S.Amdt. 3239

SA 3239. Mr. ROCKEFELLER (for himself, Ms. Collins, and Mr. Kohl)
submitted an amendment intended to be proposed to amendment SA 2786
proposed by Mr. Reid (for himself, Mr. Baucus, Mr. Dodd, and Mr.
Harkin) to the bill H.R. 3590, to amend the Internal Revenue Code of
1986 to modify the first-time homebuyers credit in the case of members
of the Armed Forces and certain other Federal employees, and for other
purposes; which was ordered to lie on the table; as follows:

On page 2074, after line 25, add the following:

TITLE X--ADVANCE CARE PLANNING AND COMPASSIONATE CARE

SECTION 10001. SHORT TITLE.

This title may be cited as the ``Advance Planning and
Compassionate Care Act of 2009''.

SEC. 10002. DEFINITIONS.

In this title:
(1) Advance care planning.--The term ``advance care
planning'' means the process of--
(A) determining an individual's priorities, values and
goals for care in the future when the individual is no longer
able to express his or her wishes;
(B) engaging family members, health care proxies, and
health care providers in an ongoing dialogue about--
(i) the individual's wishes for care;
(ii) what the future may hold for people with serious
illnesses or injuries;
(iii) how individuals, their health care proxies, and
family members want their beliefs and preferences to guide
care decisions; and
(iv) the steps that individuals and family members can take
regarding, and the resources available to help with,
finances, family matters, spiritual questions, and other
issues that impact seriously ill or dying patients and their
families; and
(C) executing and updating advance directives and
appointing a health care proxy.
(2) Advance directive.--The term ``advance directive''
means a living will, medical directive, health care power of
attorney, durable power of attorney, or other written
statement by a competent individual that is recognized under
State law and indicates the individual's wishes regarding
medical treatment in the event of future incompetence. Such
term includes an advance health care directive and a health
care directive recognized under State law.
(3) CHIP.--The term ``CHIP'' means the program established
under title XXI of the Social Security Act (42 U.S.C. 1397aa
et seq.).
(4) End-of-life-care.--The term ``end-of-life care'' means
all aspects of care of a patient with a potentially fatal
condition, and includes care that is focused on specific
preparations for an impending death.
(5) Health care power of attorney.--The term ``health care
power of attorney'' means a legal document that identifies a
health care proxy or decisionmaker for a patient who has the
authority to act on the patient's behalf when the patient is
unable to communicate his or her wishes for medical care on
matters that the patient specifies when he or she is
competent. Such term includes a durable power of attorney
that relates to medical care.
(6) Living will.--The term ``living will'' means a legal
document--
(A) used to specify the type of medical care (including any
type of medical treatment, including life-sustaining
procedures if that person becomes permanently unconscious or
is otherwise dying) that an individual wants provided or
withheld in the event the individual cannot speak for himself
or herself and cannot express his or her wishes; and
(B) that requires a physician to honor the provisions of
upon receipt or to transfer the care of the individual
covered by the document to another physician that will honor
such provisions.
(7) Medicaid.--The term ``Medicaid'' means the program
established under title XIX of the Social Security Act (42
U.S.C. 1396 et seq.).
(8) Medicare.--The term ``Medicare'' means the program
established under title XVIII of the Social Security Act (42
U.S.C. 1395 et seq.).
(9) Orders for life-sustaining treatment.--The term
``orders for life-sustaining treatment'' means a process for
focusing a patients' values, goals, and preferences on
current medical circumstances and to translate such into
visible and portable medical orders applicable across care
settings, including home, long-term care, emergency medical
services, and hospitals.
(10) Palliative care.--The term ``palliative care'' means
interdisciplinary care for individuals with a life-
threatening illness or injury relating to pain and symptom
management and psychological, social, and spiritual needs and
that seeks to improve the quality of life for the individual
and the individual's family.
(11) Secretary.--The term ``Secretary'' means the Secretary
of Health and Human Services.

Subtitle A--Consumer and Provider Education

PART I--CONSUMER EDUCATION

Subpart A--National Initiatives

SEC. 10101. ADVANCE CARE PLANNING TELEPHONE HOTLINE.

