Amended in Senate June 1, 2015

Amended in Senate April 14, 2015

Amended in Senate March 17, 2015

Senate BillNo. 128


Introduced by Senators Wolk and Monning

(Principal coauthors: Senators Jackson and Leno)

(Principal coauthors: Assembly Members Alejo and Eggman)

(Coauthors: Senators Block, Hall, Hancock, Hernandez, Hill, McGuire, and Wieckowski)

(Coauthors: Assembly Members Chu, Cooper, Frazier, Cristina Garcia,begin insert Low,end insert Quirk, Rendon, and Mark Stone)

January 20, 2015


An act to add Part 1.85 (commencing with Section 443) to Division 1 of the Health and Safety Code, relating to end of life.

LEGISLATIVE COUNSEL’S DIGEST

SB 128, as amended, Wolk. End of life.

Existing law authorizes an adult to give an individual health care instruction and to appoint an attorney to make health care decisions for that individual in the event of his or her incapacity pursuant to a power of attorney for health care.

This bill would enact the End of Life Option Act authorizing an adult who meets certain qualifications, and who has been determined by his or her attending physician to be suffering from a terminal disease, as defined, to make a request forbegin delete medicationend deletebegin insert a drugend insert prescribed pursuant to these provisions for the purpose of ending his or her life. The bill would establish the procedures for making these requests. The bill would also establish the forms to requestbegin delete aid-in-dying medicationend deletebegin insert an aid-in-dying drugend insert and, under specified circumstances, an interpreter declaration to be signed subject to penalty of perjury, thereby imposing a crime and state-mandated local program.begin insert This bill would require specified information to be documented in the individual’s medical record, including, among other things, all oral and written requests for an aid-in-dying drug.end insert

This bill would prohibit a provision in a contract, will, or other agreement from being conditioned upon or affected by a person making or rescinding a request for the above-describedbegin delete medication.end deletebegin insert drug.end insert The bill would prohibit the sale, procurement, or issuance of any life, health, or accident insurance or annuity policy, health care service plan, contract, or health benefit plan, or the rate charged for any policy or plan contract, from being conditioned upon or affected by the request. The bill would prohibit an insurance carrier from providing any information in communications made to an individual about the availability ofbegin delete aid-in-dying medicationend deletebegin insert an aid-in-dying drugend insert absent a request by the individual, his or her attending physician at the behest of the individual, or the individual’s designee. The bill would also prohibit any communication from containing both the denial of treatment and information as to the availability of aid-in-dyingbegin delete medicationend deletebegin insert drugend insert coverage.

This bill would provide immunity frombegin delete civil or criminalend deletebegin insert civil, criminal, administrative, employment, or contractualend insert liability or professional disciplinary action for participating in good faith compliance with the act, and would specify that the immunities and prohibitions on sanctions of a health care provider are solely reserved for conduct provided for by the bill. The bill would provide that participation in activities authorized pursuant to this bill shall be voluntary. The bill would authorize a health care provider to prohibit its employees, independent contractors, or other persons or entities, including other health care providers, from participating in activities under this act while on the premises owned or under the management or direct control of that prohibiting health care provider, or while acting within the course and scope of any employment by, or contract with, the prohibiting health care provider.

This bill would make it a felony to knowingly alter or forge a request forbegin delete medicationend deletebegin insert drugsend insert to end an individual’s life without his or her authorization or to conceal or destroy abegin insert withdrawal orend insert rescission of a request forbegin delete medicationend deletebegin insert a drugend insert, if it is done with the intent or effect of causing the individual’s death. The bill would make it a felony to knowingly coerce or exert undue influence on an individual to requestbegin delete medicationend deletebegin insert a drugend insert for the purpose of ending his or her life or to destroy abegin insert withdrawal orend insert rescission of a request. By creating a new crime, the bill would impose a state-mandated local program. The bill would provide that nothing in its provisionsbegin insert is toend insert be construed to authorize ending a patient’s life by lethal injection, mercy killing, or active euthanasia, and would provide that action taken in accordance with the act shall not constitute, amongbegin delete others,end deletebegin insert other things,end insert suicide or homicide.

This bill would require the State Public Health Officer to adopt regulations establishing additional reporting requirements for physicians and pharmacists to determine the use of, and compliance with, the act, and would require thebegin delete stateend deletebegin insert Stateend insert Public Health Officer to annually review a sample of certain records and the State Department of Public Health to make a statistical report of the information collected.

begin delete

This bill would require specified information to be documented in the individual’s medical record, including, among other things, all oral and written requests for aid-in-dying medication.

end delete

Existing constitutional provisions require that a statute that limits the right of access to the meetings of public bodies or the writings of public officials and agencies be adopted with findings demonstrating the interest protected by the limitation and the need for protecting that interest.

This bill would make legislative findings to that effect.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated local program: yes.

The people of the State of California do enact as follows:

P3    1

SECTION 1.  

Part 1.85 (commencing with Section 443) is
2added to Division 1 of the Health and Safety Code, to read:

3 

4PART 1.85.  End of Life Option Act

5

 

6

443.  

This part shall be known and may be cited as the End of
7Life Option Act.

P4    1

443.1.  

As used in this part, the following definitions shall apply:

2(a) “Adult” means an individual 18 years of age or older.

3(b) “Aid-in-dyingbegin delete medication”end deletebegin insert drugend insertbegin insertend insert meansbegin delete medicationend deletebegin insert a drugend insert
4 determined and prescribed by a physician for a qualified individual,
5which the qualified individual may choose to self-administer to
6bring about his or her death due to a terminal disease.

7(c) “Attending physician” means the physician who has primary
8responsibility for the health care of an individual and treatment of
9the individual’s terminal disease.

10(d) begin delete“Competent” end deletebegin insert“Capacity to make medical decisions” end insertmeans
11that,begin delete in the opinion of a court orend delete in the opinion of an individual’s
12attending physician, consulting physician, psychiatrist, or
13psychologist,begin delete the individual hasend deletebegin insert pursuant to Section 4609 of the
14Probate Code, the individual has the ability to understand the
15nature and consequences of a health care decision, the ability to
16understand its significant benefits, risks, and alternatives, andend insert
the
17ability to make and communicate an informed decision to health
18care providers, including communication through a person familiar
19with the individual’s manner of communicating, if that person is
20available.

