigh in on the proposed physician assisted suicide bill, HB 6645, also known as right to die, or aid in dying.

I'm aware that a similar proposal was killed in Committee in 2009 and I know that Massachusetts and other states have voted down this bill.

I also wish to see this current bill defeated, too.

With all the testimony that's been given today, the cons against assisted suicide, I still think that enough material has not been presented and I would suggest, I'm asking that each one of you here continue to educate yourselves fully as to why you should not be a part of voting for this or similar bills.

There is so much information out there. I myself just went on the Internet, Googled in some of the names that came up on the Oregon situation and some of the problems that they did encounter there. You just have to Google certain names. I've got here Kate Chaney. Kate Chaney's Oregon death illustrates dangers, and there's a whole printout and there's a bunch of other names with problems that arose in the Oregon situation.

So again, I'm suggesting that people on their own look up this information. There is so much of it, and I don't think all of the negatives have really still been brought up today.

Look at other countries and look at how things have evolved there, the Netherlands and European countries, and how this bill has just evolved into something horrific. It's like Pandora's box. Once you open it, there's no end.

As I said, in Oregon there are publicized cases, including published letters from doctors showing that the two-doctor approach failed to protect vulnerable patients.

REP. JOHNSON: Would you just summarize?

EVA CESTARI: Yeah. I just wanted to mention that I took care of my husband for 13 years. He had a stroke and then all kinds of other medical complications after that. I was his primary care giver. There was a lot of exhaustion involved. He was in and out of hospitals and other kinds of facilities, but all throughout his illness we just utilized a positive approach and this worked.

He was well taken care of with compassionate care. Every available assistance was provided to him as far as pain management and end of life care and this was a much, much better positive approach for all of us in the family.

REP. JOHNSON: Thank you so much for sharing your story with us. Does anybody have any questions? Thank you so much. Much appreciated.

EVA CESTARI: Thank you.

REP. JOHNSON: Mary Pollock, followed by John Pollock, then Thomas Meyer. Are you Thomas Meyer? Please come forward. And then Susan and David Giles. Thank you so much for being here. Please state your name for the record and give us your testimony.

THOMAS MEYER: Madam Chairs and Members of the Committee. My name is Thomas Meyer. I am from Roxbury, Connecticut. I am speaking in support of House Bill 6645 AN ACT CONCERNING COMPASSIONATE AID IN DYING FOR THE TERMINALLY ILL.

Had this bill been law six years ago there's a good chance I would not be living with the stigma and hardship of being a convicted felon.

On an August afternoon in 2006 I received an unexpected call from the nursing home where my 97-year-old mother, a long-time member and part-time activist in the Hemlock Society was trying to recover from a bad fall.

When I entered her room, the first words she said were, I'm having difficulty breathing, I'm suffering and I want to go home right now. Those words triggered memories of the many conversations we as a family had had over the years concerning her death and what she perceived as her right to self determination.

She had made it clear that when she knew the end was near, she did not want to be lying in bed under heavy medication waiting for organ failure. What is the point, she would say? There is no quality of life in living like that.

She worked hard to enact physician aid in dying legislation in the 1990s. When the vote failed, she was left with no recourse other than the how-to method of the day, that recommended in Derek Humphrey's Final Exit.

So it was easy to understand when my mother uttered the word suffering, I knew the situation was very serious. I might very well be losing mom today. Unbeknownst to me and according to the police affidavit she had disclosed just that intention to a friend that visited her the night before. She had also stopped taking her medication.

The details of the following couple of hours are too involved for me to convey in this short period of time, but suffice it to say, I would subsequently face a choice, either be faithful to my mother, or obey the law.

In actuality, there was no decision. She was so helpless and weak I couldn't leave her alone to fumble away and suffer through the night if she failed. Mom meant the world to me. I helped her, as I always did every day when I visited her at dinner.

As hard as that was, this was her wish. I had to respect it. The following morning I contacted the authorities and make a complete confession.

At the time and to this day, I know in my heart I did the right thing. We handled the act of dying, one of the most personal family issues as she saw best. In the final analysis, we didn't hurt anyone else. We didn't harm society. There was no public spectacle. She just died peacefully in her own bed on her own terms.

After leading an incredibly long, joyous, fulfilling and productive life, shouldn't she have this liberty? When you reach the point when you know you can go no further, who are others to say how you must die. This bill would go a long way to ensuring that others with terminal conditions had a choice in how their life ends. Thank you very much for this opportunity.

REP. JOHNSON: Thank you for sharing your story and your testimony this evening. Are there any questions? Thank you so much and have a good evening.

THOMAS MEYER: Thank you.

REP. JOHNSON: The next person is, or Susan and David Giles, followed by Laura Borelli. Welcome and please state your name for the record and proceed.

SUSAN GILES: My name is Dr. Susan Giles. Good evening, Madam Chairs and Members of the Public Health Committee. Thank you for your long suffering, and I should say it's just me testifying tonight. My husband is not here.

REP. JOHNSON: Okay, you were signed in together.

SUSAN GILES: We weren't sure, we were a tag team. One or the other would be here, as we had home responsibilities. I'm a physician. I'm a board certified internist and rheumatologist and a geriatrician, and I am here to request you to vote no to HB 6645.

This legislation undermines the ethical foundations of my profession. We physicians have vowed to first do no harm. We are simply not in the business of killing our patients.

Were we to assist in doing so, even in the rarest or the most dire of circumstances, we would undermine the concept of trust, which is fundamental to the doctor/patient relationship.

Our patients would be forced to forever question our motives.

There are other reasons not to legalize physician aided dying. Allow me to enumerate them briefly.

Firstly, it legitimizes suicide and suicide in my mind is never dignified.

It may subtly invite pressure and coercion transforming the right to die into the duty to die.

It may provide subtle financial incentives to third party payers for premature deaths.

It is opposed by the AMA and not part of the hospice philosophy.

It may increase the vulnerability of socially marginalized and disabled groups.

It isn't really needed as it is ethically acceptable to refuse or discontinue futile treatment artificially prolonging life. Currently, it is legal and ethical for physicians caring for terminally ill patients to increase pain meds as necessary, even with the unintended consequences of respiratory depression, a practice common in good palliative care.

Saying no to physician assisted suicide is not about removing a patient's right to die, but rather about removing a doctor's right to kill.

This bill being presented in Connecticut is more lenient than laws in Oregon and Washington and I won't go through those reasons. They have been well discussed.

I also find it disturbing that this bill allows a physician signing the death certificate to write the cause of death as the underlying terminal illness while omitting the suicide.

My reading would suggest that the Oregon records require little documentation for physician assisted suicide and that their Public Health Division destroys source documentation after a year. These details do not engender transparency or truth-telling.

There is no question that the introduction of this bill is a wake-up call for us call, physicians and policy makers alike to improve palliative care for terminally ill patients so that they may experience their lives end with dignity, compassion, autonomy, adequate pain control and without undue expensive prolongation.

Please join me in voting no to HB 6645 and yes to live with integrity for physicians and more importantly, life with dignity for our patients.

REP. JOHNSON: Thank you so much for your testimony. Are there any questions? Yes. Representative Ziobron.

REP. ZIOBRON: Thank you, Madam Chair, and thank you so much for your testimony. I'm intrigued by one of the comments you just made, which was you have shown us that we need to improve palliative care.

So my question to you, ma'am, would be, can you give me two examples of how that care can be improved in your mind to allow the dignity of some of the patients who are advocating for this bill?

SUSAN GILES: Yes. The first that comes to mind is, patients come to a hospital and have a code status, a DNR code status and many times that translates, that do not resuscitate translates into do not treat and I was involved in a lot of medical education, resident education and I would always stress to the residents, a DNR does not equal do not treat.

Rather, it compels you to put all your efforts into palliative care to make sure this patient is indeed comfortable. There's good communication between patient and family, so that would be one example.

The second example I think is just communication, communication, communication. Encourage families to do advanced directives, to have them very explicit, done well ahead of time.

REP. ZIOBRON: Thank you for your testimony. Thank you, Madam Chair.

REP. JOHNSON: Thank you. Any additional questions? Thanks so much. Oh yes, Representative Demicco.

REP. DEMICCO: Thank you, Madam Chair. Just briefly, we've heard a fair amount of testimony this afternoon and this evening from people with regard to pain and suffering that cannot be relieved, and I was just wondering, what would be your answer to that, or your reaction to that?

SUSAN GILES: It's, I think pain at the end of life can be relieved because we have that principle of increasing pain medication with the unintended consequences of, you know, potentially giving respiratory depression, so I think end of life, the very end of life pain can be relieved.

And in my personal experience being present with many, many dying patients is that the end is peaceful. The end is peaceful.

But the near end is not always peaceful and I think it is filled with fear. I think many decisions are based on this fear and it's just a reminder to us as physicians to be present and have good communication with our patients, to, you know, be constantly assessing for pain. You know, we call that an extra vital sign. We used to look at temperature and pulse rate and you know, we talk about pain scales as another vital sign.

It's not a perfect world. There's some pain that's not treatable. Chronic arthritis is very painful, but in my experience with it, I think the diseases, the diseases in which physicians aid in dying may be more prevalent such as the degenerative neurologic diseases like ALS, pain is not always at the top of the list.

And when you look at patients who are requesting physician aid in dying, those patients aren't necessarily concerned. They are more concerned about loss of autonomy and enjoying life and pain isn't always at the top of their list.

REP. DEMICCO: Fair enough. Thank you. Thank you, Madam Chair.

REP. JOHNSON: Thank you. Thank you so much.

SUSAN GILES: Thank you.

REP. JOHNSON: The next person, Laura Borrelli, followed by Eileen Bianchini.

EILEEN BIANCHINI: Good evening.

REP. JOHNSON: When the red light is on, that's when, very good.

EILEEN BIANCHINI: Hi. I'm Eileen Bianchini. I'm the Chairperson of the Connecticut Right to Life and as the Chairperson, we're a statewide organization, so we're very interested in issues like this, not only from an individual patient point of view, but also from the state's point of view.

We want to know what is the impact, what are the dangers, what are the (inaudible) and so (inaudible) physician assisted suicide.

In 2010 Superior Court Judge Julia Aurigemma suggested that when she rejected an opportunity to legalize physician assisted suicide then, she said if it comes up again in the Legislature, we should look at the ramifications again on both levels, on the state level and for patients.

And she made it very clear that her opinion at that time was that it is a crime and it is suicide, no matter what words are used, and so she did suggest that we very carefully take a look at what the unintended consequences could be.

One of the things that I took a look at was suicide and checked out the suicide rate in Oregon, a natural to look at because it's the model for the first place in the United States where physician assisted suicide was passed, so it's good to go back and take a look at it to see well, how did they do there in that state?

At the state level we did find that the suicide rate after they passed the law began to climb and by the time, my numbers are, by the time 2010 came, the rate was 41 percent higher than the national average.

Somebody else earlier today said it's gone up higher than that.

Also, what was not mentioned today is with regard to teens, aged 15 to 24, that the normal, the national suicide rate, or the national second leading cause of death of the young people is suicide and on a national level it's the third cause of death, leading cause of death. In Oregon, however, it's the second leading cause of death.

So, we also took at look at why people ask for suicide and what we found is what has been mentioned before, that it's loss of autonomy, decreasing ability to participate in activities that are enjoyable, loss of dignity and a feeling of being a burden.

Yet, in spite of this, these patients are not automatically and as a practice referred to psychological help. So for example, in 2009 to 2012, in 2009 none of the 59 patients who died from physician assisted suicide were referred for help.

Now, I'm getting this out of the Oregon Annual Report, and in my attachment to my testimony, there's a link to those reports. You can take a look at this yourself, so anything that I say here can be verified.

These facts are real facts and in 2010 only one of 65 patients were referred. In 2011 only one of 71 patients were referred. In 2012, two of 77 were referred. That's not a very good record. What's going on here?

REP. JOHNSON: Could you please summarize. Apparently, our buzzer is broken, so.

EILEEN BIANCHINI: All right. We also found that four years after the law was passed in Oregon that the referrals to palliative care decreased.

In checking with doctors, leading doctors like oncologists who deal with people who are dying and terminal on a daily basis in a position paper that represented 600 of them, they say a prognosis of six months can be wrong more often than trite.

If you check with the National Cancer Institute, they explain why. They say there's so many variables. There's the kind of cancer, the location of the cancer, whether the patient has other illnesses, et cetera.

And of course in looking at Oregon again, we have a number of case histories where the prognosis was wrong. There's Maryann Clayton, there's Janet Hall and here in Massachusetts thee was Senator Edward Kennedy, and Senator Edward Kennedy's wife said, she was really made. Her husband was given only a couple of months to live and then lived 15 months. She said, thank God we didn't go the way of assisted suicide, and she said here's the truth.

The language of the proposed law is not about bringing families together to make end of life --

REP. JOHNSON: Excuse me. I asked you to summarize. It would be very good of you because lots of other people are waiting and they're going to be here longer than you are.

EILEEN BIANCHINI: Okay. And what she recommended is that we extend or we expand palliative care and in concluding, that's what I'm recommending.

I'm saying that if there are cases of abuses and in Oregon and other states or in the world or other places in the world, why don't we continue to do what we've been doing right along, find and expand palliative care and hospice?

REP. JOHNSON: Thank you so much. Are there any questions? Thank you so much for being here this evening. Much appreciated. Peter Wolfgang, followed by John Lysaught, and then Dr. Thomas F inn.

PETER WOLFGANG: Chairperson Johnson, Members of the Committee, my name is Peter Wolfgang. I'm the President of Family Institute of Connecticut Action here to testify against 6645. You have my written testimony. It's late. I'm going to summarize some key points from the day.

You heard testimony today that this bill requires only one doctor, not two, to certify that the person can take their life. Recall the testimony, recall Representative Sayers asking Representative Ritter about doctor shopping. Recall that there was testimony about there being no waiting period. Notice the conflict between Senator Meyer's testimony and Representative Ritter's.

Senator Meyer seemed to understand that there were significant problems with this bill, which he supported and that even he was open to more safeguards. Representative Ritter was against the waiting period, or seemed to be.\

Senator Meyer said he didn't know the drug that takes a life in this bill, but he knew it was 100 percent effective. Meyer quoted the New Haven Register editorial in favor of the bill. In fact, the editorial was against the bill. Quote, even if a second doctor signs off, this is life and death and there's no taking it back. Diagnosis of terminal illness itself has been made in error before. The Legislature should seek the counsel of hospice care givers, and you heard from the hospice care givers today.

You heard the Association say that Connecticut ranks last in the length of hospice stays and this indicates (inaudible) stays, referrals, and that that is the thing that should be addressed instead.