(a) In General.--Not later than January 1, 2011, the
Secretary, acting through the Director of the Centers for
Disease Control and Prevention, shall establish and operate
directly, or by grant, contract, or interagency agreement, a
24-hour toll-free telephone hotline to provide consumer
information regarding advance care planning, including--

[[Page S13269]]

(1) an explanation of advanced care planning and its
importance;
(2) issues to be considered when developing an individual's
advance care plan;
(3) how to establish an advance directive;
(4) procedures to help ensure that an individual's
directives for end-of-life care are followed;
(5) Federal and State-specific resources for assistance
with advance care planning; and
(6) hospice and palliative care (including their respective
purposes and services).
(b) Establishment.--In carrying out the requirements under
subsection (a), the Director of the Centers for Disease
Control and Prevention may designate an existing 24-hour
toll-free telephone hotline or, if no such service is
available or appropriate, establish a new 24-hour toll-free
telephone hotline.

SEC. 10102. ADVANCE CARE PLANNING INFORMATION CLEARINGHOUSES.

(a) Expansion of National Clearinghouse for Long-Term Care
Information.--
(1) Development.--Not later than January 1, 2010, the
Secretary shall develop an online clearinghouse to provide
comprehensive information regarding advance care planning.
(2) Maintenance.--The advance care planning clearinghouse,
which shall be clearly identifiable and available on the
homepage of the Department of Health and Human Service's
National Clearinghouse for Long-Term Care Information
website, shall be maintained and publicized by the Secretary
on an ongoing basis.
(3) Content.--The advance care planning clearinghouse shall
include--
(A) any relevant content contained in the national public
education campaign required under section 10104;
(B) content addressing--
(i) an explanation of advanced care planning and its
importance;
(ii) issues to be considered when developing an
individual's advance care plan;
(iii) how to establish an advance directive;
(iv) procedures to help ensure that an individual's
directives for end-of-life care are followed; and
(v) hospice and palliative care (including their respective
purposes and services); and
(C) available Federal and State-specific resources for
assistance with advance care planning, including--
(i) contact information for any State public health
departments that are responsible for issues regarding end-of-
life care;
(ii) contact information for relevant legal service
organizations, including those funded under the Older
Americans Act of 1965 (42 U.S.C. 3001 et seq.); and
(iii) advance directive forms for each State; and
(D) any additional information, as determined by the
Secretary.
(b) Establishment of Pediatric Advance Care Planning
Clearinghouse.--
(1) Development.--Not later than January 1, 2011, the
Secretary, in consultation with the Assistant Secretary for
Children and Families of the Department of Health and Human
Services, shall develop an online clearinghouse to provide
comprehensive information regarding pediatric advance care
planning.
(2) Maintenance.--The pediatric advance care planning
clearinghouse, which shall be clearly identifiable on the
homepage of the Administration for Children and Families
website, shall be maintained and publicized by the Secretary
on an ongoing basis.
(3) Content.--The pediatric advance care planning
clearinghouse shall provide advance care planning information
specific to children with life-threatening illnesses or
injuries and their families.

SEC. 10103. ADVANCE CARE PLANNING TOOLKIT.

(a) Development.--Not later than July 1, 2010, the
Secretary, in consultation with the Director of the Centers
for Disease Control and Prevention, shall develop an online
advance care planning toolkit.
(b) Maintenance.--The advance care planning toolkit, which
shall be available in English, Spanish, and any other
languages that the Secretary deems appropriate, shall be
maintained and publicized by the Secretary on an ongoing
basis and made available on the following websites:
(1) The Centers for Disease Control and Prevention.
(2) The Department of Health and Human Service's National
Clearinghouse for Long-Term Care Information.
(3) The Administration for Children and Families.
(c) Content.--The advance care planning toolkit shall
include content addressing--
(1) common issues and questions regarding advance care
planning, including individuals and resources to contact for
further inquiries;
(2) advance directives and their uses, including living
wills and durable powers of attorney;
(3) the roles and responsibilities of a health care proxy;
(4) Federal and State-specific resources to assist
individuals and their families with advance care planning,
including--
(A) the advance care planning toll-free telephone hotline
established under section 10101;
(B) the advance care planning clearinghouses established
under section 10102;
(C) the advance care planning toolkit established under
this section;
(D) available State legal service organizations to assist
individuals with advance care planning, including those
organizations that receive funding pursuant to the Older
Americans Act of 1965 (42 U.S.C. 3001 et seq.); and
(E) website links or addresses for State-specific advance
directive forms; and
(5) any additional information, as determined by the
Secretary.

SEC. 10104. NATIONAL PUBLIC EDUCATION CAMPAIGN.