21(e) “Consulting physician” means a physicianbegin insert who is
22independent from the attending physician andend insert
who is qualified by
23specialty or experience to make a professional diagnosis and
24prognosis regarding an individual’s terminal disease.

begin delete

25(f) “Counseling” means one or more consultations, as necessary,
26between an individual and a psychiatrist or psychologist licensed
27in this state for the purpose of determining that the individual is
28competent and is not suffering from a psychiatric or psychological
29disorder or depression causing impaired judgment.

end delete
begin delete

30 (g)

end delete

31begin insert(f)end insert “Department” means the State Department of Public Health.

begin insert

32(g) “End of Life Option Act Checklist” means a checklist
33identifying each and every requirement that must be fulfilled by a
34health care provider to be in good faith compliance with the End
35of Life Option Act should the health care provider choose to
36participate.

end insert

37(h) “Health care provider” or begin delete “provider” means a person
38licensed, certified, or otherwise authorized or permitted by law to
39administer health care or dispense medication in the ordinary
40course of business or practice of a profession, including, but not
P5    1limited to, physicians, doctors of osteopathy, and pharmacists.
2“Health care provider” or “provider” includes a health care facility
3as identified in Section 1250.end delete
begin insert “provider of health care” means
4any person licensed or certified pursuant to Division 2
5(commencing with Section 500) of the Business and Professions
6Code; any person licensed pursuant to the Osteopathic Initiative
7Act or the Chiropractic Initiative Act; any person certified pursuant
8to Division 2.5 (commencing with Section 1797) of this code; and
9any clinic, health dispensary, or health facility licensed pursuant
10to Division 2 (commencing with Section 1200) of this code.end insert

11(i) “Informed decision” means a decision by an individual with
12a terminal disease to request and obtain a prescription for
13begin delete medicationend deletebegin insert a drugend insert that the individual may self-administer to end
14the individual’s life, that is based on an understanding and
15acknowledgment of the relevant facts, and that is made after being
16fully informed by the attending physician of all of the following:

17(1) The individual’s medical diagnosis and prognosis.

18(2) The potential risks associated with taking thebegin delete medicationend delete
19begin insert drugend insert to be prescribed.

20(3) The probable result of taking thebegin delete medicationend deletebegin insert drugend insert to be
21prescribed.

22(4) The possibility that the individual may choose not to obtain
23thebegin delete medicationend deletebegin insert drugend insert or may obtain thebegin delete medicationend deletebegin insert drugend insert but may
24decide not tobegin delete takeend deletebegin insert ingestend insert it.

25(5) The feasible alternatives or additional treatment
26opportunities, including, but not limited to, comfort care, hospice
27care, palliative care, and pain control.

28(j) “Medically confirmed” means the medicalbegin delete opinionend deletebegin insert diagnosis
29and prognosisend insert
of the attending physician has been confirmed by
30a consulting physician who has examined the individual and the
31individual’s relevant medical records.

begin insert

32(k) “Mental health specialist assessment” means one or more
33consultations between an individual and a mental health specialist
34for the purpose of determining that the individual has the capacity
35to make medical decisions and is not suffering from impaired
36judgment due to a mental disorder.

end insert
begin insert

37(l) “Mental health specialist” means a psychiatrist or a licensed
38psychologist.

end insert
begin delete

39 (k)

end delete

P6    1begin insert(m)end insert “Physician” means a doctor of medicine or osteopathy
2currently licensed to practice medicine in this state.

begin delete

3(l)

end delete

4begin insert(n)end insert “Public place” means any street, alley, park, public building,
5any place of business or assembly open to or frequented by the
6public, and any other place that is open to the public view, or to
7which the public has access.

begin delete

8 (m)

end delete

9begin insert(o)end insert “Qualified individual” meansbegin delete a competent adult whoend deletebegin insert an
10adult who has the capacity to make medical decisions andend insert
is a
11resident of California and has satisfied the requirements of this
12part in order to obtain a prescription forbegin delete medicationend deletebegin insert a drugend insert to end
13his or her life.

begin delete

14 (n)

end delete

15begin insert(p)end insert “Self-administer” means a qualified individual’s affirmative,
16conscious, and physical act ofbegin delete usingend deletebegin insert ingestingend insert thebegin delete medicationend delete
17begin insert aid-in-dying drugend insert to bring about his or her own death.

begin delete

18 (o)

end delete

19begin insert(q)end insert “Terminal disease” means an incurable and irreversible
20disease that has been medically confirmed and will, within
21reasonable medical judgment, result in death within six months.

22

443.2.  

(a) Abegin delete competent,end delete qualified individual who is an adult
23withbegin insert the capacity to make medical decisions and withend insert a terminal
24disease may make a request to receive a prescription for
25begin delete aid-in-dying medicationend deletebegin insert an aid-in-dying drugend insert if all of the following
26conditions are satisfied:

27(1) Thebegin delete qualifiedend delete individual’s attending physician has
28begin delete determinedend deletebegin insert diagnosedend insert the individualbegin delete to be suffering fromend deletebegin insert withend insert a
29terminal disease.

30(2) Thebegin delete qualifiedend delete individual has voluntarily expressed the wish
31to receive a prescription forbegin insert anend insert aid-in-dyingbegin delete medication.end deletebegin insert drug.end insert

32(3) Thebegin delete qualifiedend delete individual is a resident of California and is
33able to establish residency through any of the following means:

34(A) Possession of a California driver license or other
35identification issued by the State of California.

36(B) Registration to vote in California.

37(C) Evidence that the person owns or leases property in
38California.

39(D) Filing of a California tax return for the most recent tax year.

P7    1(4) Thebegin delete qualifiedend delete individual documents his or her request
2pursuant to the requirements set forth in Section 443.3.

begin insert

3(5) The individual has the physical and mental ability to
4self-administer the aid-in-dying drug.

end insert

5(b) A personbegin delete may not qualifyend deletebegin insert shall not be considered a
6“qualified individual”end insert
under the provisions of this part solely
7because of age or disability.

8(c) A request for a prescription forbegin delete aid-in-dying medicationend deletebegin insert an
9aid-in-dying drugend insert
under this part shallbegin insert be made solely and directly
10by the individual diagnosed with the terminal disease and shallend insert

11 not be made on behalf of thebegin delete patientend deletebegin insert patient, including, but not
12limited to,end insert
through a power of attorney, an advance health care
13directive,begin delete or a conservator. end deletebegin insert a conservator, health care agent,
14surrogate, or any other legally recognized health care
15decisionmaker.end insert

16

443.3.  