You heard concerns about competence, Senator Welch saying, what does it mean to be competent? Senator Kane saying, shouldn't we determine that a person is of sound mind? We're talking about killing yourself.

You heard Representative, you heard Dr. Blick say that Judge Aurigemma in the Blick decision said that the Legislature should consider whether or not to legalize assisted suicide. She had some very specific things in the Blick decision that she instructed the Legislature to consider, and I'm quoting from her Blick decision. This is what the Legislature should consider according to Judge Aurigemma, whether a physician assisted suicide threatens the most vulnerable in society, including the poor, the elderly, and the disabled, who are at risk of being threatened, coerced or influenced to end their lives to spare their families the financial cost and emotional strain of caring for them and if so, who best to protect vulnerable individuals from undue influence, pressure or coercion.

Whether physician assisted suicide shifts the focus of physicians and insurers away from vitally important measures such as identifying and treating depression and providing end of life pain control and palliative care, and if so, how best to ensure that all appropriate treatment and care options are considered and made available to patients who may be considering suicide.

Whether physician assisted suicide undermines the physician/patient relationship and the integrity of the medical profession by eroding patient trust in the doctor's role as healer, and if so, how best to avoid or limit such harms, and whether physician assisted suicide opens the door to the possibility of involuntary euthanasia as has occurred in the Netherlands because, and here she's quoting the U.S. Supreme Court, Washington v. (inaudible) case.

Quote, because what is couched as a limited right to physician assisted suicide is likely in effect, a much broader license, which could prove extremely difficult to police and contain. Unquote.

Judge Aurigemma quotes a Connecticut citizen the last time there was a public hearing on this.

Is assisted suicide the kind of choice, assuming it can be made in a fixed and rational manner, that we wish to offer a gravely ill person. Will we not sweep up in the process, some who are not really tired of life but think others are tired of them, some who do not really want to die but feel that they should not live on because to do so when there exists a legal alternative is a selfish and cowardly act.

Will not some feel an obligation to have themselves eliminated in order --

A VOICE: (Inaudible).

REP. JOHNSON: Yes, this is the timer.

PETER WOLFGANG: Okay.

REP. JOHNSON: And I timed it exactly by my computer and my phone. So thank you so much. Please summarize.

PETER WOLFGANA: Well, there's just one sentence left. Eliminated in order that the funds allocated for their illness might be better used by their families or financial worries aside, in order to relieve the families of the emotional strain involved.

I mean, in summary, there is no amendment that would make this a good bill. This is a bad bill because it's about the taking of human life and unless it's an amendment to prevent the taking of human life, this is a bill that should be defeated. Thank you.

REP. JOHNSON: Thank you. Are there any questions? Thank you so much for being here and taking the time to be with us this evening. Dr. Thomas Finn, followed by Linda Campanella and then Theresa Wells. Good evening and please state your name for the record.

THOMAS FINN: Good evening. My name is Dr. Thomas Finn. Again, good evening, Madam Chair and Members of the Committee. I admire your stamina for sure.

I am a licensed psychologist from Southington with over 30 years of clinical experience, and I think certainly we'd all agree, especially from the stories we've heard, that terminal illness is clearly a difficult road, and although I have personally walked this road with both my parents, good friends and clients who have died after long struggles with terminal illnesses, I do not believe this bill will benefit the citizens of Connecticut.

My primary objection to this bill centers on the concept of "the qualified patient". The bill defines a qualified patient as one who voluntarily seeks his or her own death and confidently makes informed decisions about this choice and his or her life.

In reality, accurately identifying someone terminally ill as a qualified patient may be extremely difficult. Suicide ideation and behavior are recognized as symptoms of depression and have been associated with levels of psychological distress in terminally ill patients that impair their decision-making abilities.

Clinically there is a negative triad in a patient's thinking style, made up of depressive use of one's self of their present circumstances and of their future.

A person's capacity to competently assess his or her medical situation can be distorted by such a cognitive depressive states. These cognitive distortions increase feelings of helplessness, guilt and worthlessness, leading patients, to patients' misperceptions that their life is meaningless.

The hopelessness experience by these patients often distorts their understanding of objective information regarding the quality of their remaining days and could limit their ability to perceive benefit from hospice and palliative care.

Compounding these individual challenges to sound judgment are the high prevalence of depressive symptoms in patients with terminal illness, the frequency with which depressive symptoms are not identified by their general practitioners and the low rate of psychiatric evaluations historically performed on persons seeking physician assisted suicide.

In addition, the highly questionable practice of competence determinations and lethal dosing being provided by the same physician is also of grave concern.

In summary, the root meaning, we heard before of the word compassion, meant to suffer with. But the root meaning of the word suffer means to bear, and a terminally ill's person desire to die should be viewed as a request for help in bearing the grief and fear that they're experiencing and we should work toward the compassionate provision of services that target effective pain management along with emotional and social support.

Please oppose Bill 6645 and physician assisted suicide, and I thank you for your time.

REP. JOHNSON: Thank you so much for your testimony and my apologies for my trying to figure out --

THOMAS FINN: Sounds like my kids at home.

REP. JOHNSON: Thank you. Are there any questions? Thank you so much. I'm not going to try to set my alarm any more. Okay. Linda Campanella, Theresa Wells and Nina Garrett. Welcome, and please state your name for the record.

LINDA CAMPANELLA: Thank you. My name is Linda Campanella. I'm a resident of West Hartford and I'm author of a memoir, Chronicle in a Joy Filled Year between my terminally ill mother's diagnosis and her death and I'm author of an op ed in the Hartford Courant in January entitled Compassionate Care, Key for Dying Patients, that caught a Legislator's eye and she suggested that I come to testify, so I'm here tonight to draw attention to compassionate end of life alternatives that is already and readily available for the dying.

I'm here as a passionate advocate for hospice care, the core purpose of which is to help terminally ill patients to live their remaining days or weeks and months with joy and dignity and without physical or emotional suffering.

I'm also here as a daughter, a daughter who felt enormous gratitude, not guilt or regret, when her mother took her last breath. My terminally ill mother wanted to live, love and laugh until her last day on earth, so my father, my siblings and I committed ourselves to doing everything we could to help her live fully and joyfully.

Nine months after her diagnosis and following both chemotherapy for her lung cancer and radiation therapy for the multiplying tumors in her brain, my mother's disease had reached a point where her physician thought it made sense for us to move to hospice care, which meant among other things, stopping further treatments to extend her life.

Hospice wasn't recommended as a way to hasten death. It was recommended as a way to live life and we welcomed this.

In July, 2009, hospice joined us on our quest for joyful living and peaceful dying. I'm here today to tell you that the hospice helped my mother and the loved ones who were caring for her, achieved what we hoped for and so much more.

I do not mean to suggest that I believe hospice is or should be the best alternative for every patient or every family. However, I suspect that a relatively large percentage of those who advocate in favor of assisted suicide as the compassionate end of life option have not hear of hospice or do not understand what it is.

Many are in favor of assisted suicide as an option because they're afraid of suffering, either their own or a loved one's, or because they want to spare their family members the anguish that comes with watching someone we love suffer.

Perhaps hearing stories like mine will help these assisted suicide proponents understand that hospice relieves pain and suffering for the patients and at the same time it wraps the despairing family in a blanket of support that makes the unbearable bearable for them, too.

My terminally ill mother died at home at peace, with dignity and without pain, physical or emotional. For three months, the hospice team that included a nurse who stayed in regular contact with my mother's primary care physician, a spiritual counselor, a social worker, a bereavement counselor and a special group of volunteers surrounded her and her family with love and support.

Reassurances that my mother's pain would be kept under control assuaged one of her biggest fears and ours. Arguably, even more important than hospice's promises about pain management, though, is the fact that hospice providers understand suffering is not just the physical phenomenon caused by symptoms of disease and pain. Suffering is also caused by the existential distress one feels when experiencing anxiety, fear, loss of hope, loss of dignity, loss of control.

Our hospice team lovingly addressed my mother's emotional pain, which was much more intense than her physical suffering.

So to conclude, I would say that I believe too few people understand what hospice is and too many believe it is something it isn't. At the same time, I understand that people will and should follow their conscience when making life and death decisions. It's not my desire to render opinions about one option being right and another being wrong. I'm not here to judge.

I'm here ultimately because I hope more people will ask for hospice or welcome it when it's suggested, understanding that hospice is as focused on ensuring quality of life during the final weeks, months and days as it is on ensuring death with dignity and without pain when the end finally comes and when it's that time, hospice represents assisted dying, not assisted suicide.

Finally, there arguably is no more compelling example of compassionate care in our health care system today than hospice. I hope more daughters, sons, husband, wives and parents will feel the sense of profound gratitude I experienced in the midst of my grief, gratitude for the gift of hospice and gratitude that we had given mom a good death. She was at peace and so were we.

REP. JOHNSON: Thank you so much for sharing your story with us this evening. It's much appreciated. Are there any questions? Thank you so much and have a good evening.

The next person on the list is Theresa Wells, followed by Nina Garrett and then Lorraine ZuWallack.

A VOICE: Lorraine ZuWallack is here.

REP. JOHNSON: Please come forward, Lorraine. It's like Theresa will have to follow you, if that's okay. Okay, you're not Theresa? Thank you so much. Please state your name for the record.

LORRAINE ZUWALLACK: My name is Lorraine ZuWallack. I am a registered nurse and I'm testifying in opposition to Bill 6645.

I am a registered nurse and my nursing specialty certification was for hospice nursing. I worked as a home hospice nurse for a large home care agency for ten years. Our program cared for hundreds of patients and in that entire span of time, not one patient ever asked to hasten his or her death, not one. The subject was never raised.

Each patient was discussed at our weekly hospice team meetings and had this been an issue, it would have come up and it never die. And the reason it never did was that we afforded our patients excellent end of life care.

We addressed their spiritual, psychological, social and especially symptom control issues and we made it our mission to provide excellent pain control to optimize their quality of life.

Most of our patients were on narcotics for pain control and many had in their possession enough narcotics to end their lives if they had wished to do so. None ever tried.

Taking an overdose is the opposite of death with dignity. Hospice care does afford death with dignity. It neither hastens nor hinders death and is the compassionate answer to end of life care.

Suicide is not even remotely in the realm of medical care and I would caution the Legislature against being fooled that it is.

I would also like to point out the wording in Section 8, line 12b in this bill stating, this shall not constitute suicide.

This is suicide. Calling it anything else is sugar-coated language. It doesn't change the fact that it's suicide and by the way, it violates the first medical ethics law primum nono cure, first do no harm. I can think of nothing more harmful than killing somebody.

And by the way, the National Hospice Association of this United States, National Hospice and Palliative Care organization's physician's statement, which I did not add to my thing that I e-mailed you but I do have here states that they are against physician assisted suicide.

This bill has a provision stating the positioning patient has informed of the action for palliative care, but who will explain it? How well will they understand it? And if they have a six-month prognosis, they should be receiving palliative care. If they're not, it's a failure of the medical system.

The other reality is that some patients far outlive their terminal diagnosis, but if they commit suicide, they have no chance to outlive their terminal diagnosis.

Finally, before I was a hospice nurse I was an acute care nurse and worked in the intensive care unit at St. Francis Hospital and I cared for patients who had taken overdoses and I can tell you from firsthand experience that an overdose is in no way dignified.

Having cared for both overdose patients and hospice patients, I will say that there is no question in my mind that this legislation would do nothing to enhance end of life care in our state and instead will hinder it and we can do better than this for our dying citizens. Thank you.

REP. JOHNSON: Thank you so much. Are there any questions? Thank you for staying here to provide the testimony. The next person on the list is Ted Tumicki, followed by Sara Coors and then Matt Bennett.

A VOICE: (Inaudible.)

REP. JOHNSON: Oh, yes. I thought you said you weren't, you're not Theresa Wells.

NINA GARRETT: Madam Chair and Members of the Committee. It has indeed been a very long day and I'm so grateful to all of you (inaudible) testimony.

My name is Nina Garrett. I live in Old Saybrook, Connecticut, and support Bill 6645.

My father died of Alzheimer's disease. Before his mind went, he suffered huge psychological distress at the progress of his illness, and I know from his own words earlier in his life, that he would certainly have chosen to hasten his death by any means available to him. None was.

My younger brother died four years ago from ALS and though he felt little pain, his suffering was inconceivably terribly, and it lasted five years. Palliative care could do nothing to ease it. He was on hospice care and we appreciated hospice immensely.

I know from firsthand experience how good hospice care is, but in the case of ALS, it was pretty useless. He longed to end his life sooner on his own terms, not waiting to suffocate over the period of a very long week.

Certainly, we need to improve end of life care, but we are not faced here with an either or choice. We must have the best possible end of life care and in addition, we must have the right to choose to avoid pointless suffering at our end, i.e., we must have a strong compassionate aid in dying law.

I've completed my own advanced directive, my end of life wishes and I've discussed them with my family, who has accepted them, in the hope of easing my suffering in such a situation.

But without this law, I and my family may be able to carry out my wishes no matter how carefully and how responsibly written. My elected Representatives should support me in making decisions about my own life.

A huge amount of data confirms that laws such as the one this bill proposes do not, in fact, lead to the abuses, the scary places that its opponents suggest and the bill's provisions guard against any such abuses.

I have the utmost respect for those of the disability community who fear the limitation of their choices, their autonomy. They insist, quite rightly, that individuals have the right to choose their level of care and support basing their choice entirely on their quality of life.

This bill explicitly provides safeguards for their right to choose, and I must beg for, indeed, I must insist that I have that right for myself as well, if I face a prolonged and miserable end.

The right to decide when one's own end of life suffering should be cut short is a basic, civil right. I respect those whose religious beliefs prohibit their act of asking to shorten their own life when they have a terminal illness. But freedom of religion is one of the basic principles on which this country is founded and it gives me the right to follow my own beliefs and principles in this matter.

No one has the right to impose their religious beliefs and principles on me or to impose needless suffering on the end of my life.

REP. JOHNSON: Could you summarize, please.

NINA GARRETT: Two more sentences. I defy anyone to tell me that I have to accept his or her sense of my spiritual or existential needs. I've heard a lot about communication here, but that doesn't seem to include very much listening to my concerns.

I urge Connecticut lawmakers to enact this bill and thus to support one of our most sacred and fundamental freedoms. Thank you.

REP. JOHNSON: Thank you. Thank you so much for your testimony. Are there any questions? Yes, Representative Ziobron.

REP. ZIOBRON: Thank you, Madam Chair. Thank you so much for your testimony at 10:39, oh, 11:00. I'm starting to get cross-eyed.

NINA GARRETT: I've only been here 14 hours.