(a) National Public Education Campaign.--
(1) In general.--Not later than January 1, 2011, the
Secretary, acting through the Director of the Centers for
Disease Control and Prevention, shall, directly or through
grants, contracts, or interagency agreements, develop and
implement a national campaign to inform the public of the
importance of advance care planning and of an individual's
right to direct and participate in their health care
decisions.
(2) Content of educational campaign.--The national public
education campaign established under paragraph (1) shall--
(A) employ the use of various media, including regularly
televised public service announcements;
(B) provide culturally and linguistically appropriate
information;
(C) be conducted continuously over a period of not less
than 5 years;
(D) identify and promote the advance care planning
information available on the Department of Health and Human
Service's National Clearinghouse for Long-Term Care
Information website and Administration for Children and
Families website, as well as any other relevant Federal or
State-specific advance care planning resources;
(E) raise public awareness of the consequences that may
result if an individual is no longer able to express or
communicate their health care decisions;
(F) address the importance of individuals speaking to
family members, health care proxies, and health care
providers as part of an ongoing dialogue regarding their
health care choices;
(G) address the need for individuals to obtain readily
available legal documents that express their health care
decisions through advance directives (including living wills,
comfort care orders, and durable powers of attorney for
health care);
(H) raise public awareness regarding the availability of
hospice and palliative care; and
(I) encourage individuals to speak with their physicians
about their options and intentions for end-of-life care.
(3) Evaluation.--
(A) In general.--Not later than July 1, 2013, the
Secretary, acting through the Director of the Centers for
Disease Control and Prevention, shall conduct a nationwide
survey to evaluate whether the national campaign conducted
under this subsection has achieved its goal of changing
public awareness, attitudes, and behaviors regarding advance
care planning.
(B) Baseline survey.--In order to evaluate the
effectiveness of the national campaign, the Secretary shall
conduct a baseline survey prior to implementation of the
campaign.
(C) Reporting requirement.--Not later than December 31,
2013, the Secretary shall report the findings of such survey,
as well as any recommendations that the Secretary determines
appropriate regarding the need for continuation or
legislative or administrative changes to facilitate changing
public awareness, attitudes, and behaviors regarding advance
care planning, to the appropriate committees of the Congress.
(b) Repeal.--Section 4751(d) of the Omnibus Budget
Reconciliation Act of 1990 (42 U.S.C. 1396a note; Public Law
101-508) is repealed.

SEC. 10105. UPDATE OF MEDICARE AND SOCIAL SECURITY HANDBOOKS.

(a) Medicare & You Handbook.--
(1) In general.--Not later than 60 days after the date of
enactment of this Act, the Secretary shall update the online
version of the ``Planning Ahead'' section of the Medicare &
You Handbook to include--
(A) an explanation of advance care planning and advance
directives, including--
(i) living wills;
(ii) health care proxies; and
(iii) after-death directives;
(B) Federal and State-specific resources to assist
individuals and their families with advance care planning,
including--
(i) the advance care planning toll-free telephone hotline
established under section 10101;
(ii) the advance care planning clearinghouses established
under section 10102;
(iii) the advance care planning toolkit established under
section 10103;
(iv) available State legal service organizations to assist
individuals with advance care planning, including those
organizations that receive funding pursuant to the Older
Americans Act of 1965 (42 U.S.C. 3001 et seq.); and
(v) website links or addresses for State-specific advance
directive forms; and
(C) any additional information, as determined by the
Secretary.
(2) Update of paper and subsequent versions.--The Secretary
shall include the information described in paragraph (1) in
all paper and electronic versions of the Medicare & You
Handbook that are published on or after the date that is 60
days after the date of enactment of this Act.
(b) Social Security Handbook.--The Commissioner of Social
Security shall--
(1) not later than 60 days after the date of enactment of
this Act, update the online version of the Social Security
Handbook for

[[Page S13270]]

beneficiaries to include the information described in
subsection (a)(1); and
(2) include such information in all paper and online
versions of such handbook that are published on or after the
date that is 60 days after the date of enactment of this Act.

SEC. 10106. AUTHORIZATION OF APPROPRIATIONS.

There is authorized to be appropriated for the period of
fiscal years 2010 through 2014--
(1) $195,000,000 to the Secretary to carry out sections
10101, 10102, 10103, 10104 and 10105(a); and
(2) $5,000,000 to the Commissioner of Social Security to
carry out section 10105(b).

Subpart B--State and Local Initiatives

SEC. 10111. FINANCIAL ASSISTANCE FOR ADVANCE CARE PLANNING.