(a) begin deleteA qualified end deletebegin insertAn end insertindividualbegin delete wishing to receiveend deletebegin insert seeking
17to obtainend insert
a prescription forbegin delete aid-in-dying medicationend deletebegin insert an aid-in-dying
18drugend insert
pursuant to this part shall submit two oral requests, a
19minimum of 15 days apart, and a written request to his or her
20attending physician. The attending physicianbegin delete mustend deletebegin insert shall directly,
21and not through a designee,end insert
receive all three requests required
22pursuant to this section.

23(b) A valid written request forbegin delete aid-in-dying medicationend deletebegin insert an
24aid-in-dying drugend insert
under subdivision (a) shall meet all of the
25following conditions:

26(1) The request shall be in substantially the form described in
27Section 443.9.

28(2) The request shall be signed and dated, in the presence of
29two witnesses in accordance with paragraph (3), by thebegin delete qualified
30individualend delete
begin insert individualend insert seeking thebegin delete medication.end deletebegin insert aid-in-dying drug.end insert

31(3) The request shall be witnessed by at least two other adult
32persons who, in the presence of thebegin delete qualifiedend delete individual, shall attest
33that to the best of their knowledge and beliefbegin insert thatend insert thebegin delete qualifiedend delete
34 individual is all of the following:

35(A) begin deleteCompetent. end deletebegin insertA person who has the capacity to make medical
36decisions.end insert

37(B) Acting voluntarily.

38(C) Not being coerced tobegin insert make orend insert sign the request.

39(c) Only one of the two witnesses at the time the written request
40is signed may:

P8    1(1) Be related to the qualified individual by blood, marriage,
2begin insert registered domestic partnership,end insert or adoption or be entitled to a
3portion of thebegin delete person’send deletebegin insert individual’send insert estate upon death.

4(2) Own, operate, or be employed at a health care facility where
5thebegin delete qualifiedend delete individual is receiving medical treatment or resides.

6(d) The attendingbegin delete physicianend deletebegin insert physician, consulting physician, or
7mental health specialistend insert
of thebegin delete qualifiedend delete individual shall not be one
8of the witnesses required pursuant to paragraph (3) of subdivision
9(b).

10

443.4.  

(a) begin deleteA qualified end deletebegin insertAn end insertindividual may at any timebegin insert withdraw
11orend insert
rescind his or her request forbegin delete aid-in-dying medicationend deletebegin insert an
12aid-in-dying drug, or decide not to ingest an aid-in dying drug,end insert

13 without regard to thebegin delete qualifiedend delete individual’s mental state.

14(b) A prescription forbegin delete aid-in-dying medicationend deletebegin insert an aid-in-dying
15drugend insert
provided under this part may not be written without the
16attending physicianbegin insert directly, and not through a designee,end insert offering
17thebegin delete qualifiedend delete individual an opportunity tobegin insert withdraw orend insert rescind the
18request.

19

443.5.  

(a) Before prescribingbegin delete aid-in-dying medication,end deletebegin insert an
20aid-in-dying drug,end insert
the attending physician shall do all of the
21following:

22(1) Make the initial determination of all of the following:

23(A) begin insert(i)end insertbegin insertend insert Whether the requesting adultbegin delete is competent.end deletebegin insert has the
24capacity to make medical decisions.end insert

begin insert

25(ii) If there are indications of a mental disorder, the physician
26shall refer the individual for a mental health specialist assessment.

end insert
begin insert

27(iii) If a mental health specialist assessment referral is made,
28no aid-in-dying drugs shall be prescribed until the mental health
29specialist determines that the individual has the capacity to make
30medical decisions and is not suffering from impaired judgment
31due to a mental disorder.

end insert

32(B) Whether the requesting adult has a terminal disease.

33(C) Whether the requesting adult has voluntarily made the
34request forbegin delete aid-in-dying medicationend deletebegin insert an aid-in-dying drugend insert pursuant
35to Sections 443.2 and 443.3.

36(D) Whether the requesting adult is a qualified individual
37pursuant to subdivision (m) of Section 443.1.

38(2) begin deleteEnsure the qualified end deletebegin insertConfirm that the end insertindividual is making
39an informed decision by discussing with him or her all of the
40following:

P9    1(A) His or her medical diagnosis and prognosis.

2(B) The potential risks associated withbegin delete takingend deletebegin insert ingestingend insert the
3begin insert requestedend insert aid-in-dyingbegin delete medication to be prescribed.end deletebegin insert drug.end insert

4(C) The probable result ofbegin delete takingend deletebegin insert ingestingend insert the aid-in-dying
5begin delete medication to be prescribed.end deletebegin insert drug.end insert

6(D) The possibility that he or she may choose to obtain the
7aid-in-dyingbegin delete medicationend deletebegin insert drugend insert but not take it.

8(E) The feasible alternatives or additional treatment
9begin delete opportunities,end deletebegin insert options,end insert including, but not limited to, comfort care,
10hospice care, palliative care, and pain control.

11(3) Refer thebegin delete qualifiedend delete individual to a consulting physician for
12medical confirmation of the diagnosis and prognosis, and for a
13determination that thebegin delete qualified individual is competentend deletebegin insert individual
14has the capacity to make medical decisionsend insert
and has complied with
15the provisions of this part.

begin delete

16(4) Refer the qualified individual for counseling if appropriate.
17No aid-in-dying medication shall be prescribed until the person
18performing the counseling determines that the patient is not
19suffering from a psychiatric or psychological disorder or depression
20causing impaired judgment.

end delete
begin delete

21 (5) Ensure

end delete

22begin insert (4)end insertbegin insertend insertbegin insertConfirmend insert that the qualified individual’s request does not
23arise from coercion or undue influence by another person by
24discussing with the qualified individual, outside of the presence
25of any other persons, whether or not the qualified individual is
26feeling coerced or unduly influenced by another person.

begin delete

27 (6)

end delete

28begin insert(5)end insert Counsel the qualified individual about the importance of all
29of the following:

30(A) Having another person present when he or shebegin delete takesend deletebegin insert ingestsend insert
31 the aid-in-dyingbegin delete medicationend deletebegin insert drugend insert prescribed pursuant to this part.