REP. ZIOBRON: And you delivered it with a little bit of spunk and I always like to see that.

But you know, you kept talking about safeguards and I would submit to you that this, the Connecticut proposal is not as safeguarded, one would say, as the Oregon proposal, specifically in the waiting period.

So I would ask you, do you believe that one day waiting period or the same day waiting period has any benefit compared to a 15-day waiting period and would that make a difference to you? That's one of the considerations I'm thinking about.

NINA GARRETT: I understand that, but in fact, I think it's very much a matter of individual cases. We've heard a lot about the problem of time limitation and I'm thinking not so much whether the time of somebody's death is going to sort of eclipse the waiting period, but rather whether the window of opportunity of self-administration of the drug can be curtailed by having to wait.

That is, there is a period, there certainly was in my brother's life, for example, a period during which he was capable of self-ingesting, of ingesting a medication to die if it had been available to him, which it was not, but there was a period after which he was no longer capable of it, even though he still wished it very, very strongly.

So judging by individual cases seems to me to be much fairer than legislating a specific waiting period.

REP. ZIOBRON: Thank you for your response. Thank you, Madam Chair.

REP. JOHNSON: Thank you.

NINA GARRETT: Thank you, all.

REP. JOHNSON: Thank you so much. Have a good evening. Next person on the list, is Theresa Wells here? Okay, she must have gone. Then the next, Ted Tumicki. Welcome. Please state your name for the record.

TED TUMICKI: Good evening. I am Father Ted Tumicki. I am a moral theologian, a canon lawyer and the pastor of three Catholic parishes in Griswold, Preston and Voluntown, and I presently live in the Borough of Jewett City and I am representing myself.

I am speaking against House Bill 6645, the so-called ACT CONCERNING COMPASSIONATE AID IN DYING FOR TERMINALLY ILL PATIENTS. I say so-called because what is being described in the bill, namely the taking of one's own life with the assistance of at least one other person is assisted suicide.

Why the bill is not accurate and truthful in terminology is a good question. Is it because compassionate aid in dying sounds better than physician assisted suicide and stands a better chance of being passed into law?

If physician assisted suicide is so good for society, then why not be honest in the terminology and the analogy of stabbing versus surgery falls apart.

Another part is that there is no timeline for when the qualified patient is supposed to ingest medication. The patient simply receives the lethal medication and then nothing may happen.

But what happens if the patient dies before taking the medication and a young grandchild or niece or nephew finds the medication and ingests it? Who is going to ensure that such a young child is informed of how to dispose of such a medication in accordance with the law, and how is such informing supposed to happen if the patient chose not to tell anyone that he or she was going to commit suicide and the existing medication is unknown or its discovery comes as a complete surprise?

What happens if the qualified patient takes the medication and it does not work as he or she intends it to? Can the patient sue for malpractice? Can the patient sue their doctor for wrongful life or wrongful living? Will the legal landscape now include lawsuits for both wrongful death and wrongful life? How is that upholding public health?

One very disturbing aspect of this bill is the prescribed manner in which qualified patients must die in order to enjoy the safety of the proposed law.

I had an uncle who was diagnosed with cancer. He said when it got to a terminal stage he would simply put a bullet through his head. He said it very rationally and he was legally competent to make decisions. If he carried out his plan under this proposed law, his process would be illegal.

If he wanted to commit suicide legally, he would have had to follow the process of death by suicide described and prescribed in your proposed legislation.

Is it the role of the Public Health Committee to dictate how a person must die in order to enjoy the favor of the law? Are you comfortable in your role as Legislators dictating to suicide-seeking law abiding citizens the manner in which they must commit suicide in order to enjoy your favor of granting lawfulness?

Is it the role of government to hasten the death and demise of its law-abiding citizens? I answer no. I hope you answer the same. Please vote against this bill.

REP. JOHNSON: Thank you so much for your well-timed testimony. It's much appreciated.

TED TUMICKI: I practiced.

REP. JOHNSON: Very nice. Very nice. Are there any questions? Thank you so much for taking the time to be here with us this evening. Okay. Next person on the list is Dr. Sara Coors, then Matt Bennett and then Robert (inaudible). I don't see anybody coming forward, so we'll continue on. Katherine Wushing, James Farrell, Peter Black. Are you James Farrell? Oh, welcome, please come and sit down.

JAMES FARRELL: I think if you're sleepy, maybe if you guys could be allowed to play poker on line or (inaudible) checkers, it might keep you awake. It does wonders to me.

REP. JOHNSON: Glad to have you here today, and please state your name for the record and proceed with your testimony.

JAMES FARRELL: I'm James Farrell from Meriden and I'm opposed to this measure of assisted suicide and you know, the right to live is an inalienable right.

We had intolerable cruelty from King George when we became a republic. We had the right to rebel, and a (inaudible) rebellion, well that's for a less reason, so that led to a Constitutional Convention and a Bill of Rights.

So it being an inseparable right, inalienable, a suicidal person gets arrested for trying, you know. And there's danger of abuse by neglect as the law gives opportunities for additional abuse, I'll read here, abuse to elders.

What about insurance companies? Now, how are they going to cover these so-called natural deaths? Okay? That can bankrupt them. There goes the economy. A beneficiary, he can be the witness to the patient's request for suicide. Probably help with it, too, help the patient sign up for suicide, help the patient shop for a doctor, a little doctor shopping there. He might even speak for the patient, help him decide, or even tell people that he already did (inaudible).

And then there's no requirement that a distanced witness be present when the patient ingests the lethal dose if he even knows it's a lethal dose. What if he's told it's oatmeal, although it wouldn't taste like oatmeal, would it? But, you know, there might be some way of doctoring it up, so it's open to abuse.

How do we know the patient even consented? A matter of fact, this Margaret Doe, whoever that is, a right to rescind a request for the lethal dose at any time is not the same thing as a right to consent when the lethal dose is administered. Do you really want to die? Yeah, okay, you know.

So I think that we should kill the bill, you know, table it. That's my recommendation.

REP. JOHNSON: Thank you so much for your testimony. It's very much appreciate.

JAMES FARRELL: You're welcome.

REP. JOHNSON: And are there any questions?

JAMES FARRELL: Good. I'm off the hook. I can tiptoe out the door.

REP. JOHNSON: Thank you for taking the time to be with us this evening. Is Peter Black here? Very good.

PETER BLACK: Thank you, Madam Chair, Members of the Committee. Peter Black from Branford, Connecticut. I'm here to testify in favor of this bill, really on behalf of my sister who passed away in 2008. She was diagnosed with breast cancer a few years prior. She received a lot of painful treatment. She thought she was cured in April of 2008. She was informed that there was some cancer left in her body.

The truth is, what doesn't get killed the first time is very hard to kill. She did resume some chemotherapy but it was ripping right through her body, dissolving her bones and she chose home hospice care. Her desire was to die at home.

I delayed my own deployment to Iraq to spend the last time with her and the night before I had to fly out, actually she was lingering on quite a bit. Dr. Blick mentioned people dying in their feces. She lost control of her bowels. She again was wracked by pain. She was receiving morphine. It was not effective. Perhaps the home hospice care program that she had wasn't the best one, but at that point, you can't find a different program.

She, the night before I left I heard her asking her husband for assistance. She was under the impression that the hospice people would have left drugs that they would be able to up and ease her out of life with dignity.

The next morning she asked me very directly for assistance and frankly, if I had the medical knowledge to do it, I would have given her what she needed. I cried for the first time really since I was 12 because the one thing that I could do for her, there was no way to make her any better and the morphine wasn't taking away her pain.

She'd already said her goodbyes to everyone. That's actually one of the good things about cancer is, unlike say a heart attack that you get to put your affairs in order. She had said goodbye to all her family. My brother had flown out the day before and I was leaving that day. She said goodbye to her grandchildren. She knew she had a good life and she lingered on in agony for three more weeks.

So you know, there have been some people here, well hospice is good or the morphine works. It doesn't always work, you know. Somebody from hospice said, well, most of the time it works.

My sister made a very clear request to myself and previously to her husband, my brother-in-law and you know, she was very competent. She was still able at that point to have administered the drug herself. Later on, she wouldn't have been.

As far as a waiting period, you'd have to work it with sometimes a diagnosis would preclude that, that somebody might become incapable of administering the drug within a waiting period if that waiting period's too long.

If you have a long waiting period then people will probably ask for the drugs just in case as a safety valve and you'll have more people that won't use them.

So you know, I don't know where to strike the balance, but you know, if you're, a 30-day waiting period might make sense if you had six months to live, but if you get diagnosed with 30 or 60 days to live, it may not make sense.

REP. JOHNSON: Thank you so much.

PETER BLACK: Thank you.

REP. JOHNSON: You can make a summary.

PETER BLACK: Yeah. My summary is just that as far as the doctor's trust, I feel a doctor should care for people and sometimes easing people out is the only way and this bill doesn't impose other's moral values on anyone else. It's an option and it should be available for those who need it and I think it has sufficient safeguards. If you want to throw in a few more, I don't care. Thank you very much.

REP. JOHNSON: Thank you so much and thank you for sharing your story with us. Are there any questions? Thank you. Have a good evening, sir.

PETER BLACK: Thank you.

REP. JOHNSON: Okay, the next one, is Amanda Lucaster, followed by Herbert Ross and Meg McDerman. Okay. Herbert Ross? Thomas Meehan? Joan Cavanaugh. Good evening and please state your name for the record and proceed.

JOAN CAVANAUGH: My name is Joan Cavanaugh and I'm here to strongly oppose this bill. This testimony, and you have it on line, and it's offered in the memory of my mother, February 22, 1922-May 23, 2012, Catherine Cavanaugh.

My summary is that this bill is a wolf in sheep's clothing. I can recognize its terrifying implications because of my own personal experience with the health care system.

Couched in terms of compassion and choice, the outcomes of this bill and the mentality behind it will be anything but compassionate and for most of us, they will not be about choice. This bill cannot be tweaked or improved to be made safe or unthreatening to those of us who are physically, mentally and/or emotionally vulnerable, and as you consider this bill, I ask each and every one of you to remember that if not today, some day all of us will be physically, mentally and/or emotionally vulnerable.

This is a very painful discussion to have. I know that there are a lot of people who are compassionately supporting this bill for reasons that they believe to be compassionate.

What those advocates fail to realize and to recognize, possibly because so many of them come from places of relative physical and social advantage, and I've heard them today, with all of the health care privileges that that implies, and that there is a malevolent agenda behind this bill.

This is an agenda that has snaked, and I want to tell you I've experienced it personally, and if you read my testimony you will see how I experienced harassment, intimidation and attempts to get me, to terminate my mother's care against her wishes and mine for many, many years, escalating through the end of her life.

I had, and you can read the testimony. I'm not going to go into the whole thing right now but it was a terrifying experience, and fortunately I had support of some good doctors.

Many of those people were no doubt convinced of their moral right. It's the people who were approaching me from every angle to terminate her care, but they were perhaps unaware or they may have been conditioned to accept terms of a debate that were imposed for many less altruistic reasons from where they came from.

Again, you can read my testimony about this whole situation. It goes on for four pages. I'm not going to go into that now, but I do want to say, I do want to summarize with the last things that I say here.

If we lived in a society where the, with a health care system that was geared human needs, not profit, which we do not. And that's one of my big objections to this bill. You cannot introduce a bill like this in a society which, where the entire agenda is becoming toward medical cost cutting. It is an incredibly dangerous mix. It's leading us down a slope that we don't want to go. It's making, and believe me I saw it.

My mother's life was considered expendable and I had to fight for every breath that she took for a very long time, and I am a progressive person. I support reproductive freedom. I support all the rights that we're talking about here. So I don't take this position lightly.

I implore you. Passage of this bill will do nothing to improve health care. It will do nothing to offer equal access to quality health care to the most vulnerable among us. It will do nothing to provide physical or emotional support to any of us as we face our inevitable mortality.

It will merely take us further down a path that compromises our humanity and makes us all justifiably fearful of our health care providers and I learned to fear many of my mother's health care providers. I lived with her in the hospital and I learned to fear them because of their agenda.

My mother was 91 years old. She was a Medicaid patient, Title 19, had dementia. Her life was considered expendable to many of these people. Trust me. I was there.

The only true beneficiaries of this bill will be those who already profit from the inequitable health care system in the first place.

I ask you, stop this bill right here, end it here, and turn your attention to these other fundamental issues whose resolution could truly relieve much suffering.

REP. JOHNSON: Thank you so much for your testimony. Are there any questions? Thank you so much. Arlene Cavanaugh? Claude Holcomb? Elaine Kolb? Okay. Pam Lucashu.

PAM LUCASHU: Good evening.

REP. JOHNSON: Hi. Good evening. Welcome.

PAM LUCASHU: Thank you for staying up with me. Perhaps I should, if I wait just a minute more, I can say good morning.

Okay. My name is Pam Lucashu. I'm from Durham, Connecticut and I want to thank Senator Gerratana and Representative Johnson and the rest of the Public Health Committee for hearing my testimony.

I am here in opposition to House Bill 6645. I ask you to vote against this bill, which lacks compassion in seeking physician assisted suicide in Connecticut.

The history available where physician assisted suicide exists demonstrates that the majority of those seeking it do so because of concerns about quality of life issues, not pain.

The bill is not about providing choice. Palliative and hospice care offer choices to the terminally ill but help to maintain dignity and quality of life.

Where PAS exists, doctor shopping and undue influence have occurred.

Physician assisted suicide opens the door to euthanasia and creates a duty to die.

Evidence of the duty to die mentality is present in the cases of Barbara Wagner and Randy Stroup. Barbara and Randy, both on Medicaid in Oregon received letters from the insurance company telling them their insurance would not cover their treatment but would pay for assisted suicide. I cannot imagine a more callous way of being told I am not worth of life.

I volunteered as a hospice worker. I've spoken to patients and families who were grateful for hospice and palliative care, which provided dignity and pain management for the dying.

Many people who have not experienced hospice care and are fearful of the end of life are relieved to learn about the many ways that pain can be alleviated and life celebrated.

Medication is available not only for pain management, but also anxiety and depression, along with referrals for counseling. The dying were able to get past the depression, resolve issues in their lives and spend quality time with their loved ones before death.

Physician assisted suicide would deprive them of the positive closure that is available to hospice and palliative care.

I won't address the differences between this bill and Oregon and the safeguards that you've discussed so far. I am going to conclude in just a minute because I know you're going to ask me to wrap up.

I don't think that there are any safeguards that are sufficient to preserve the public policy that exists that does recognize the value that we place on life.