(a) Legal Assistance for Advance Care Planning.--
(1) Definition of recipient.--Section 1002(6) of the Legal
Services Corporation Act (42 U.S.C. 2996a(6)) is amended by
striking ``clause (A) of'' and inserting ``subparagraph (A)
or (B) of''.
(2) Advance care planning.--Section 1006 of the Legal
Services Corporation Act (42 U.S.C. 2996e) is amended--
(A) in subsection (a)(1)--
(i) by striking ``title, and (B) to make'' and inserting
the following: ``title;
``(C) to make''; and
(ii) by inserting after subparagraph (A) the following:
``(B) to provide financial assistance, and make grants and
contracts, as described in subparagraph (A), on a competitive
basis for the purpose of providing legal assistance in the
form of advance care planning (as defined in section 10002 of
the Patient Protection and Affordable Care Act, and including
providing information about State-specific advance
directives, as defined in that section) for eligible clients
under this title, including providing such planning to the
family members of eligible clients and persons with power of
attorney to make health care decisions for the clients;
and''; and
(B) in subsection (b), by adding at the end the following:
``(2) Advance care planning provided in accordance with
subsection (a)(1)(B) shall not be construed to violate the
Assisted Suicide Funding Restriction Act of 1997 (42 U.S.C.
14401 et seq.).''.
(3) Reports.--Section 1008(a) of the Legal Services
Corporation Act (42 U.S.C. 2996g(a)) is amended by adding at
the end the following: ``The Corporation shall require such a
report, on an annual basis, from each grantee, contractor, or
other recipient of financial assistance under section
1006(a)(1)(B).''.
(4) Authorization of appropriations.--Section 1010 of the
Legal Services Corporation Act (42 U.S.C. 2996i) is amended--
(A) in subsection (a)--
(i) by striking ``(a)'' and inserting ``(a)(1)'';
(ii) in the last sentence, by striking ``Appropriations for
that purpose'' and inserting the following:
``(3) Appropriations for a purpose described in paragraph
(1) or (2)''; and
(iii) by inserting before paragraph (3) (as designated by
clause (ii)) the following:
``(2) There are authorized to be appropriated to carry out
section 1006(a)(1)(B), $10,000,000 for each of fiscal years
2010, 2011, 2012, 2013, and 2014.''; and
(B) in subsection (d), by striking ``subsection (a)'' and
inserting ``subsection (a)(1)''.
(5) Effective date.--This subsection and the amendments
made by this subsection take effect July 1, 2010.
(b) State Health Insurance Assistance Programs.--
(1) In general.--The Secretary shall use amounts made
available under paragraph (3) to award grants to States for
State health insurance assistance programs receiving
assistance under section 4360 of the Omnibus Budget
Reconciliation Act of 1990 to provide advance care planning
services to Medicare beneficiaries, personal representatives
of such beneficiaries, and the families of such
beneficiaries. Such services shall include information
regarding State-specific advance directives and ways to
discuss individual care wishes with health care providers.
(2) Requirements.--
(A) Award of grants.--In making grants under this
subsection for a fiscal year, the Secretary shall satisfy the
following requirements:
(i) Two-thirds of the total amount of funds available under
paragraph (3) for a fiscal year shall be allocated among
those States approved for a grant under this section that
have adopted the Uniform Health-Care Decisions Act drafted by
the National Conference of Commissioners on Uniform State
Laws and approved and recommended for enactment by all States
at the annual conference of such commissioners in 1993.
(ii) One-third of the total amount of funds available under
paragraph (3) for a fiscal year shall be allocated among
those States approved for a grant under this section that
have adopted a uniform form regarding orders regarding life
sustaining treatment (as described in section 10002) or a
comparable approach to advance care planning.
(B) Work plan; report.--As a condition of being awarded a
grant under this subsection, a State shall submit the
following to the Secretary:
(i) An approved plan for expending grant funds.
(ii) For each fiscal year for which the State is paid grant
funds under this subsection, an annual report regarding the
use of the funds, including the number of Medicare
beneficiaries served and their satisfaction with the services
provided.
(C) Limitation.--No State shall be paid funds from a grant
made under this subsection prior to July 1, 2010.
(3) Authorization of appropriations.--There is authorized
to be appropriated to the Secretary to the Centers for
Medicare & Medicaid Services Program Management Account,
$12,000,000 for each of fiscal years 2010 through 2014 for
purposes of awarding grants to States under paragraph (1).
(c) Medicaid Transformation Grants for Advance Care
Planning.--Section 1903(z) of the Social Security Act (42
U.S.C. 1396b(z)) is amended--
(1) in paragraph (2), by adding at the end the following