32(B) Notbegin delete takingend deletebegin insert ingestingend insert the aid-in-dyingbegin delete medicationend deletebegin insert drugend insert in a
33public place.

34(C) Notifying the next of kin of his or her request for
35begin delete aid-in-dying medication.end deletebegin insert an aid-in-dying drug.end insert A qualified
36individual who declines or is unable to notify next of kin shall not
37have his or her request denied for that reason.

38(D) Participating in a hospice program.

begin insert

39(E) Maintaining the aid-in-dying drug in a safe and secure
40location until the time that the qualified individual will ingest it.

end insert
begin delete

P10   1(7)

end delete

2begin insert(6)end insert Inform thebegin delete qualifiedend delete individual that he or she maybegin insert withdraw
3orend insert
rescind the request forbegin delete aid-in-dying medicationend deletebegin insert an aid-in-dying
4drugend insert
at any time and in any manner.

begin delete

5(8)

end delete

6begin insert(7)end insert Offer thebegin delete qualifiedend delete individual an opportunity tobegin insert withdraw
7orend insert
rescind the request forbegin delete aid-in-dying medicationend deletebegin insert an aid-in-dying
8drugend insert
before prescribing the aid-in-dyingbegin delete medication.end deletebegin insert drug.end insert

begin delete

9(9)

end delete

10begin insert(8)end insert Verify, immediately prior to writing the prescription for
11aid-in-dyingbegin delete medication,end deletebegin insert drug,end insert that the qualified individual is
12making an informed decision.

begin delete

13(10) Ensure

end delete

14begin insert (9)end insertbegin insertend insertbegin insertConfirmend insert that allbegin insert requirements are met and allend insert appropriate
15steps are carried out in accordance with this part before writing a
16prescription forbegin delete aid-in-dying medication.end deletebegin insert an aid-in-dying drug.end insert

begin delete

17(11)

end delete

18begin insert(10)end insert Fulfill the record documentation required under Sections
19begin delete 443.16 and 443.19.end deletebegin insert 443.7 and 443.17.end insert

begin insert

20(11) Complete the End of Life Option Act Checklist and include
21it in the individual’s medical record.

end insert

22(b) If the conditions set forth in subdivision (a) are satisfied,
23the attending physician may deliver the aid-in-dyingbegin delete medicationend delete
24begin insert drugend insert in any of the following ways:

25(1) begin deleteDispense aid-in-dying medications end deletebegin insertDispensing the
26aid-in-dying drug end insert
directly, including ancillary medication intended
27to minimize the qualified individual’s discomfort, if the attending
28physician meets all of the following criteria:

29(A) Is authorized to dispense medicine under California law.

30(B) Has a current United States Drug Enforcement
31Administration (USDEA) certificate.

32(C) Complies with any applicable administrative rule or
33regulation.

34(2) With the qualified individual’s written consent,begin delete the attending
35physician may contactend delete
begin insert contactingend insert a pharmacist,begin delete informend deletebegin insert informingend insert
36 the pharmacist of the prescriptions, andbegin delete deliverend deletebegin insert deliveringend insert the
37written prescriptions personally, by mail, or electronically to the
38pharmacist, who may dispense thebegin delete medicationsend deletebegin insert drugend insert to the qualified
39individual, the attending physician, or a person expressly
P11   1designated by the qualified individual and with the designation
2delivered to the pharmacist in writing or verbally.

3(c) Delivery of the dispensedbegin delete medicationend deletebegin insert drugend insert to the qualified
4individual, the attending physician, or a person expressly
5designated by the qualified individual may be madebegin delete by:end deletebegin insert byend insert personal
6delivery,begin insert or, with a signature required on deliverend insertbegin inserty, byend insert United Parcel
7Service, United States Postal Service, Federal Express, or by
8messengerbegin delete service with a signature required at delivery.end deletebegin insert service.end insert

9

443.6.  

Prior to a qualified individual obtainingbegin delete aid-in-dying
10medicationend delete
begin insert an aid-in-dying drugend insert from the attending physician, the
11consulting physician shall perform all of the following:

12(a) Examine thebegin delete qualifiedend delete individual and his or her relevant
13medical records.

14(b) Confirm in writing the attending physician’s diagnosis and
15prognosis.

16(c) begin deleteVerify, in the opinion of the consulting physician, that the
17qualified individual is competent, end delete
begin insertDetermine that the individual
18has capacity to make medical decisions, is end insert
acting voluntarily, and
19has made an informed decision.

begin insert

20(d) If there are indications of a mental disorder, the consulting
21physician shall refer the individual for a mental health specialist
22assessment.

end insert
begin delete

23 (d)

end delete

24begin insert(e)end insert Fulfill the record documentation required underbegin delete Sections
25443.16 and 443.19.end delete
begin insert this part.end insert

begin delete
26

443.7.  

(a) Unless otherwise prohibited by law, the attending
27physician may sign the qualified individual’s death certificate.

28(b) The cause of death listed on the death certificate of an
29individual who uses aid-in-dying medication shall be the underlying
30terminal disease.

end delete
begin insert
31

begin insert443.7.end insert  

All of the following shall be documented in the
32individual’s medical record:

33(a) All oral requests for aid-in-dying drugs.

34(b) All written requests for aid-in-dying drugs.

35(c) The attending physician’s diagnosis and prognosis, and the
36determination that a qualified individual has the capacity to make
37medical decisions, is acting voluntarily, and has made an informed
38decision, or that the attending physician has determined that the
39individual is not a qualified individual.

P12   1(d) The consulting physician’s diagnosis and prognosis, and
2verification that the qualified individual has the capacity to make
3medical decisions, is acting voluntarily, and has made an informed
4decision, or that the consulting physician has determined that the
5individual is not a qualified individual.

6(e) A report of the outcome and determinations made during a
7mental health specialist’s assessment, if performed.

8(f) The attending physician’s offer to the qualified individual
9to withdraw or rescind his or her request at the time of the
10individual’s second oral request.

11(g) A note by the attending physician indicating that all
12requirements under Sections 443.5 and 443.6 have been met and
13indicating the steps taken to carry out the request, including a
14notation of the aid-in-dying drug prescribed.

end insert
15

443.8.  

A qualified individual may not receive a prescription
16forbegin delete aid-in-dying medicationend deletebegin insert an aid-in-dying drugend insert pursuant to this
17begin delete part,end deletebegin insert partend insert unless he or she has made an informed decision.
18Immediately before writing a prescription forbegin delete aid-in-dying
19medicationend delete
begin insert an aid-in-dying drugend insert under this part, the attending
20physician shall verify that the individual is making an informed
21decision.