I've heard a couple of people testify today in support of this bill and they used the word alone. We want to be left alone. We want to make our decision alone. But the public policy exists so far today, that recognizes we are not alone. We do not make our decisions alone. We live in relationships. We live in community, and you work as Legislators recognizing that we are working together to create a community that is respectful of one another.

So I urge you to vote against this bill and to do anything that you can to promote the education for increased hospice and palliative care, both for education in the community and education in the medical field. Thank you.

REP. JOHNSON: thank you so much for your testimony this evening, and you did make it to the next day.

PAM LUCASHU: Thank you very much. And I knew that Amanda wasn't here because Amanda is my daughter-in-law. She's a medical student and she's on her way to a conference.

REP. JOHNSON: Oh, very good. Sorry we missed her.

PAM LUCASHU: She submitted testimony in opposition to the bill as well.

REP. JOHNSON: Very good. Thank you so much. Any questions? Thank you. Thank you so much.

PAM LUCASHU: Thank you.

REP. JOHNSON: The next person on the list is Phyllis Ross, followed by Moe Provencher and then Bill O'Brien. That's Phyllis Ross. Moe Provencher.

A VOICE: (Inaudible).

MOE PROVENCHER: I'm Moe Provencher. My credentials are not religious, legal or medical. It's more of that my credentials are I am a lifetime resident of Connecticut and I fully support this bill as I believe you should.

So far I've listened to a lot of testimony today and some of it I find had really no bearing on this, especially if it's religious. All I can think of to say in response to that is, separation of church and state.

As far as some of the other things when we talk about people who have mental or physical disabilities, elderly and they kept saying, well, it's going to affect them.

No. As far as I know, none of those are terminal illnesses. They are not what we're talking about. We're talking about people with terminal illness, not disabilities, not somebody who's in pain, not somebody who's getting older. There's a big difference between that.

As far as the woman who was in a hospice care and said she never experienced anyone who had an adverse reaction to morphine, I applaud her. I'm not in the medical field, but I rolled the dice wrong and had to witness it was my mother. It was a horrible thing and I hope no one here ever has to see that, especially with a loved one. It is very brutal to watch, and it was so bad that the doctor actually gave a card to my father with his cell phone on it if we needed any assistance.

You know a doctor does not give you his personal phone number. That's the kind of thing that we're talking about. It's helping these people, these people that are dying.

These are the people we like to throw around the term, loss of dignity. Let's say what it really is. You're having to now wear diapers because you can't control your bowels. You have to have somebody feed you because you can't do it anymore. You can't bathe yourself. It's sad, but that's really what terminal illness is.

REP. JOHNSON: Thank you so much for your testimony. Please state your name for the record before you go.

MOE PROVENCHER: Oh, Moe Provencher.

REP. JOHNSON: Very good, and are there any questions? Thank you so much for being here this evening. Okay. The next person on the list is Bill O'Brien. Welcome, and please state your name for the record.

BILL O'BRIEN: Thank you, Madam Chairman, Members of the Public Health Committee. My name is Bill O'Brien from Wolcott. I'm President of the Connecticut Right to Life Corporation.

A couple of other members of our group have already spoken about certain problems with the bill.

I want to make it perfectly clear that we are opposed to this bill in principle.

One of the reasons is, first reason is that in ancient times when it was the physician who healed and the sorcerer who killed, the physician and sorcerer were often one and the same person. That changed with after Hippocrates, who lived around 400 B.C. when physicians began to take the oath do no harm.

This bill would take medicine back to the barbarians when doctors were killers. Who would go to a doctor anymore? Who could you trust? Many people already don't trust certain doctors with their own or their relatives' health care.

Secondly, let's remember that those who do not learn from history are condemned to repeat it.

H.B. 6645 assumes that some people who are terminally ill will want to avail themselves of assisted suicide.

Though this bill is written as though this is an option, what the Committee is really doing is taking the first step to create a category of people whose life is determined not worth living. That term was first used in a book, a German book, called in English, Allowing the Destruction of Life Unworthy of Life, written in 1920.

Again, that book is termed, one of the terms in that book is, allowing, again, and this book, or this bill, would allow something, but we all know how that book turned out. It wasn't the Nazis who wrote the next ugly chapters. It was those who thought they could control death, the professors, psychiatrists, physicians, social workers and government officials.

But as we know, in less than 20 years after publication of that book, those in Germany who were considered living lives not worth living included people who were brain damaged, mentally retarded, psychiatrically ill. Then it was people in other categories, those with disabilities. Then it was homosexuals. Then interracial couples, political dissidents and criminals and they didn't stop there. They went to create more categories including non-white, or non-Caucasian peoples, then Romani peoples, then it was the communists and then the Jehovah's Witnesses and then some clergy, and oh yes, did I mention the Jews?

REP. JOHNSON: Excuse me, sir, could you please summarize.

BILL O'BRIEN: Yes. There was a Doctor Leo Alexander. He wrote about, he was in the office of chief counsel of war crimes in Nuremberg. He wrote in 1949 in the England Journal of Medicine, the beginnings were merely a subtle shift in the emphasis and the basic attitude of the physicians.

It started with the acceptance, basic in the euthanasia movement, that there is such a thing as a life not worth living. In 1984 he warned these same lethal attitudes are taking root in the United States.

REP. JOHNSON: Are you almost through?

BILL O'BRIEN: Just a couple more sentences.

REP. JOHNSON: Okay.

BILL O'BRIEN: Dr. Alexander recalling his research in the Nuremburg trials said that barriers against killing are coming down.

So Connecticut Right to Life opposes this bill because even though it seems to be starting simply, if it were for only one category of people as we have seen, there's no reason to believe that two could not lead to genocide. Thank you.

REP. JOHNSON: Thank you. Thank you very much for your testimony. Are there any questions? Thank you for taking the time to be with us. Much appreciated.

BILL O'BRIEN: Thank you.

REP. JOHNSON: The next Bill is Senate Bill 1038 and the first person on the list is David Shapiro, followed by Kathy LaVorgna, and then Brian Lynch and Joseph Treadwell. Good morning and welcome.

KATHLEEN LAVORGNA: Good morning, Madam Chair and Members of the Committee. Thank you for letting me present. My name is Dr. Kathleen Lavorgna. I am a general trauma surgeon, an acute care surgeon and I am here as President of the Connecticut Chapter of the American College of Surgeons. I'm also a former President of the Connecticut State Medical Society, so I'm representing both organizations to speak in support of Senate Bill 1038 AN ACT DEFINING A DEFINITION OF SURGERY.

Twenty-five states in this country have a definition of surgery on their books. Connecticut does not. However, the term surgery is used repeatedly in state statutes in this state, but it's never been officially defined.

How do we allow a person to practice surgery without defining what it is that they are doing? How do we protect patients from any health care provider performing the surgery, if again, we're not defining what it is that they're performing?

As a surgeon, I know that anything that incises or destroys living tissue is a weapon in the wrong hands. I have operated with scissors, scalpels, heated electrical knives, high intensity sound waves, high intensity water jets and lasers. They all cut. They all work very well when used appropriately, and they can all go awry if used by people who have no experience or training in the use of those.

Defining surgery in our state is not a scope of practice issue. It is merely defining a term with accuracy and precision, and that's exactly how surgery should be. Thank you.

REP. JOHNSON: Thank you so much for your testimony this evening. One of the things that was recommended by the Department of Health was that we would refer this for a scope of practice review, but I would suspect that you have a vision for what surgery is already and you've been, you've gone to school and you've been practicing in that area and let me just ask you.

What do you think the definition should be?

KATHLEEN LAVORGNA: Well, we've submitted the definition in the testimony.

REP. JOHNSON: And I don't see your testimony on line here, so that would be part of the reason why.

KATHLEEN LAVORGNA: We submitted this morning.

REP. JOHNSON: Okay.

KATHLEEN LAVORGNA: It's somewhat lengthy and let me just paraphrase it rather than just stating it exactly.

It is exactly that describing the manipulation of human tissue by the various instruments that I talked about not only cutting, piercing, manipulating, using ionizing radiation, manipulating fractures, so it clearly, the definition is clearly defined by both the national organization like the American College of Surgeons and the American Medical Association. The definition is, I think, very inclusive.

Now in terms of scope of practice, if you're asking who can perform according to this, that is also clearly defined by different boards in medicine. That's not something that we as a state I think have to invent.

REP. JOHNSON: But let me just follow quickly because the hour is late, but there are already procedures, codes in existence and would it make sense for us to utilize some of those in terms of how we look at what surgery is and sometimes I have, when I got to the doctor for a particular item and I get the bill back and the explanation says surgery and it was no, to my knowledge, manipulation or cutting or anything like you described, so I just wondered.

Will there be a disparity in our definition of the statutes between what the ICD codes say?

KATHLEEN LAVORGNA: No, I don't believe, what I've read that was submitted, I do not believe there would be any disparity, no.

REP. JOHNSON: Okay. Any questions? Yes, Representative Srinivasan.

REP. SRINIVASAN: Thank you, Madam Chair. Thank you for being here for testimony. Good morning to you.

That indeed, 25 states that you say have the definition, the definition that you're proposing to us, which is as per the AMA and everything else, is that similar to what the other states have in our country?

KATHLEEN LAVORGNA: I believe it is. The most recent one has been Virginia and that's been looked at and that clearly goes along with the American College of Surgeons Recommendations for defining surgery.

I can't speak to the others. I just know that according to the American College of Surgeons website, 25 states do have a definition on their books.

REP. SRINIVASAN: Thank you very much, and I definitely agree with you. This is a definition that we need for our state and is not a scope of practice issue at all, so I'm glad you brought this up for us so that we have also the definition for our own state. Thank you very much. Thank you, Madam Chair.

REP. JOHNSON: Thank you. Any additional questions? Thank you so much. The next person is Brian Lynch, followed by Joseph Treadwell and Dr. Steven Thornquist. How about Dr. Michael Darren or Dineen? I can't really read your writing, sir. Sorry.

DR. MICHAEL DARREN: I flunked scribbling. Most people can. Thank you very much. My name is Dr. Michael Darren. Thank you Representative Johnson and the other Members of the Committee.

I am a thoracic surgeon who has also done vascular and general surgery. I'm from New London. I'm President-Elect of the Connecticut Chapter of the American College of Surgeons, and as I mentioned before, Past President of the Connecticut State Medical Society and been very active in the AMA and in that capacity looked at the definition of surgery.

So on behalf of the 8,000 physicians and physicians in training, we bring this to you as supporting the testimony here on Bill 1038 AN ACT DEFINING SURGERY.

We've had a great deal of number of changes in medicine, implementation of quality, the Affordable Care Act and so forth and I think you're all very familiar with it.

I would say, as previously mentioned, I began surgery almost 30 years ago and it has changed in light years and that's why right now the type of surgery that I do, still taking out a portion of the lung, operating on the chest in various capacities and others, we rarely use a knife. We almost only use that knife to make a small incision and then insert various instruments.

We also have robots. All of those are different types of surgery. We rarely cut with a knife as most people think, a scalpel. We cut with sound waves. We cut with water jets. We cut with electrical currents. We cut with lasers, and as somebody said, you know, you have a laser. It's like a gun. You shoot the laser you can't stop it. All of these are different ways of operating and doing surgery, and that's why the definition of surgery needs to be codified and looked at.

And it's not just sort of a superficial one, but one, which is very detailed, and that's why we have given you that detailed definition, which comes from the American College of Surgeons. It's being endorsed here by the Connecticut Chapter of the American College of Surgeons, which represents virtually almost all of the general surgeons and a good deal of the surgeons here in the State of Connecticut as well as the Connecticut State Medical Society.;

And so we would ask you to support that to go forward.

And I would really like to reiterate that we're not taking anything away from practitioners who are already doing what they're doing. It's not a scope of practice issue. If you're doing it today, you pass this definition of surgery tomorrow, you will still be able to do that tomorrow.

I'd like to stop there and ask if there are any particular questions in regard to this.

REP. JOHNSON: Well, thank you so much for your well-timed testimony. Are there any questions? Yes, Senator Welch.

SENATOR WELCH: Thank you, Madam Chair. So the groups that I think we've the most from are podiatrists, ophthalmologists, who are concerned that this definition might preclude them from doing some of the things that they currently do. I don't know if you'd care to comment on that at all?

MICHAEL DARREN: Those are scope of practice, this is not changing the scope of practice of you're already doing it. That would be covered under that definition.

This is gone to the scope of practice issue as you've mentioned and the majority, I'm not sure I'm familiar with absolutely every single one of the sub-specialties, but they have looked at it and they have agreed.

For example, we had, I had a resident who, I asked him what he was going to do. He said, well, I'm going to be surgeon. I said, do you really want to be a surgeon, you know? That's a very difficult thing. That's like me, I have to get up at 4:00 o'clock in the morning, and he said oh, I'm not going to be that type of surgeon, I'm going to be a radiologist because radiologists do minimally invasive.

I just saw a patient today who had an abdominal aortic aneurism repaired. He went home the next day. It was done minimally invasive.

I did an operation, which took five and a half hours, the patient would be in the hospital almost always for about a week.

Now it's done with a vascular surgeon and a radiologist moving together, so things have changed and it's not going to, we're just simply defining what it is and again, if you are a radiologist who have looked at this and were afraid it would preclude them from doing various things. They've looked at it and as far as I know, they have said no, it doesn't, they're happy with it.

REP. JOHNSON: Thank you. Yes, Representative Zoni.

REP. ZONI: Just one question. Thank you, Madam Chair. I'm looking at the testimony from Dr. Mullen, the Commissioner of Public Health and she said that the American College of Surgeons, Connecticut Chapter, had requested a scope review.

Yet you are testifying today that this does not change the scope of practice. I'm not really sure what scope review means, but you used the word scope, she used the word scope.

MICHAEL DARREN: Yes. In other words, it was, to look at this legislation, I'm not totally with the nuances, but I thought that that was sent to say that, is this a scope of practice issue, okay? And as far as I'm understanding, I don't know that it's gone through every specialty but it does not look as if it's a scope of practice issue.

REP. ZONI: It just looked like you were requesting a scope review, and that's where my concern came in that perhaps you thought the scope of practice needed to be reviewed, and hence, perhaps changed.

MICHAEL DARREN: I think that we were looking for someone else to take a look at it independently.

REP. ZONI: Thank you.

REP. JOHNSON: Thank you. Yes, Representative Srinivasan.

REP. SRINIVASAN: Thank you, Madam Chair. Thank you very much for your testimony. We have the definition, we don't have a definition yet in our state. We have it in statute, obviously.

But if the definition were not to be there, could you just enlighten us as to what are the pitfalls, what are the limitations? Thank you.

MICHAEL DARREN: Well, I'm not exactly sure of what that implies, but it would allow people, what I would say is, something like without a definition of surgery, how would you protect patients from practitioners who were just going outside and doing anything that they wanted to do?

And so, I think that's a, how could you allow someone to do a procedure, really, without defining what that is, and that's the particular issue.

Things have changed, as I mentioned. I don't do the same type of surgery I did 30 years ago. We're doing all of these different types of procedures and we'll continue. That's no criticism of the medical profession. It's the science. It's moving along and we're going to have to take a look at that science and we've got to make the changes that go along with those new ideas, those new types of surgery and the methods that we use.

REP. SRINIVASAN: Thank you for that. And for our own clarification, people, various medical specialties who are doing surgery at this point because of this definition, that will not change what they do. That is what I heard you say and I just want to make sure that nobody's capacity to do surgery in any way is altered because of the definition.

MICHAEL DARREN: Yes, and I think the best, looking at the radiologist. Nobody thinks, we don't call, a radiologist is somebody who normally reads x-rays. We actually don't even have x-rays any more. It's not an x-ray department, it's an imaging department because we just don't do that, and we call them interventional radiologists because they do procedures in type which amount to a type of surgery, and what they're doing now, they will be able to do in the future. And we've asked them and consulted them on that.

REP. SRINIVASAN: Thank you. Thank you very much. Thank you, Madam Chair.

REP. JOHNSON: Thank you. Thank you so much. Thank you for waiting.

MICHAEL DARREN: You're welcome.

REP. JOHNSON: Thank you for your testimony. Let's see, moving on to Senate Bill 1067, Dr. Defelice and then Dr. Goodkind. Welcome.

PATRICK FELICE: Good morning.

REP. JOHNSON: Good morning, sir.

PATRICK FELICE: Dr. Patrick Felice from Bloomfield and I certainly want to thank you all for your endurance and hanging in there with us to hear all these testimonies. We certainly appreciate your efforts.

I'm personally having flashbacks from my surgical residence days as 1:00 o'clock approaches, so we'll move it along.

I'm here today as the President of the Connecticut Society of Plastic and Reconstructive Surgeons and in support of SB 1067.

I'd also like to state that the Connecticut State Medical Society has, with our several discussions, supported my testimony that has been submitted to you.

I would also submit, we will be submitting photographs some of the things I will be describing, a couple examples of patient injuries that I will be referring to.

To quote a recent article in Philly.com, it's becoming a little bit of a wild west out there and the explosion of med spas around the country have led to a variety of injuries and even deaths in these facilities.

We're before you today with the hope of avoiding that outcome in Connecticut.

To be clear, med spas are facilities where surgical and non-surgical procedures are performed. Currently there are no licensure requirements in Connecticut and therefore there's no regulatory oversight by the Department of Health. There's no facility inspections, no infection control requirements or other patient safety and quality care guidelines now in place for us in hospitals, us meaning physicians offices.

Several states have moved to regulate these facilities with Massachusetts requiring licensure as a clinic. In fact, we would like to see these facilities licensed by the Department, that can't be true, licensed by the Department of Public Health, but because of budgetary constraints, we've suggested some requirements be established in this short term to address safety concerns while further licensure requirements are explored.

Understand that currently some med spas, in some med spas, procedures are performed without supervision of a physician and without patients being seen or evaluated by a physician. In fact, some facilities have medical directors who are retired and no longer even practicing.

The bill before you does not fully address the real concerns that currently exist. I attached a copy of language, which we have addressed with the Department of Public Health and believe to be a step in the right direction.

The language adds more specificity to the definition of med spas, broadens the requirements of the medical director and includes an advertising provision similar to what is in place for other specialties.

This is essential so patients can make informed decisions about their health care.

In my own practice, in summary, I've seen patients and I've spoken to several of our colleagues around the state that have seen patients who have treated in facilities where there was no physician oversight and they needed corrective intervention.

These patients present with the regular contours from liposuction procedures, problems associated with lidocain toxicity, from local anesthetic procedures, unnatural features from Botox and cosmetic fillers and scarring from lasers.

The DPH has documented a number of these proceedings filed against designated providers in med spas for inappropriate and illegal actions.

This body addressed concerns over patient safety in the office setting several years ago and required physicians offices that provided certain levels of anesthesia to become licensed as outpatient surgical centers.

A new type of facility, the med spa has been established since that time requiring further regulatory oversight in order to ensure the safety and well being of Connecticut's patients.

I hope you will take this issue seriously and address the safety concerns that exist today before we read about a patient that has succumbed to a treatment in the State of Connecticut. Thank you.

REP. JOHNSON: Thank you so much for your testimony. Are there any questions? Yes. Representative Srinivasan.

REP. SRINIVASAN: Thank you, Madam Chair. Good morning and thank you for your testimony.

PATRICK FELICE: Good morning.

REP. SRINIVASAN: So as we understand now, these medical spas, some of the medical spas may not even have a medical director or an M.D. at the time when patients are seen in these spas?

PATRICK FELICE: Correct. The only requirement right now is that the med spa has a medical director. Oftentimes, we see over and over again that medical director never sees the patients. They're all delegated to other staff members and they're not being seen, and our feeling is that these patients should be at least initially evaluated by a physician and then the duties can be delegated if so desires.

But we have instances of med spas that really kind of took advantage of the loophole that we have from this ambulatory surgery center requirement, and that is moderate sedation. In other words, they feel under local anesthesia, they could do anything.

We're seeing a lot of problems around the state and they're increase in frequency with lidocain toxicity because they don't understand that doing liposuction you infiltrate an area with Novocain, lidocain, you numb the area and then you suction out fat.

Well, that could be considered a local procedure, but not they're extending to do suctioning more than one area, so their support of that is saying, well, we give them time in between. We let them go have some coffee, they sit around. Some of these patients are in their office for eight hours, and what they're failing to realize is that lidocain just keeps increasing in your blood system. It doesn't peak until 12 hours, so even though they're giving them this time in between procedures, it's very dangerous because they're still administering more and more and more.

So there's a lack of understanding of that and several of our emergency rooms have seen patients from these facilities that have presented with lidocain toxicity.

REP. SRINIVASAN: Thank you. And through you, Madam Chair, ideally you would prefer that these medical spas be licensed is what I gather from your testimony, but given the fact that we have fiscal constraints --

PATRICK FELICE: Sure.

REP. SRINIVASAN: You are suggesting some stop gap arrangements between now and the final licensure of these med spas?

PATRICK FELICE: Right. I feel that, you know, the wording we've come up to at least right now define them better. Define what a medical director's role is and certainly get in there that the medical director who is receiving a fee from these facilities to be medical director prominently display what their specialty is. Is it urology? Is it radiology? Is it, you know, plastic surgery, dermatology, whatever it is. In all advertising that should be displayed. So that's our wording that we'd like to get started with.

As far as licensure, we can begin a task force with the Department of Public Health. We're certainly willing to work on that to proceed toward licensure. I believe as Massachusetts has done and several other states have done, by the way. I have data from Maryland, California, they're all moving toward recognizing that these facilities are truly medical facilities and there should be a licensure requirement at some point, and that we'd be happy to work on that task force to help you with that.

REP. SRINIVASAN: And my final question. You did mention a few states. Do we have states here that already have the licensure in process, established in our country?

PATRICK FELICE: Yes, California, Maryland, Florida has some provisions. They're not there yet but they're in the process, and Massachusetts. Our neighbor, Massachusetts has already proceeded with licensure of med spas.

REP. SRINIVASAN: Thank you. Thank you for your testimony. Thank you, Madam Chair.

REP. JOHNSON: Thank you. Any additional questions? Thank you so much. Dr. Goodkind. Gordon Willard on House Bill 6591, followed by Dr. Chris Gargonelli and then Nancy Parker. Welcome. Please state your name for the record.

GORDON WILLARD: Hi. My name is Gordon Willard. I'm the Executive Director at the Connecticut Humane Society. I've been at the Humane Society for about three years and I have been in animal welfare for over 30 years.

I'm here today to ask the Committee, to testify for HB 6591. Previous drafts of the bill had included a penalty provision. CHS urges the Committee to add a penalty to this bill, where any person who uses gunshot and causes an animal to suffer be charged with a felony crime. Without a penalty, this bill will be ineffective.

The Buddy Bill is named after a dog whose name was Buddy and he was one of my pets. He was surrendered to the Connecticut Humane Society at the Westport Shelter. Working with a rescue partner organization Buddy was adopted and then shot to death 40 hours after his adoption.

There was no provocation and Buddy was confined. He posed no risk.

I'm not only here to speak for Buddy but for all animals who suffer from such inhumane and callous treatment. The case was never prosecuted. While everyone was debating about who owned Buddy, my question is, did it really matter?

Our laws are created to protect all creatures regardless of ownership. Suffering is not diminished by ownership.

The Newington Branch of the Connecticut Humane Society has a full-time veterinarian who oversees all practices, including those performed by veterinary technicians and trained staff.

While Newington has the largest veterinary staff, our other two shelters have veterinary technicians and limited veterinary coverage, but our shelters remain open seven days a week and are routinely presented dire circumstances where pets need relief.

CHS does not take this statutory responsibility lightly. In order to maintain the highest standards to performance and to maintain the most caring humane practices for those animals in need, our most senior staff, experienced staff and veterinary technician staff are selected, trained, evaluated before authorized to perform euthanasia.

The responsibility associated with the veterinarians whose DAA license is used, commands the highest standards to performance, the same as any practice in the state.

The role of the Connecticut Humane Society in the eyes of the public, for the last 132 years, this to be the last refuge for citizens with animal issues.

Time and time again we need to relieve suffering and deal with animals in dire circumstances continues to be presented to all of our shelters and adoption centers.

Those shelters must retain the statutory exemption established in 1981 to be able to provide humane euthanasia. Nothing in 2013 has changed since enacting the law in 1981.

CHS has identified the Buddy Law as a top priority in 2013. We hope you will support HB 6591 as presented with the addition of the penalty provision. Thank you.

REP. JOHNSON: Thank you for your testimony and waiting so long. Are there any questions? Yes, Representative Ziobron.

REP. ZIOBRON: Thank you, Madam Chair. Thank you for your testimony. I'm looking at the bill now and can you direct me to where the penalty is in the bill, and if you can't do that, tell me how much it is, please.

GORDON WILLARD: Unfortunately, during some transmission to this Committee, the penalty was left out and that's why I'm urging the Committee for some mechanism to put a penalty in. I believe the original penalty was a year in jail and maybe $1,000. I'm suggesting let's go a little higher. It should be a felony when someone provides that kind of brutality on an animal.

REP. ZIOBRON: Can you tell me how much it costs for somebody to euthanize their pet?

GORDON WILLARD: Where?

REP. ZIOBRON: As you're suggesting here, if somebody were to take --

GORDON WILLARD: That depends --

REP. ZIOBRON: -- their pet to a veterinarian.

GORDON WILLARD: It would depend on the practice.

REP. ZIOBRON: Can you give me a ballpark, please?

GORDON WILLARD: Well, I think it would be several hundreds of dollars, easily. At Connecticut Humane price is not an issue. If people can provide some payment that's fine, but the animal is the key component and we would do it at no charge.

REP. ZIOBRON: So would in fact you say that a regular, average person who could not afford to go to a veterinarian could go bring their animal to the Humane Society? Is that what you're suggesting?

GORDON WILLIAMS: I'm suggesting it and encouraging it because if we don't have that access we will find animals abandoned more often, which then brings animal control into the picture. The animals have to be maintained for seven days and then they have to transport them to a veterinarian to have it done.

I'm suggesting in my world, in my experience, that people who don't have a resource and the capacity to go to a standard practice, need that access and Connecticut Humane supplies that.

REP. ZIOBRON: That's really great to hear. Is that something that you advertise for people so that they understand that that option is available to them?

GORDON WILLARD: Well, we walk a fine line because we're not here to take business away from private practice, but it's on our website and we're aware, we have a full service veterinary clinic for people who cannot use typical providers, and we provide that service there as well.

And it may be something, you've seen a big change in the economy and who used to be in the middle income is no longer there, so they're seeing our services, you know. They're using our service much more often.

REP. ZIOBRON: Thank you, Madam Chair. Thank you for your testimony.

REP. JOHNSON: Thank you. Yes, Representative Srinivasan.

REP. SRINIVASAN: Thank you, Madam Chair. Thank you for your testimony and I'm glad you made it clear that the felony component was not in the bill and that that needs to be included, because obviously we do need to do that.

GORDON WILLARD: Yeah. The bill would be ineffective and I think would not send the right message unless the penalty was in there.

REP. SRINIVASAN: And thank you for all the work that you do at the Connecticut Humane Society. And as you said, you do not advertise obviously, for obvious reasons but is Newington the only location that you have in the state or are there other locations in the state as well?

GORDON WILLARD: We have three locations, Newington the largest in central Connecticut. We have one in Westport and we have a shelter in Waterford. Those are the two shelters. They're busy but we're not able to keep full-time veterinary service in those shelters, so our veterinarian at Newington certainly oversees the vet techs and the staff there.

But they're open seven days. They're presented with the same kind of circumstances that we see in Newington. We just may see more of it but then again, in a community like Waterford where services may not be as accessible, they may see more of it per capita.

REP. SRINIVASAN: And my final question to you, you use the word vet tech. Are they also there in a conventional veterinarian practice, those technicians are being supervised by the veterinarian.

GORDON WILLARD: Most of the work that they do is, I would say manage and directed by our veterinary protocols. If it's anything outside those protocols we use local veterinarians or they will confer with our practicing veterinarians at the Newington shelter or at the Fox Clinic.

If it's not available, then we always refer to local veterinarians, and they have some veterinary service there. We have contracted veterinarians that come in, but it's very minimal, but they do a lot of the treatment and they do a lot of direction as well.

REP. SRINIVASAN: And my final question, for services rendered, is payment on a, is that expected or only if the person is capable of paying or is there a sliding scale that you will have?

GORDON WILLARD: We have a suggested price but at Connecticut Humane, the overriding and most important component is to provide relief to the animal, so it's irrelevant if they provide that income. Many times people will come to us, they've already been to a veterinarian and could not pay that fee and could not get that service.

If they could not provide that income to us, remember we're a donor subsidized organization and the animal is our primary concern. We try to do, you know, as much as we can for them.

REP. SRINIVASAN: Thank you, and thank you for all your services.

GORDON WILLARD: Thank you.

REP. SRINIVASAN: We appreciate that. Thank you. Thank you, Madam Chair.

REP. JOHNSON: Thank you. Representative Zoni.