22

443.9.  

(a) A request forbegin delete aid-in-dying medicationend deletebegin insert an
23aid-in-dying drugend insert
as authorized by this part shall be in substantially
24the following form:


25

 

REQUEST FORbegin delete MEDICATIONend deletebegin insert AN AID-IN-DYING DRUGend insert TO END MY LIFE IN A HUMANE AND DIGNIFIED MANNER I, ......................................................, am an adult of sound mind and a resident of the State of California.
I am suffering from ................, which my attending physician has determined is in its terminal phase and which has been medically confirmed.
I have been fully informed of my diagnosis and prognosis, the nature of the aid-in-dyingbegin delete medicationend deletebegin insert drugend insert to be prescribed and potential associated risks, the expected result, and the feasible alternatives or additional treatmentbegin delete opportunities,end deletebegin insert options,end insert including comfort care, hospice care, palliative care, and pain control.
I request that my attending physician prescribebegin delete medicationend deletebegin insert an aid-in-dying drugend insert that will end my life in a humane and dignified manner if I choose to take it, and I authorize my attending physician to contact any pharmacist about my request.
INITIAL ONE:
............ I have informed one or more members of my family of my decision and taken their opinions into consideration.
............ I have decided not to inform my family of my decision.
............ I have no family to inform of my decision.
I understand that I have the right tobegin insert withdraw orend insert rescind this request at any time.
I understand the full import of this request and I expect to die if I take the aid-in-dyingbegin delete medicationend deletebegin insert drugend insert to be prescribed. My attending physician has counseled me about the possibility that my death may not be immediately upon the consumption of thebegin delete medication.end deletebegin insert drug.end insert
I make this request voluntarily, without reservation, and without being coerced.
 
Signed:..............................................
Dated:...............................................
 
 
DECLARATION OF WITNESSES
We declare that the person signing this request:
(a) is personally known to us or has provided proof of identity;
(b) signed this request in our presence;
(c) is an individual whom we believe to be of sound mind and not under duress, fraud, or undue influence; and
(d) is not an individual for whom either of us is the attendingbegin delete physician.end deletebegin insert physician, consulting physician, or mental health specialist.end insert
............................Witness 1/Date
............................Witness 2/Date
NOTE: Only one of the two witnesses may be a relative (by blood, marriage,begin insert registered domestic partnership,end insert or adoption) of the person signing this request or be entitled to a portion of the person’s estate upon death. Only one of the two witnesses may own, operatebegin insert,end insert or be employed at a health care facility where the person is a patient or resident.
P13  335P13  22

 

34(b) (1) The written language of the request shall be written in
35the same translated language as any conversations, consultations,
36or interpreted conversations or consultations between a patient and
37his or her attending or consulting physicians.

38(2) Notwithstanding paragraph (1), the written request may be
39prepared in English evenbegin delete whereend deletebegin insert whenend insert the conversations or
40consultations or interpreted conversations or consultationsbegin delete whereend delete
P14   1begin insert wereend insert conducted in a language other than English if the English
2language form includes an attached interpreter’s declaration that
3is signed under penalty of perjury. The interpreter’s declaration
4shall state words to the effect that:

 

I (INSERT NAME OF INTERPRETER), am fluent in English and (INSERT TARGET LANGUAGE).

On (insert date) at approximately (insert time), I read the “Request forbegin delete Medicationend deletebegin insert an Aid-In-Dying Drugend insert to End My Life” to (insert name of individual/patient) in (insert target language).

Mr./Ms. (insert name of patient/qualified individual) affirmed to me that he/she understood the content of this form and affirmed his/her desire to sign this form under his/her own power and volition and that the request to sign the form followed consultations with an attending and consulting physician.

I declare that I am fluent in English and (insert target language) and further declare under penalty of perjury that the foregoing is true and correct.

Executed at (insert city, county, and state) on this (insert day of month) of (insert month), (insert year).

X______Interpreter signature

X______Interpreter printed name

X______Interpreter address

P13  22

 

23(3) An interpreterbegin insert whose services areend insert providedbegin delete byend deletebegin insert pursuant toend insert
24 paragraph (2) shall not be related to the qualified individual by
25blood, marriage,begin insert registered domestic partnership,end insert or adoption or
26be entitled to a portion of the person’s estate upon death. An
27interpreterbegin insert whose services areend insert providedbegin delete byend deletebegin insert pursuant toend insert paragraph
28(2) shall meet the standards promulgated by the California
29Healthcarebegin delete Interpretersend deletebegin insert Interpretingend insert Association or the National
30Council on Interpreting in Health Care or other standards deemed
31acceptablebegin insert by the departmentend insert for health care providers in
32California.

33

443.10.  

(a) A provision in a contract, will, or otherbegin delete agreement,end delete
34begin insert agreement executed on or after January 1, 2016,end insert whether written
35or oral, to the extent the provision would affect whether a person
36maybegin delete makeend deletebegin insert make, withdraw,end insert or rescind a request forbegin delete aid-in-dying
37medication,end delete
begin insert an aid-in-dying drugend insert is not valid.

38(b) An obligation owing under any contractbegin delete in effectend deletebegin insert executedend insert
39 on or after January 1, 2016, may not be conditioned or affected by
P15   1a qualified individualbegin delete makingend deletebegin insert making, withdrawing,end insert or rescinding
2a request forbegin delete aid-in-dying medication. end deletebegin insert an aid-in-dying drug.end insert

3

443.11.  

(a) The sale, procurement, or issuance of a life, health,
4begin insert orend insert accident insurance or annuity policy, health care service plan
5contract, or health benefit plan, or the rate charged for a policy or
6plan contract may not be conditioned upon or affected by a person
7making or rescinding a request forbegin delete aid-in-dying medication.end deletebegin insert an
8aid-in-dying drug.end insert

9(b) Notwithstanding any other law, a qualified individual’s act
10of self-administeringbegin delete aid-in-dying medicationend deletebegin insert an aid-in-dying drugend insert
11 may not have an effect upon a life, health, or accident insurance
12or annuity policy other than that of a natural death from the
13underlying disease.