REP. ZONI: Hello. Thank you, Madam Chair. Gordon, it's good to see you again.

GORDON WILLARD: Good morning.

REP. ZONI: I just wanted to say thank you for all your great work.

GORDON WILLARD: Thank you.

REP. ZONI: Other than the penalty aspect, you're okay with this bill as written?

GORDON WILLARD: Yes, as written it does include, it does refer to the statutory regulation that allows Connecticut Humane to continue to do euthanasia within our community. That needs to remain in the bill.

I see it perfectly fine. Let's get the penalty in there. Mr. Camillo wanted it in there. We all wanted it in there. I think everybody wants it in there, both to make a statement to the community and to put bad people into the penal system.

REP. ZONI: Thank you so much.

GORDON WILLARD: Thank you.

REP. JOHNSON: Thank you. Thank you for your testimony this evening, this morning. Okay. Nancy Parker. Welcome.

NANCY PARKER: Good evening.

REP. JOHNSON: Actually, good morning.

NANCY PARKER: Good morning, good evening. I couldn't think of what it was. I guess I'm sort of loopy. The last time I was here this late was the last night of the Session in May, so I am here briefly.

My name is Nancy Parker. I'm from Hartford. I'm an animal rights advocate and a psychiatric social worker and I just want to, I did not submit testimony. I'm sorry. And I wanted to speak in support of House Bill Number 6591 AN ACT REQUIRING THE EUTHANISATION OF ANY CAT OR DOG BE PERFORMED BY A LICENSED VETERINARIAN.

I also, and I'm sorry I got not in time to hear Representative Urban's testimony this morning.

I also, I know it's cost me different amounts of money to have some of my, I've had cats for many decades and I've had to have some put to sleep and it cost me different amounts of money, depending on the medical care that went along with it to try to keep them alive.

But I also wanted to speak in favor of House Bill 6645 AN ACT CONCERNING COMPASSIONATE AID IN DYING FOR TERMINALLY ILL PATIENTS. I hope I said I'm in support of that.

I really feel that if a person wants or chooses to leave this world they have that right if other avenues have been explored and their life has just become miserable and unmanageable, and I just think to tell a terminally ill person they have to suffer beyond belief is inhumane and unfair.

So I just wanted to speak in support of those two bills.

REP. JOHNSON: Well thank you for being here and waiting and being so quick about providing your testimony. Are there any questions? Thank you so much and have a good evening.

NANCY PARKER: Thank you.

REP. JOHNSON: The next bill is Senate Bill 1128 and the first person I have who apparently may be left is Mary Consoli, followed by Michelle Lopez, then Karen Lynsted or Linster and then Mary O'Brien. Welcome and state your name for the record, please.

MARY CONSOLI: Good morning. I'm Mary Consoli. I'm President of the Danbury Nurses Union. We represent 600 registered nurses in Danbury Hospital and I'm here to speak in opposition to Raised Bill 1128 AN ACT CONCERNING INFLUENZA IMMUNIZATION FOR HEALTH CARE EMPLOYEES.

Neither does CVC nor the Joint Commission has determined conclusively that mandatory immunization is a useful policy. More and more studies are showing a decreased effectiveness of the vaccine.

We're in support of influenza immunization but opposed to the mandatory nature of this bill. Instead, a voluntary comprehensive employee influence program campaign would be more effective, giving employees the choice of wearing a mask or taking the flu vaccine.

In fact, a mask may be more effective than the

flu vaccine.

Through a collaborative effort between the Danbury Nurses Union, New Milford Hospital nurses and Western Connecticut Health Network, such a voluntary program was put into place for the whole network and were very successful in reaching the 90 percent compliance for immunization that was suggested by the Healthy 2020.

And more and more hospitals throughout the country are using this approach, giving employees the, educating them and giving them the choice.

In my written testimony I have a few listed. I wanted to add (inaudible). I had forgotten that. In California, Washington State and Oregon they are becoming more and more using a comprehensive approach to the flu vaccine.

Also, in this Connecticut General Statutes, the Department of Public Health allows for medical and religious exemptions for child care or school immunization programs. I don't see this in the Raised Bill 1128 and it should.

The CDC recommends that if someone has a severe or allergic reaction to the influenza vaccine for any reason, this is a contradiction to future receipt of the vaccine. One of our nurses had a life-threatening reaction and does this mean she can't work for the flu season?

The bill prevents any such employee from earning a living as written.

As another preventive measure the CDC recommends limited exposure during the flu season if one has symptoms. This was not done. Nurses at Danbury Hospital were not limited. There is a sign that says if you have symptoms, do not visit. There's no one policing the policy and visitors ignored the signage and I'm sure this probably happens throughout the other Connecticut hospitals. I don't think Danbury was alone.

In summary, I stress that flu vaccination is only one part and may not be the most important part of a comprehensive program and I urge the Committee to not adopt the bill as written. Give the employees a choice. And I'd be happy to take any questions.

REP. JOHNSON: Thank you so much for your testimony. Are there any questions? Yes, Representative Tercyak.

REP. TERCYAK: Thank you very much, Madam Chair. I'll try to be brief because the hour is late. Thank you for coming again. You were here last week and stayed very late then, too.

MARY CONSOLI: Right to the midnight hour.

REP. TERCYAK: You mentioned that you thought a mask might be as effective or more effective than a flu shot. Do you have, are there any studies about that?

MARY CONSOLI: No. One of the things that we had done is, many of our nurses got the flu shot and they still got the flu, and --

REP. TERCYAK: Are there any studies that say wearing a mask is as effective as a flu shot to prevent it.

MARY CONSOLI: I'll have to do research and I can look and give it to you.

REP. TERCYAK: I'm not aware of any. I've looked. Yes, flu shots are not 100 percent effective. Are you aware of any studies that show that people are less likely to get the flu without a flu shot than they are with the flu shot?

MARY CONSOLI: Say that again?

REP. TERCYAK: Are you aware of any studies that show that a person who does not get a flu shot is likely to get flu less often than a person who does get a flu shot?

MARY CONSOLI: Am I aware of a person that does not get the flu shot?

REP. TERCYAK: Yes. Yes. I'm specifically referring to your statement that they're not 100 percent effective. I'm of the opinion that if it was 60 percent effective, it would be effective more often than nothing would be.

Are you aware of any studies that not taking a flu shot is more effective in preventing the flu or even the spread of flu than taking a flu shot is?

MARY CONSOLI: Not now. I'd have to do research. But you know, I would have to say that --

REP. TERCYAK: Thank you very much. Thank you very much. Should you do any research and find evidence that patients are safer with care givers who have not taken flu shots than they are with care givers who have flu shots, please pass it on to me and I'll make sure I share it with the rest of the Committee.

MARY CONSOLI: I'd be happy to do that. One of the things that we have a problem with at Danbury, we had visitors coming in because they were not compliant with limiting as CDC has suggested, with bringing in the flu.

We had a major problem with visitors coming in who were symptomatic and they were not restricted.

So who's to say, now who would give the patient some of the symptoms. The patients may not have been in there for the flu but there were in there and they could have been exposed by the other visitors coming in. It wasn't just the health care employees as this would suggest.

REP. TERCYAK: Thank you. So are you saying that you believe that a person who is surrounded by folks who have not had flu shots is less likely to get, is less likely to get the flu than a person who's surrounded by folks, some of whom have had flu shots and some of whom have not?

MARY CONSOLI: No. What I'm saying is, if you have a voluntary program with a comprehensive education program as we did at Western Connecticut Health Care, we were successful in having 90 percent.

I'm saying mandatory flu shot is not the only option to achieve a successful rate in getting people to be immunized.

As I said before, we're in favor of immunization but not a mandatory. We feel there's other options that facilities can take, as we did, to achieve the goal that you are suggesting.

Mandating someone to take a flu shot is not the only option and should not be the only option.

REP. TERCYAK: An option that wasn't a mandate, that was open and people taking flu shots would be good. An option that wasn't a mandate that, I'm fine if you've got a non-mandated way to make everybody get a flu shot. But barring that, I don't see why in a health setting we would be ignoring the good disease preventing effects of vaccinations.

MARY CONSOLI: We're not ignoring it. What you're doing is, some of the people cannot take this. They have certain religious rites, they have beliefs to do that and they have medical reasons why they shouldn't take the flu shot, and they should have the option. They could wear a mask. That was acceptable to be --

REP. TERCYAK: I'm sorry. We haven't yet established that wearing a mask succeeds as well as a flu shot in preventing infection, preventing passing on the flu.

MARY CONSOLI: but what we're saying is --

REP. TERCYAK: What you're saying is, you don't think that people should have to take flu shots and I understand that.

MARY CONSOLI: I just way if they have a medical reason or religious exemption, they should be allowed to. Children going to school are allowed to have religious or medical reasons for not getting the children's immunizations and they're allowed to go to school.

REP. TERCYAK: Yes, and now we see many of the diseases we thought were eradicated coming back and it will be interesting to see how many children, how many parents have to stay up all night worrying about their children's effects from whooping cough before we decide maybe we've been too generous with allowing parents to claim a religious exemption.

But that part of children is neither here nor there. We're talking now about adults in a health care facility where people come expecting that every effort will be made to keep them from being exposed to diseases.

MARY CONSOLI: Right, and what I'm telling you is, we did at Danbury and had a 90 percent effective immunization rate, and one of the things that we have to be careful of when you do a mandating, 100 percent if you don't take it you lose your job, for something that is maybe a crap shot because you (inaudible) see that the flu vaccine is done, it's not like say a polio that was 100 percent.

You have to take it and you can see the efficacy rate is up and down and you wanted to make sure that somebody --

REP. TERCYAK: Excuse me, ma'am. You keep implying that something less than 100 percent must equal zero. That's not true.

MARY CONSOLI: No. I didn't say. I'm not implying that.

REP. TERCYAK: Okay, I'm sorry. I'm very sorry, ma'am. I'm very sorry for going on like this. You came to testify and you did. I thank you very much. You didn't come to be interrogated by me. Excuse me, thank you. Thank you very much for your indulgence, Madam Chair. Next time I try this, you can slap me.

REP. JOHNSON: Thank you. Yes, Representative Srinivasan.

REP. SRINIVASAN: Thank you, Madam Chair. Thank you very much for your testimony. I do understand the religious part for exemption, whatever that is, how that works out.

But in terms of adverse reactions, are you referring to a person who had a reaction to the flu shot in the past that does not, according to you now does not need to get one because of the reaction, or was it the allergic reaction in egg that kind of precludes them from getting the flu shot? Which of the two are you referring to, or to both?

MARY CONSOLI: Well, we have a nurse and she'll be testifying after me. She had a severe most life-threatening reaction and the CDC says that in the future anybody that has a severe reaction shouldn't get another flu vaccination.

So what's going to happen to this nurse next year in the flu season if she can't take the flu shot? Is she not going to have a job if we have a mandating that it has to be, get a flu shot or no job? That's what I'm asking.

REP. SRINIVASAN: Thank you. Thank you for the testimony. Thank you, Madam Chair.

REP. JOHNSON: Thank you. Any additional questions? Thank you so much for your testimony this evening.

MARY CONSOLI: You're welcome.

REP. JOHNSON: Thank you for waiting. The next person on the list is Michelle Lopez, followed by Karen Lynster and then Mary O'Brien and then Christopher O'Brien. Welcome, and please state your name for the record and then proceed.

MICHELLE LOPEZ: Hi. I'm Michelle Lopez. I'm a registered nurse. I work for Danbury Hospital. I worked there for six, going on my seventh year this year, and I am here in opposition to Raised Bill 1128.

This year I was given an option by my employer to wear a mask, a surgical face mask or to get a flu vaccine. And after four weeks of extended surgical mask wearing, I developed an upper airway esophageal reaction. It was so bad that I choked and had to have an emergency endoscopy to save my life. That was on Tuesday, January 29, 2013.

On Friday of that same week, I had already contacted employee health and that day I went to employee health to voice my concern about the requirement to wear a mask for such a long period of time, my shift is 12 hours and we were not even allowed to take the mask off in transit, like walking to the cafeteria or anything like that.

At that point, since I had raised the concern and since the emergency had happened and been reported to my employer, they gave me the choice to get a preservative free, Thimerisol free vaccine or to take paid time off until they could figure out what to do with me or until the flu season was over.

I have two children that both have genetic Von Willibrands disease and I am their sole provider for their medical benefits and I thought about this for a pretty long time and then I decided I didn't really have much of a choice but to get the immunization, so I was given the immunization.

Several hours later I was working that day, my left arm was swollen to twice its usual size and I had prepared before I went because I had the feeling that this was what was going to happen, so I had started 24 hours prior taking Allegra D every morning to ward off any allergies that I might have.

It was swollen to twice its usual size. It was red. It was hot. It was inflamed. I started to break out in hives from head to toe and I had an eczema-like rash all over my body so bad that my patient told me you need to get seen for this. I was also wheezing and rather ill appearing.

I had gone to employee health. They were closed. I was seen in my own emergency department. I was given immunosuppressive therapy. About an hour after that my symptoms started to go down. I wasn't wheezy anymore and I wasn't fiery red. They told me to continue taking allergy medications. I continued on a (inaudible) pack at home.

I recovered over the weekend and returned to work the following week and I was okay, but in order for me to take this vaccine in the future, I not only have to violate personal beliefs but I'm forced to get immunosuppressive therapies, compromise my own health and safety and take heavy duty allergy medications for a long time.

As a medical note, allergies generally get worse before, as you have repeated exposures and someday I might get that reaction and I might die from it, and I think that it's unfair to ask me to take an injection or not work, or to have this as a condition of my employment.

My testimony has been sent to you prior to my coming here and prior to that whole incident. I had personal e-mail exchanges with the Centers for Disease Control regarding mask wearing and flu vaccine.

If you read my testimony in there is a note from Dr. Raymond Romberg who is from the Centers for Disease Control where he indicates how vaccinated persons spread flu, too.

REP. JOHNSON: Thank you so much for your testimony today and sharing your story with us. It's very, very difficult for you to have to go through having the flu shot when you knew you might have some sensitivity.

I was wondering, there are flu shots that are supposed to be hypo-allergenic that are available now. Was that the one you took, or was this --

MICHELLE LOPEZ: They gave me Thimerisal free, which is the one that does not have mercury in it. I do not have an allergy to eggs. I know that. I've eaten eggs and do not have a problem. This was as preserve free as it comes.

An important note, the immunization that they're giving to health care providers is high dose, even though Centers for Disease Control recommends high dose for those 65 and older.

If you're a health care worker, they give you the high dose anyway, even though it is written as a Category C for pregnancy risks. They're still giving it to women of child-bearing age and that comes with a higher risk associated with it because it is a higher dose. Normally it's only given to people who are 65 and older.

REP. JOHNSON: Well, it's my understanding with a higher dose that they space it by two or three weeks or a month. You get one dose and then another. They didn't do that with you?

MICHELLE LOPEZ: No.

REP. JOHNSON: Anyway, I'm sorry that you went through all that and thank you so much for sharing your story with us, and are there any other questions? Thank you so much.

The next person on the list is Karen Lynster, followed by Mary O'Brien and then Christopher O'Brien and I hope that I'm reading your name correctly.

KAREN LYNSTER: You did. Thank you very much.

REP. JOHNSON: Thank you.

KAREN LYNSTER: My name is Karen Lynster. I am also a licensed and practicing registered nurse at Danbury, Connecticut for 15 years. I'm working in the emergency room setting.

I am in opposition to Raised Bill 1128 even though I am a proponent of the flu vaccine. I opted to receive the flu vaccine but that was my elected decision to do so.

I don't believe that it should be mandatory for all health care workers. Michelle is an example of why.

One of the problems with the raised bill is that (inaudible) is that all health care workers (inaudible) should receive the flu vaccine.

There are of course, some employees who cannot because of their potential reactions to vaccine such as what Michelle Lopez has.

The mandatory status can negatively impact those health care workers therefore, who cannot receive it for those medical reasons, and then of course there are also others who by virtue of their religious beliefs decide not to receive it.

Presently, as Mary mentioned before, it's not required in schools and child care areas. In case of influenza outbreak, arrangements are made to excuse those who cannot receive the vaccine from that setting.

The bill does not include any arrangements for those workers who cannot receive the vaccine and that is an issue because it is a real fact that people do have allergies and it's not just the egg component or the preservative component. Even by removing those components, rather the preservative component, people still have had reactions to this.

And the reactions that one can have range from mild adverse reactions that are myalgias or (inaudible) fevers. In children sometimes there have been seizures and this is documented.

And there are neuritis, sometimes neuritis inflammation of the nerves, particularly Michelle has been documented as well, and the more serious one would be the Gionne Varay syndrome where it actually causes an autoimmune reaction.

Because the purpose of the vaccine is to prompt the body to produce a heightened immune response to the virus that can result is more (inaudible).

And Mary also said to you that the vaccine is only 65 percent effective at the best. At the best. That's their guesstimate, because they're just guessing what strains of the virus will be out for the particular season and then their vaccine is based on their best guesstimate.

And in 2010 the efficacy was only around 50 percent. This year, unfortunately, it's a lot less. They didn't really guess properly and the risk to the patient is actually greatest in the public setting, not in the hospital setting.

In the hospital setting, health care workers maintain universal precautions to protect their patients and that includes mask wearing and mask wearing prevents droplets and in the case of the flu it's droplet and airborne and we have masks for that as well and we wear that protective gear so therefore it protects the patients.

The greatest risk to the patients in a hospital setting is actually people who are coming in to visit the patient and they bring it in with them, and there is no way for us to mandate the general public to take that vaccine or even come in and be honest and perhaps wear the mask. We requested that they do so.

REP. JOHNSON: Could you please summarize.

KAREN LYNSTER: So, in summary, it's that there is a danger by mandating that all the health care workers actually have the vaccine, a danger to their person, bodily harm, and I think there has to be in the bill, if the bill is going to go through to mandate the vaccine, to have some kind of allowance for those who cannot take the vaccine in the health care setting, the nurses and or health care workers do wear protective gear that protects that patient.

REP. JOHNSON: Thank you so much for your testimony. Are there any questions? Yes. Representative Ziobron.

REP. ZIOBRON: Thank you, Madam Chair. I hesitate at the hour and I apologize to my colleagues but I can't help myself. I'd like to know what mandated vaccines besides this one you are forced to take?

For instance, shingles or other items that may be a public health, or is the only vaccine that you are, and I'm sure you're hospital suggests that you take this vaccine. So are there other ones that they also ask that you consider taking?

KAREN LYNSTER: Yes, of course there are, and they actually test us for --

REP. ZIOBRON: Okay.

KAREN LYNSTER: -- (inaudible).

REP. ZIOBRON: So you do not object to taking any of those vaccines.

KAREN LYNSTER: No. I don't. As a matter of fact, when I first started (inaudible) I stated that I, myself am a proponent of the flu vaccine. I have elected to receive it.

I do very strongly believe, though, that it should not be mandated for others to definitely taken when it is detrimental.

REP. ZIOBRON: Are the other vaccines mandated?

KAREN LYNSTER: Unless someone has an allergic response or a reason not to take the vaccine. It's not mandated.

REP. ZIOBRON: Okay.

KAREN LYNSTER: In the other vaccines --

REP. ZIOBRON: You don't need to elaborate. I'm sorry. I don't mean to cut you off. I just wanted to get a quick answer to my question for the benefit of my colleagues. Thank you very much. Thank you, Madam Chair.

REP. JOHNSON: Thank you so much. Thank you for your testimony. Mary O'Brien, followed by Christopher O'Brien. Welcome, and please state your name for the record.

MARY O'BRIEN: Good evening. Public Health Committee, thank you for having me here. My name is Mary O'Brien. I'm from West Haven, Connecticut and I'm strongly opposed to this Bill 1128.

I believe that it should not be mandated for any health care worker to receive the flu shot or any other medical procedure, which is what the shot is, a medical procedure.

The medical professional should be allowed the choice whether to get it or not. The flu seasons, I'm sorry, the season of flu changes every year and so does the vaccine, and I'm sorry.

Yes. It changes every single year and like she just said before, you know, it's a prediction on whether or not they can match the vaccine with that flu strain that's going to come up for that season. And even when they are matched up it's not a perfect match. It's only 62 percent effective preventing that flu for that season or year.

And this past year it was even less than that and one of the least effective vaccines that they've come up with.

I do work as an EMT. I work for Hunter's Ambulance over in Meriden and also I'm a nursing student at Gateway Community College where I was forced to get the flu shot against my beliefs.

Just as I said, I don't believe that we should be forced into anything, any kind of medical procedure and I was forced into getting this shot saying that if I don't get this shot then I'd have to leave the program, something that I've been working three years for, studying for and everything like that and finally getting into the program and they say I have to leave it if I did not get a shot.

I did research on the shot and I did find there were seven brands this past flu season that were approved, one being flu mist, which is an inhaled version of the flu shot, and I found out that this one form the FDA cautioned saying that anyone seeking this vaccine needs to be away from immunocompromised people for three weeks because they are considered contagious.

And I was doing my clinical over at Yale in Smilow Cancer Center with immunocompromised patients, so if I did not get the shot, then I could not attend my clinical according to my professors being in the program, and if I obtained this particular vaccine, I could not work in front of my patients because they're immunocompromised.

A point I wanted to touch on here. One big thing in the medical profession that we should be aware of. We know of the six rights. Any time we give a medication or a medical procedure, the six rights are follow up, make sure you have the right patient, the right medication, the right dose, and it's the correct time and the medication has not expired.

In nursing school we also heard talk of the seventh right which is the right to refuse and the patient has the right to refuse any kind of medical procedure or medication if they feel that they're uncomfortable for any reason in not taking that medication or feel that they should not go through with that procedure, they have the right to refuse.

When that needle, you know, when that injection needle is pointed toward you, you are now the patient and you have the right to refuse also.

I don't want that right to be taken away from me or from anyone else here or otherwise, especially my fellow medical professionals.

By mandating the flu vaccine that right is being taken away.

REP. JOHNSON: Could you please summarize?

MARY O'BRIEN: Yes. I'm almost done. I will never force any of my patients to do something that they don't want to do and I don't want to be forced myself.

While working at Yale, I found out also that they were receiving a certain amount for the percentage of the employees that were being immunized. If this is true, there and other hospitals in my opinion is an unethical conflict of interest when talking about somebody's health and jobs when you want to put a monetary figure on it.

REP. JOHNSON: Thank you so much and thank you for waiting and providing testimony. Are there any questions? Thank you and have a good evening. And the next person I have on my list is Christopher O'Brien. Good morning and please state your name for the record and proceed with your testimony.

CHRISTOPHER O'BRIEN: Good morning and thank you for staying here at this late hour. My name is Christopher O'Brien. I'm a paramedic from Wolcott. I work in Waterbury and I used to work in Meriden as well.

You know, this is one of the first times I'm aware of that a vaccine has been forced or has been primarily been required to not be for the benefit of the recipient. In fact, it's for the patients that they treat instead.

Most vaccines you receive once a, you know, shortly after birth in your first few years of life with a booster ten years later, whereas the flu vaccine is given every single year.

There's been a lot of concerns over the last few years about autism and the epidemic of peanut allergies. Peanut oil many years ago was used in vaccines as an additive and autism as well.

I'd like to look over the testimony of the Dr. Steven Aronan from Waterbury Hospital. He's the chief of infectious disease, where he talks about, he glances at the side effects but doesn't talk about side effects. He calls them myths and misconceptions. They are simply not true and the benefits clearly outweigh the side effects but doesn't include them.

I bring these up because when you give a medical procedure to an employee, they become a patient. Let me repeat that. When you give a medical procedure to an employee they become a patient and they are entitled to informed consent where you're given the benefits, the risks, any alternatives you can have and also what can happen if you don't take the vaccine or other medical procedure.

When you are coerced into doing this at the risk of your employment, you don't have informed consent. In fact, the risk that other folks before me had talked about, there is no compensation for.

There's clearly, you know, the proponents of the bill and of the flu vaccine always talk about, say you can't get sick from the vaccine, or you can't get the flu from the vaccine, and that's clearly not true.

I'm sure all of us know of people that have had side effects. In fact, the CDC on their website list the side effects and they're very similar to the flu. They might be a little milder where you incur a low-grade fever as well as aches and pains.

And you know what? If we're telling our employees that you can't get sick, well, maybe you can't be contagious either, so you can show up for work, and I know of a lot of co-workers that have showed up for work. We have had door to door folks with the flu and other vaccines and other diseases and this impairs their judgment.

I know my time is up. I know Senator Markley previously submitted a bill that protect a worker's rights and so that they would not be laid off.

And one more point I have, OSHA just last year came out with a statement saying that at this time OSHA believes there is insufficient evidence for the federal government to promote mandatory influenza vaccine programs that may result in employment termination, and of course this goes back to the efficacy that other folks have talked about. I'd be happy to address some of the Representatives questions from earlier.

REP. JOHNSON: Great. Thank you very much for your testimony. Very much appreciated. Are there any questions?

CHRISTOPHER O'BRIEN: May I attempt to -- ?

REP. JOHNSON: Just quickly, yes.

CHRISTOPHER O'BRIEN: I know Representative Ziobron asked about other vaccines, hepatitis would be strongly encouraged and up until about two years ago tuberculosis was mandatory but that's been downgraded now to being recommended.

As far as studies, I believe it was the flu vaccine again, folks could still sick of some kind of illness that may still, if you get the vaccine, I'm 34 years old. I've had the flu probably two or three times in my life. People that get the vaccine have these side effects that make them sick and force them to leave work more often than I will, who have not gotten sick in my 34 years of life, so.

47Certainly if there's not enough evidence. The Public Health Committee of course can institute a study to see the efficacy of that flu vaccine as well. Thank you.

REP. JOHNSON: Thank you for your testimony. I really appreciate it. All right. And the next bill that we'll be hearing is Senate Bill 1129 and Jane McNichol who signed as the speaker. I don't believe I see Jane anywhere in the audience. There's nobody signed up. I have no one here on 6647. Oh, you did sign up for 6647? Well, please come right on. Step right up. You're not on my list. My paper is blank. Sorry about that. But anyway, welcome and please state your name for the record, and then I'll write your name on my sheet.

RAJA STAGGERS-HAKIM: Okay. Good morning. I'm Dr. Raja Staggers-Hakim and I'm the Executive Director of the Connecticut Commission on Health Equity.

The mission of the Connecticut Commission on Health Equity is to eliminate disparities in health status based on race, ethnicity, gender and linguistic ability, thereby improving the health for all of Connecticut residents.

I'm here today, this morning, to offer testimony in support of Raised Bill 6647 AN ACT CONCERNING THE COLLECTION OF DATA REGARDING RECIPIENTS OF SOCIAL SERVICE PROGRAM BENEFITS.

As the bill is written, the purpose of the bill is to require certain state agencies to collect, maintain and review identifying information concerning the person such agency serves.

However, I appeal to you to consider the larger potential of this raised bill, to develop and implement in Connecticut an ongoing quality improvement program and annual review in order to assess and come into compliance, with federal data collection standards, including standardizing data collection measures.

It is understood nationally, as it is here in Connecticut that identifying disparities and effectively targeting and monitoring efforts to reduce them, has been limited by a lack of specificity, uniformity and quality in data collection and reporting procedures.

Consistent methods for collecting, reporting health data, will help us better characterize and compare the nature of health problems in underserved populations in Connecticut.

Many racial and ethnic minorities, people with limited English proficiency, people with disabilities, lesbian, gay, bisexual and transgender communities in Connecticut as well as other commonly understood populations face unique health challenges and often have reduced access to health care and insurance leading to poorer health throughout their lives.

According to recent analyses of progress on Health People 2010 objectives, leading health indicators have demonstrated little progress in reducing disparities over the past decade.

A recent Institute of Medicine report emphasizes that inadequate data on race, ethnicity and language lowers the likelihood of effective action to address health disparities.

Streamlining data standards in Connecticut will help us improve the ability to monitor health disparities among people of diverse groups and to better identify the significant health differences that often exist between or within ethnic groups.

To explain this better, I borrow an example from the U.S. Department of Health and Human Services. As we consider the diabetes related mortality rate for Mexican-Americans, for examples, and Puerto Rican, which are twice as high as the diabetes rated mortality rate for Cuban Americans, we can better appreciate how this information would remain unknown without more specific dimensions in data collection.

Data specificity offers the ability to direct certain preventative messages and health awareness campaigns to reduce unnecessary deaths in specific populations.

Section 4302 of the Affordable Care Act requires adherence to uniform categories and collection of individual level data for any federally conducted or supported health care or public health program activity or survey to the greatest extent possible.

And in closing, the monitoring of health disparities in Connecticut is dependent on accurate and high quality data collection and reporting.

If this law is not passed, state agencies that receive federal funding to provide health and social services to Connecticut residents will continue to be limited and their ability to comply with federal data standards.

The potential effect of noncompliance with the Affordable Care Act standards include reduced ability to compete for federal funding opportunities and limited ability to address health disparities.