14(c) An insurance carrier shall not provide any information in
15communications made to an individual about the availability of
16begin delete aid-in-dying medicationend deletebegin insert an aid-in-dying drugend insert absent a request by
17the individual, his or her attending physician at the behest of the
18individual, or the individual’s designee. Any communication shall
19not include both the denial of treatment and information as to the
20availability of aid-in-dyingbegin delete medicationend deletebegin insert drugend insert coverage. For the
21purposes of this subdivision, “insurance carrier” means a health
22care service planbegin delete pursuant toend deletebegin insert as defined inend insert Section 1345begin insert of this
23codeend insert
or abegin delete health insurer pursuant toend deletebegin insert carrier of health insurance as
24defined inend insert
Section 106 of the Insurance Code.

25

443.12.  

(a) Notwithstanding any other law, a person shall not
26be subject tobegin delete civil or criminalend deletebegin insert civil, criminal, administrative,
27employment, or contractualend insert
liability or professional disciplinary
28action for participating in good faith compliance with this part,
29including an individual who is present when a qualified individual
30self-administers the prescribed aid-in-dyingbegin delete medication.end deletebegin insert drug.end insert

31(b) A health care provider or professional organization or
32association shall not subject an individual to censure, discipline,
33suspension, loss of license, loss of privileges, loss of membership,
34or other penalty for participating in good faith compliance with
35this part or for refusing to participate in accordance with
36subdivisionbegin delete (d).end deletebegin insert (e).end insert

begin insert

37(c) Notwithstanding any other law, a health care provider shall
38not be subject to civil, criminal, administrative, disciplinary,
39employment, credentialing, professional discipline, contractual
40liability, or medical staff action, sanction, or penalty or other
P16   1liability for participating in this part, including, but not limited
2 to, determining the diagnosis or prognosis of an individual,
3determining the capacity of an individual for purposes of qualifying
4for the act, providing information to an individual regarding this
5part, and providing a referral to a physician who participates in
6this part.

end insert
begin delete

7 (c)

end delete

8begin insert(d)end insert (1) A request by a qualified individual to an attending
9physician to providebegin delete aid-in-dying medicationend deletebegin insert an aid-in-dying drugend insert
10 in good faith compliance with the provisions of this part shall not
11provide the sole basis for the appointment of a guardian or
12conservator.

13(2) begin deleteA request by an individual to a pharmacist to dispense
14aid-in-dying medication in good faith end delete
begin insertNo actions taken in end insert
15compliance with the provisions of this part shallbegin delete notend delete constitutebegin insert or
16provide the basis for any claim ofend insert
neglect or elder abuse for any
17purpose of law.

begin delete

18 (d)

end delete

19begin insert(e)end insert (1) Participation in activities authorized pursuant to this
20part shall be voluntary. A person or entity that elects, for reasons
21of conscience, morality, or ethics, not to engage in activities
22authorized pursuant to this part is not required to take any action
23in support of a patient’s decision under this part, except as required
24by Sections 442begin delete throughend deletebegin insert toend insert 442.7, inclusive.

25(2) If a health care provider is unable or unwilling to carry out
26a qualified individual’s request under this part and the qualified
27individual transfers care to a new health care provider,begin delete the prior
28health care provider shall transfer, upon request, a copy of the
29qualified individual’s relevant medical records to the new health
30care provider.end delete
begin insert the individual may request a copy of his or her
31medical records pursuant to law.end insert

begin delete

32(e) (1) Subject to paragraph (2), notwithstanding any other law,
33a health care provider may prohibit its employees, independent
34contractors, or other persons or entities, including other health care
35providers, from participating in activities under this part while on
36premises owned or under the management or direct control of that
37prohibiting health care provider or while acting within the course
38and scope of any employment by, or contract with, the prohibiting
39health care provider.

P17   1(2) A health care provider that elects to prohibit its employees,
2independent contractors, or other persons or entities, including
3health care providers, from participating in activities under this
4part, as described in paragraph (1), shall first give notice of the
5policy prohibiting participation in this part to the individual or
6entity. A health care provider that fails to provide notice to an
7individual or entity in compliance with this paragraph shall not be
8entitled to enforce such a policy against that individual or entity.

9(3) Subject to compliance with paragraph (2), the prohibiting
10health care provider may take action, including, but not limited
11to, the following, as applicable, against any individual or entity
12that violates this policy:

13(A) Loss of privileges, loss of membership, or other action
14authorized by the bylaws or rules and regulations of the medical
15staff.

16(B) Suspension, loss of employment, or other action authorized
17by the policies and practices of the prohibiting health care provider.

18(C) Termination of any lease or other contract between the
19prohibiting health care provider and the individual or entity that
20violates the policy.

21(D) Imposition of any other nonmonetary remedy provided for
22in any lease or contract between the prohibiting health care provider
23and the individual or entity in violation of the policy.

24(4) Nothing in this subdivision shall be construed to prevent,
25or to allow a prohibiting health care provider to prohibit any other
26health care provider, employee, independent contractor, or other
27person or entity from any of the following:

28(A) Participating, or entering into an agreement to participate,
29in activities under this part, while on premises that are not owned
30or under the management or direct control of the prohibiting
31provider or while acting outside the course and scope of the
32participant’s duties as an employee of, or an independent contractor
33for, the prohibiting health care provider.

34(B) Participating, or entering into an agreement to participate,
35in activities under this part as an attending physician or consulting
36physician while on premises that are not owned or under the
37management or direct control of the prohibiting provider.

38(5) In taking actions pursuant to paragraph (3), a health care
39provider shall comply with all procedures required by law, its own
P18   1policies or procedures, and any contract with the individual or
2entity in violation of the policy, as applicable.

3(6) For purposes of this subdivision:

4(A) “Notice” means a separate statement in writing advising of
5the prohibiting health care provider policy with respect to
6participating in activities under this part.

7(B) “Participating, or entering into an agreement to participate,
8in activities under this part” means doing or entering into an
9agreement to do any one or more of the following:

10(i) Performing the duties of an attending physician specified in
11Section 443.5.

12(ii) Performing the duties of a consulting physician specified in
13Section 443.6.

14(iii) Delivering the prescription for, dispensing, or delivering
15the dispensed aid-in-dying medication pursuant to paragraph (2)
16of subdivision (b) of, and subdivision (c) of, Section 443.5.

17(iv) Being present when the qualified individual takes the
18aid-in-dying medication prescribed pursuant to this part.

19(C) “Participating, or entering into an agreement to participate,
20in activities under this part” does not include doing, or entering
21into an agreement to do, any of the following:

22(i) Making an initial determination that a patient has a terminal
23illness and informing the patient of the medical prognosis.

24(ii) Providing information to a patient about the End of Life
25Option Act.

26(iii) Providing a patient, upon the patient’s request, with a
27referral to another health care provider for the purposes of
28participating in the activities authorized by the End of Life Option
29Act.

30(7) Any action taken by a prohibiting provider pursuant to this
31subdivision shall not be reportable under Sections 800 through
32809.9, inclusive, of the Business and Professions Code. The fact
33that a health care provider participates in activities under this part
34shall not be the sole basis for a complaint or report by another
35health care provider of unprofessional or dishonorable conduct
36under Sections 800 through 809.9, inclusive, of the Business and
37Professions Code.

38(f) Nothing in this part shall prevent a health care provider from
39providing an individual with health care services that do not
40constitute participation in this part.

end delete
begin insert
P19   1

begin insert443.13.end insert  

(a) Subject to subdivision (b), notwithstanding any
2other law, a health care provider may prohibit its employees,
3independent contractors, or other persons or entities, including
4other health care providers, from participating in activities under
5this part while on premises owned or under the management or
6direct control of that prohibiting health care provider or while
7acting within the course and scope of any employment by, or
8contract with, the prohibiting health care provider.

9(b) A health care provider that elects to prohibit its employees,
10independent contractors, or other persons or entities, including
11health care providers, from participating in activities under this
12part, as described in subdivision (a), shall first give notice of the
13 policy prohibiting participation under this part to the individual
14or entity. A health care provider that fails to provide notice to an
15individual or entity in compliance with this subdivision shall not
16be entitled to enforce such a policy against that individual or entity.

17(c) Subject to compliance with subdivision (b), the prohibiting
18health care provider may take action, including, but not limited
19to, the following, as applicable, against any individual or entity
20that violates this policy:

21(1) Loss of privileges, loss of membership, or other action
22authorized by the bylaws or rules and regulations of the medical
23staff.

24(2) Suspension, loss of employment, or other action authorized
25by the policies and practices of the prohibiting health care
26provider.

27(3) Termination of any lease or other contract between the
28prohibiting health care provider and the individual or entity that
29violates the policy.

30(4) Imposition of any other nonmonetary remedy provided for
31in any lease or contract between the prohibiting health care
32provider and the individual or entity in violation of the policy.

33(d) Nothing in this section shall be construed to prevent, or to
34allow a prohibiting health care provider to prohibit any other
35health care provider, employee, independent contractor, or other
36person or entity from any of the following:

37(1) Participating, or entering into an agreement to participate,
38in activities under this part, while on premises that are not owned
39or under the management or direct control of the prohibiting
40provider or while acting outside the course and scope of the
P20   1participant’s duties as an employee of, or an independent
2contractor for, the prohibiting health care provider.

3(2) Participating, or entering into an agreement to participate,
4in activities under this part as an attending physician or consulting
5physician while on premises that are not owned or under the
6management or direct control of the prohibiting provider.

7(e) In taking actions pursuant to subdivision (c), a health care
8provider shall comply with all procedures required by law, its own
9policies or procedures, and any contract with the individual or
10entity in violation of the policy, as applicable.

11(f) For purposes of this section:

12(1) “Notice” means a separate statement in writing advising
13of the prohibiting health care provider policy with respect to
14participating in activities under this part.

15(2) “Participating, or entering into an agreement to participate,
16in activities under this part” means doing or entering into an
17agreement to do any one or more of the following:

18(A) Performing the duties of an attending physician as specified
19in Section 443.5.

20(B) Performing the duties of a consulting physician as specified
21in Section 443.6.

22(C) Performing the duties of a mental health specialist, in the
23circumstance that a referral to one is made.

24(D) Delivering the prescription for, dispensing, or delivering
25the dispensed aid-in-dying drug pursuant to paragraph (2) of
26subdivision (b) of, and subdivision (c) of, Section 443.5.

27(E) Being present when the qualified individual takes the
28aid-in-dying drug prescribed pursuant to this part.

29(3) “Participating, or entering into an agreement to participate,
30in activities under this part” does not include doing, or entering
31into an agreement to do, any of the following:

32(A) Diagnosing whether a patient has a terminal disease,
33informing the patient of the medical prognosis, or determining
34whether a patient has the capacity to make decisions.

35(B) Providing information to a patient about this part.

36(C) Providing a patient, upon the patient’s request, with a
37referral to another health care provider for the purposes of
38participating in the activities authorized by this part.

39(g) Any action taken by a prohibiting provider pursuant to this
40section shall not be reportable under Sections 800 to 809.9,
P21   1inclusive, of the Business and Professions Code. The fact that a
2health care provider participates in activities under this part shall
3not be the sole basis for a complaint or report by another health
4care provider of unprofessional or dishonorable conduct under
5Sections 800 to 809.9, inclusive, of the Business and Professions
6Code.

7(h) Nothing in this part shall prevent a health care provider
8from providing an individual with health care services that do not
9constitute participation in this part.

end insert
10

begin delete443.13.end delete
11begin insert443.14.end insert  

(a) A health care provider may not be sanctioned for
12any of the following:

13(1) Making an initial determination pursuant to the standard of
14care that an individual has a terminal disease and informing him
15or her of the medical prognosis.

16(2) Providing information about the End of Life Option Act to
17a patient upon the request of the individual.

18(3) Providing an individual, upon request, with a referral to
19another physician.

20(b) A health care provider that prohibits activities under this
21part in accordance withbegin delete subdivision (e) of Section 443.12end deletebegin insert Section
22443.13end insert
shall not sanction an individual health care provider for
23contracting with a qualified individual to engage in activities
24authorized by this part if the individual health care provider is
25acting outside of the course and scope of his or her capacity as an
26employee or independent contractor of the prohibiting health care
27provider.

28(c) Notwithstanding any contrary provision in this section, the
29immunities and prohibitions on sanctions of a health care provider
30are solely reserved for actions taken pursuant to thisbegin delete partend deletebegin insert part,end insert and
31those health care providers may be sanctioned for conduct and
32actions not included and provided for in this part if the conduct
33and actions do not comply with the standards and practices set
34forth by the Medical Board of California.