By working to improve data collection standards the Raised Bill 6647 will help eliminate health disparities by race, ethnicity, gender, linguistic ability, and thereby improve the health of all of Connecticut residents. I thank you for your time this morning.

REP. JOHNSON: Thank you for your testimony this morning. Have you been looking into how this might be able to help any particular disease? You mentioned diabetes and that sort of thing. Are there any other issues that you think that we would be able to address additionally?

RAJA STAGGERS-HAKIM: I think that there are several. The Commission on Health Equity, based on data that we have in the state, some preliminary data, we are interested in mental and behavioral health. We are interested in heart disease, diabetes, HIV and a number of diseases.

I think with information like this, it could very well help to target various awareness campaigns around those specific health issues so that we can really appreciate how various, we can even look more specifically into various groups.

For example, generally, another category is oftentimes Asian, Asian-Americans are viewed as one group, but that undermines the diversity within, among Asian population groups and you will see in Asian groups based on where people are coming from that their exposure and the prevalence rates for certain diseases vary across various Asian population groups.

So for us to really appreciate how we should target and outreach with certain population groups around preventative messaging, it's really important to have this information in the state.

REP. JOHNSON: Very good. Thank you so much. Any questions? Thank you so much.

RAJA STAGGERS-HAKIM: You're welcome. Thank you so much.

REP. JOHNSON: We really appreciate your testimony. Okay. The next bill we have is Senate Bill 1129, Jane McNichol. I don't think she's here.

And then House Bill 6644. Roby Rowe. And then on to Senate Bill 1069 starting with Barbara Bunk and then Barbara Ward. Welcome. We got to the very end. We're doing a little better than we did about a week ago. We were here until 2:30 a.m.

BARBARA BUNK: My name is Barbara S. Bunk. I'm a psychologist in private practice in Glastonbury. I'm also the President of the Connecticut Psychological Association and myself and my colleague are here this evening to ask your support of Senate Bill 1069 AN ACT CONCERNING THE JOINT PRACTICE OF PHYSICIANS AND PSYCHOLOGISTS.

The purpose of this bill is, you have actually one piece of our testimony that we were able to submit yesterday and there's another that we submitted today that you'll be able to review when you get it online.

But the purpose of this bill is simply to allow psychologists, PhD psychologists to become partners in the private practice, in a practice with physicians. It's the wave of the future.

This statute and those across the nation were created when health care was utilizing an entire different system than we are now. Health care providers were in silos at that time until now, really, until recently, practicing independently and health care providers were kind of separate from one another.

Now, with the Affordable Care Act, as well as the other trends, contemporary trends in health care provision, we are integrating care and developing multi-disciplinary patient centered care, where in particular behavioral health, mental health is being integrated with physical health.

So in fact, Connecticut statutes already allow other disciplines to partner with one another, so there is a precedent for this. For example, ophthalmologists can currently partner with optometrists.

In addition, a review by the American Psychological Association Practice Organization recently concluded that just over half the states in the country do allow psychologists to broadly incorporate with other health care professionals.

Connecticut Psychological Association has talked with several other health care disciplines here in the state, the Connecticut Medical Society, the psychiatrists, some pediatricians and primary care docs and all have been enthusiastic and supportive, and you do have testimony from at least one of those in support of Senate Bill 1069.

So integrated mental and behavioral health care is also cost effective. That's what the trend around the country is. It certainly makes common sense that such things as billing costs and other overhead costs would decrease.

For example, there is also data that says that the provision of psychological services to high frequency Medicaid users resulted in a 30 percent decrease in their Medicaid utilization after one year. So not only, so it's cost effective and it's patients effective.

So finally, there's also much evidence that shows that psychological services and physical health care are inter-related, improve quality of life and increase access.

And my colleague, Dr. Barbara Ward-Zimmerman is going to speak with you about that. I'd be happy to answer any questions so far or we could have Dr. Zimmerman talk and then perhaps you'd like to ask questions.

REP. JOHNSON: Well, thank you so much and thanks for your perseverance. Much appreciated.

BARBARA BUNK: You're welcome. I was thinking earlier that I haven't been up this late since my son was a teenager and I was waiting at curfew, you know?

REP. JOHNSON: Kind of fun, isn't it?

BARBARA BUNK: Yes.

BARBARA WARD-ZIMMERMAN: Good morning.

REP. JOHNSON: Good morning. And please state your name for the record.

BARBARA WARD-ZIMMERMAN: Sure. My name is Dr. Barbara Ward-Zimmerman. I am the Chair of the Health Care Reform Task Force for the Connecticut Psychological Association, but I am also a clinical psychologist who has worked part-time in a collaborative co-location model in a large pediatric practice for over a decade.

So I have for a long time walked the walk of integrating care, but not able to do what we're asking for today in Bill 1069, which is a real joint practice of physicians and psychologists.

So I was co-located by a large mental health agency in a pediatric office, and that's really wonderful for patients to have access to psychological services right in the practice and we were able to do a whole lot of wonderful things from universal behavioral health screening in that practice to referrals to me and I could see patients on a short-term basis or triage them for longer term therapy, really wonderful for families to have that kind of immediate access.

The trust in the physicians has been transferred on to a psychologist and you really can work very efficiently and effectively with the families.

The problem with not being incorporated is then you're not fully integrated, so your records are separate from one another, billing practices are separate from one another. Even communication can be difficult although I certainly did my best to do a good job with that, but it's very different when you're really incorporated working together hand in hand, and that would really facilitate the integration of care.

And we certainly know that we want to do this. It's what the patient-centered medical home is calling for and we've coordinated services that are just readily accessible to families, efficient and also therefore more fiscally responsible as well.

We know that our minds and bodies work together and therefore it's not surprising that research has shown that up to 50 percent of primary care visits focus on behavioral health issues, whether those issues are primary to begin with, anxiety depression, causing headaches, et cetera or secondary to other medical conditions, but definitely the primary care doctors are dealing with a lot of medical, a lot of behavioral health issues.

So for those reasons we feel that psychology can really partner well with the medical folks doing a good job for our patients and it starts with communicating. Thank you.

REP. JOHNSON: Thank you very much. Are there any questions? Yes, Representative Srinivasan.

REP. SRINIVASAN: Thank you, Madam Chair. Thank you for your testimony and thank you for staying back this early in the morning.

This association, this partnership, which I think is a wonderful thing to happen, is it for a physician and a psychologist, or could a psychiatrist also be included in this mix as far as the partnership is concerned?

BARBARA BUNK; Well, in fact, of course a psychiatrist being a physician can already partners with a physician and currently, psychologists, in the State of Connecticut we do have limited incorporation accessibility now.

So that means we, psychologists can currently partner with other mental health professions, including psychiatrists.

REP. SRINIVASAN: So as I see this, this could be obviously in the best interest for the patient, a kind of a one stop where they would be seeing their primary care and if need by, the psychiatrist, and if need be the psychologist, all sharing the data and sharing the billing, as you said, so it becomes cost effective and more important, patient access.

BARBARA WARD-ZIMMERMAN: And one of the beauties of integrating care is that you can get at things much earlier so that if a physician does have access, easy access to mental health services, is doing behavioral health screening, can identify earlier, make those quick referrals rather than waiting until the problem really escalates, so you can intervene earlier and then it's briefer treatment.

The other thing that I found as a child and adolescent psychologist working in a pediatric office is that physicians became more and more educated themselves and more comfortable with doing certain prescribing.

So it's not to say that we don't need the psychiatrists. We absolutely do, but the whole goal, then, is to preserve those rare psychiatrists that we have for the kids, for adults, that really need them.

So therefore, I found that working hand in hand with the physicians, they would count on me to help monitor patients along with them and therefore they became more comfortable doing prescribing at a lower level and reserving those more extensive and elaborate evaluations that are scarcer to find and, for the kids, in my case, kids who really needed them, who were really complex, complicated, multi problems kiddoes, so it really worked very well.

And some of the physicians who early on, 13 years ago would say, you know, I'm not a heart surgeon, these are general pediatricians, I'm not prescribing say, Dylex, you know, medications for a mild kind of medication for anxiety or depression, over time becoming more familiar with the issues having somebody to work hand in hand with, they were really willing to do that and believe me, prescribing is not what we want to do. We certainly want to prevent problems, too, and that's really the beauty of having these incorporations that you can work to prevent issues before they really (inaudible).

REP. SRINIVASAN: Thank you for your testimony. And through you, Madam Chair, in an ideal setting, this partnership would be in one location where they all, under the same roof, but it doesn't have to be that way. It could be, not necessarily housed in the same office.

BARBARA WARD-ZIMMERMAN: Right. You could do a collaboration at a distance as well.

REP. SRINIVASAN: Thank you. Thank you for your testimony. Thank you, Madam Chair.

REP. JOHNSON: Thank you. Any additional questions? Well thank you so much for staying with us through this whole --

BARBARA WARD-ZIMMERMAN: Thank you for staying with us.

BARBARA BUNK: Thank you.

REP. JOHNSON: I wondered if Shannon Sanford is here? All right. Here you go. You're going to keep us here the rest of the night, right?

SHANNON SANFORD: How much caffeine have you had?

REP. JOHNSON: None. Since five.

SHANNON SANFORD: I brought some friends.

REP. JOHNSON: Welcome, and please state your name for the record and proceed.

SHANNON SANFORD: My name is Shannon Sanford. I'm an oncology clinical nurse specialist from Seymour, Connecticut, and I brought some friends.

I'm here to support the passage of House Bill 6645 AN ACT CONCERNING COMPASSIONATE AID IN DYING FOR THE TERMINALLY ILL, and as you can see from this pile with me, a great number of residents in the State of Connecticut also support House Bill 6645.

And I'd like to enter these into the record for the hearing today. Obviously in the interest of time I won't read them all, but if there's a way to enter these into the record, I would appreciate it and so would everyone who wrote to support the legislation.

REP. JOHNSON: We're all wanting to know, what is in that pile?

SHANNON SANFORD: These piles are all letters to the Public Health Committee Members from residents from the State of Connecticut in support of this bill.

REP. JOHNSON: Very good. Thank you. Very good. We'll scan them in, then.

SHANNON SANFORD: Okay. To tell you about myself and why I'm in support of this legislation. I am a registered nurse. I am a master's prepared. I went to the Yale School of Nursing and I did my thesis on the Oregon Death with Dignity Act, so please feel free to fire away any questions about that bill and I will be happy to answer them to the best of my knowledge.

I have also taught hospice nursing at Naugatuck Valley Community Technical College and I have been working as a nurse since 1999. Don't know that I want to make that know, but I will, so all of my knowledge has come from those sources as well as at the bedside.

And I can tell you that there will be patients who will want to use this legislation and they will not be norm, they will be the exception. They will not be the norm.

And they will be, because sometimes to our best efforts we will not be able to treat all the symptoms that a patient will have and being an oncology clinical nurse specialist, I will tell you that I am a proponent of hospice care. I love hospice. I teach it. I love it, and I will tell you that sometimes, despite our best efforts, we will not be able to control all the symptoms our patients have and the quality of life, and to the quality of life that our patients want.

So if our patients have a different quality of life than they want, you know, what are we supposed to tell them? That they have to live the quality of life we want them to have? That's not the answer.

Quality of life is subjective. That is the way the patient perceives their quality of life to be. This bill is not about telling a disabled person that they need to avail themselves to it. That is not the case. This is for terminal patients in their final hours or days of life.

When you give a patient a prognosis of six months or less, sometimes, you know, we have heard from other people that it's six months or more, sometimes it's less.

My dad, when he was diagnosed with a terminal prognosis, it was two weeks. That happens. It goes in the other order as well.

So I'd just like to drive home the point that it's not disabled, it's terminal. These patients, it's a medical service. It's regulated by a medical professional. This is a service that patients will again, they will not be the norm. They will be the exception to the norm if they take advantage of this legislation.

And I would also, if I can, would like to say that I do believe that this legislation should have a waiting period to it. I think that's something that should be added.

In the Oregon legislation it is two requests that are made in verbal, in 15-day-increments apart, and then a written request, and I think that could be added to the bill as a safeguard, and two M.D.s being on the bill, taking a note from Oregon. They do have the original bill legislation and I think the verbiage on that bill is a little more concrete and could be added to this legislation. Thank you. Any questions?

REP. JOHNSON: Thank you. Thank you so much. Yes, Representative Cook.

REP. COOK: One very simple question. Okay? How many people pieces of paper in that pile? Do you know?

SHANNON SANFORD: I stopped counting, believe it or not after 1,500.

REP. JOHNSON: So I was wondering, what made you decide to go into your specialty?

SHANNON SANFORD: My father. He had primary liver cancer and he had it when I was a student and I was unable, unfortunately, to control his pain. He was on hospice service while I was a student and they actually utilized me in the role as his care giver and this was an unfortunate circumstance, but it's one that happens, believe it or not to many families when you have any sort of medical knowledge.

The hospice service will actually tell you if you know anything at all, and even if you don't, they'll actually train you or tell you to give the injections for pain medications to your loved one at home and it becomes sort of unfortunate in a way because you're forced into that role of being a care giver whether you want to or not because they don't have the staff to do this.

And my father required pain medication every two hours, an injectable morphine, (inaudible). I had to inject him with morphine every two hours to control his pain, and by control his pain that meant that he would no longer grimace and groan while he was in a semi-vegetated state.

This was not the quality of life my dad wanted. He actually would tell us when we were, you know, discussing these matters, that he would want to shoot himself if he ever got cancer, and being a nurse, you know, a nursing student at the time, I was not going to shoot him, you know, unfortunately. I, you know, was not as strong as maybe some of these other people that you heard today who said that they actually were able to provide that sort of service to their loved ones, I was not.

I went for hospice service and hospice service was not able to keep his pain under control. Every two hours I injected my dad with (inaudible) morphine. I set an alarm clock, an alarm clock to keep me awake throughout the night. Every two hours it would go off and I would inject him.

I set it just in case I fell asleep. Not that I thought I would, but just in case. On the day he actually died, I did fall asleep and that alarm clock went off at 4:00 a.m. and I woke to find him dead. I pronounced my father and had to call hospice services to come over.

That's not, to me, quality medical care. That's not the hospice service, to me. That's not quality medical care, and that's not a quality of life that my father wanted, but that's the quality of life that a lot of you will see in hospice care where the care giver is the family member and they're relied upon to provide that care. And it's unfortunate. It's very unfortunate, but it's what happens, you know, at hospice service.

REP. JOHNSON: Thank you so much for sharing your story with us and waiting so long and collecting all those letters. And your work as an oncologist nurse, thank you.

SHANNON SANFORD: Thank you.

REP. JOHNSON: Does anybody else have any testimony? Okay. Well, then, I declare this public hearing closed.