35

begin delete443.14.end delete
36begin insert443.15.end insert  

(a) Knowingly altering or forging a request for
37begin delete aid-in-dying medicationend deletebegin insert an aid-in-dying drugend insert to end an individual’s
38life without his or her authorization or concealing or destroying a
39begin insert withdrawal orend insert rescission of a request forbegin delete aid-in-dying medication end delete
P22   1begin insert an aid-in-dying drug end insertis punishable as a felony if the act is done
2with the intent or effect of causing the individual’s death.

3(b) Knowingly coercing or exerting undue influence on an
4individual to requestbegin delete aid-in-dying medicationend deletebegin insert an aid-in-dying drugend insert
5 for the purpose of ending his or her life or to destroy abegin insert withdrawal
6orend insert
rescission of a request is punishable as a felony.

7(c) For purposes of this section, “knowingly” has the meaning
8provided in Section 7 of the Penal Code.

9(d) Nothing in this section shall be construed to limit civil
10liability.

11(e) The penalties in this section do not preclude criminal
12penalties applicable under any law for conduct inconsistent with
13the provisions of thisbegin delete part.end deletebegin insert section.end insert

14

begin delete443.15.end delete
15begin insert443.16.end insert  

Nothing in this part may be construed to authorize a
16physician or any other person to end an individual’s life by lethal
17injection, mercy killing, or active euthanasia. Actions taken in
18accordance with this part shall not, for any purposes, constitute
19suicide, assisted suicide,begin delete mercy killing,end delete homicide, or elder abuse
20under the law.

21

begin delete443.16.end delete
22begin insert443.17.end insert  

(a) The State Public Health Officer shall annually
23review a sample of records maintained pursuant to Sectionbegin delete 443.19end delete
24begin insert 443.7end insert and shall adopt regulations establishing additional reporting
25requirements for physicians and pharmacists pursuant to this part.

26(b) The reporting requirements shall be designed to collect
27information to determine utilization and compliance with this part.
28The information collected shall be confidential and shall be
29collected in a manner that protects the privacy of the patient, the
30patient’s family, and any medical provider or pharmacist involved
31with the patient under the provisions of this part.

32(c) Based on the information collected, the department shall
33provide an annual compliance and utilization statistical report
34aggregated by age, gender, race, ethnicity, and primary language
35spoken at home and other data the department may determine
36relevant. The department shall make the report public within 30
37days of completion of each annual report.

begin insert

38(d) The State Public Health Officer shall make available to
39health care providers the End of Life Option Act Checklist by
40posting it on its Internet Web site.

end insert
P23   1

begin delete443.17.end delete
2begin insert443.18.end insert  

A person who has custody or control of any unused
3aid-in-dyingbegin delete medicationend deletebegin insert drugsend insert prescribed pursuant to this part after
4the death of the patient shall personally deliver the unused
5aid-in-dyingbegin delete medicationend deletebegin insert drugsend insert for disposal by delivering it to the
6nearest qualified facility that properly disposes of controlled
7substances, or if none is available, shall dispose of it by lawful
8begin delete means. end deletebegin insert means in accordance with guidelines promulgated by the
9California State Board of Pharmacy or a federal Drug Enforcement
10Administration approved take back program.end insert

11

begin delete443.18.end delete
12begin insert443.19.end insert  

Any governmental entity that incurs costs resulting
13from a qualified individual terminating his or her life pursuant to
14the provisions of this part in a public place shall have a claim
15against the estate of the qualified individual to recover those costs
16and reasonable attorney fees related to enforcing the claim.

begin delete
17

443.19.  

All of the following shall be documented in the
18individual’s medical record:

19(a) All oral requests for aid-in-dying medication.

20(b) All written requests for aid-in-dying medication.

21(c) The attending physician’s diagnosis and prognosis,
22determination that a qualified individual is competent, acting
23voluntarily, and has made an informed decision, or that the
24attending physician has determined that the individual is not a
25qualified individual.

26(d) The consulting physician’s diagnosis and prognosis, and
27verification that the qualified individual is competent, acting
28 voluntarily, and has made an informed decision, or that the
29consulting physician has determined that the individual is not a
30qualified individual.

31(e) A report of the outcome and determinations made during
32counseling, if performed.

33(f) The attending physician’s offer to the qualified individual
34to rescind his or her request at the time of the qualified individual’s
35second oral request.

36(g) A note by the attending physician indicating that all
37requirements under Sections 443.5 and 443.6 have been met and
38indicating the steps taken to carry out the request, including a
39notation of the aid-in-dying medication prescribed.

end delete
P24   1

SEC. 2.  

The Legislature finds and declares that Section 1 of
2this act, which adds Sectionbegin delete 443.16end deletebegin insert 443.17end insert to the Health and Safety
3Code, imposes a limitation on the public’s right of access to the
4meetings of public bodies or the writings of public officials and
5agencies within the meaning of Section 3 of Article I of the
6California Constitution. Pursuant to that constitutional provision,
7the Legislature makes the following findings to demonstrate the
8interest protected by this limitation and the need for protecting
9that interest:

10(a) Any limitation to public access to personally identifiable
11patient data collected pursuant to Sectionbegin delete 443.16end deletebegin insert 443.17end insert of the
12Health and Safety Code as proposed to be added by this act is
13necessary to protect the privacy rights of the patient and his or her
14family.

15(b) The interests in protecting the privacy rights of the patient
16and his or her family in this situation strongly outweigh the public
17interest in having access to personally identifiable data relating to
18services.

19(c) The statistical report to be made available to the public
20pursuant to subdivision (c) of Sectionbegin delete 443.16end deletebegin insert 443.17end insert of the Health
21and Safety Code is sufficient to satisfy the public’s right to access.

22

SEC. 3.  

The provisions of this part are severable. If any
23provision of this part or its application is held invalid, that
24invalidity shall not affect other provisions or applications that can
25be given effect without the invalid provision or application.

26

SEC. 4.  

No reimbursement is required by this act pursuant to
27Section 6 of Article XIII B of the California Constitution because
28the only costs that may be incurred by a local agency or school
29district will be incurred because this act creates a new crime or
30infraction, eliminates a crime or infraction, or changes the penalty
31for a crime or infraction, within the meaning of Section 17556 of
32the Government Code, or changes the definition of a crime within
33the meaning of Section 6 of Article XIII B of the California
34Constitution.



O

    96