new subparagraph:
``(G) Methods for improving the effectiveness and
efficiency of medical assistance provided under this title by
making available to individuals enrolled in the State plan or
under a waiver of such plan information regarding advance
care planning (as defined in section 10002 of the Patient
Protection and Affordable Care Act), including at time of
enrollment or renewal of enrollment in the plan or waiver,
through providers, and through such other innovative means as
the State determines appropriate.'';
(2) in paragraph (3), by adding at the end the following
new subparagraph:
``(D) Work plan required for award of advance care planning
grants.--Payment to a State under this subsection to adopt
the innovative methods described in paragraph (2)(G) is
conditioned on the State submitting to the Secretary an
approved plan for expending the funds awarded to the State
under this subsection.''; and
(3) in paragraph (4)--
(A) in subparagraph (A)--
(i) in clause (i), by striking ``and'' at the end;
(ii) in clause (ii), by striking the period at the end and
inserting ``; and''; and
(iii) by inserting after clause (ii), the following new
clause:
``(iii) $20,000,000 for each of fiscal years 2010 through
2014.''; and
(B) by striking subparagraph (B), and inserting the
following:
``(B) Allocation of funds.--The Secretary shall specify a
method for allocating the funds made available under this
subsection among States awarded a grant for fiscal year 2010,
2011, 2012, 2013, or 2014. Such method shall provide that--
``(i) 100 percent of such funds for each of fiscal years
2010 through 2014 shall be awarded to States that design
programs to adopt the innovative methods described in
paragraph (2)(G); and
``(ii) in no event shall a payment to a State awarded a
grant under this subsection for fiscal year 2010 be made
prior to July 1, 2010.''.
(d) Advance Care Planning Community Training Grants.--
(1) In general.--The Secretary shall use amounts made
available under paragraph (3) to award grants to area
agencies on aging (as defined in section 102 of the Older
Americans Act of 1965 (42 U.S.C. 3002)).
(2) Requirements.--
(A) Use of funds.--Funds awarded to an area agency on aging
under this subsection shall be used to provide advance care
planning education and training opportunities for local aging
service providers and organizations.
(B) Work plan; report.--As a condition of being awarded a
grant under this subsection, an area agency on aging shall
submit the following to the Secretary:
(i) An approved plan for expending grant funds.
(ii) For each fiscal year for which the agency is paid
grant funds under this subsection, an annual report regarding
the use of the funds, including the number of Medicare
beneficiaries served and their satisfaction with the services
provided.
(C) Limitation.--No area agency on aging shall be paid
funds from a grant made under this subsection prior to July
1, 2010.
(3) Authorization of appropriations.--There is authorized
to be appropriated to the Secretary to the Centers for
Medicare & Medicaid Services Program Management Account,
$12,000,000 for each of fiscal years 2010 through 2014 for
purposes of awarding grants to area agencies on aging under
paragraph (1).
(e) Nonduplication of Activities.--The Secretary shall
establish procedures to ensure that funds made available
under grants awarded under this section or pursuant to
amendments made by this section supplement, not supplant,
existing Federal funding, and that such funds are not used to
duplicate activities carried out under such grants or under
other Federally funded programs.

SEC. 10112. GRANTS FOR PROGRAMS FOR ORDERS REGARDING LIFE
SUSTAINING TREATMENT.

(a) In General.--The Secretary shall make grants to
eligible entities for the purpose of--
(1) establishing new programs for orders regarding life
sustaining treatment in States or localities;
(2) expanding or enhancing an existing program for orders
regarding life sustaining treatment in States or localities;
or
(3) providing a clearinghouse of information on programs
for orders for life sustaining treatment and consultative
services

[[Page S13271]]

for the development or enhancement of such programs.
(b) Authorized Activities.--Activities funded through a
grant under this section for an area may include--
(1) developing such a program for the area that includes
home care, hospice, long-term care, community and assisted
living residences, skilled nursing facilities, inpatient
rehabilitation facilities, hospitals, and emergency medical
services within the area;
(2) securing consultative services and advice from
institutions with experience in developing and managing such
programs; and
(3) expanding an existing program for orders regarding life
sustaining treatment to serve more patients or enhance the
quality of services, including educational services for
patients and patients' families or training of health care
professionals.
(c) Distribution of Funds.--In funding grants under this
section, the Secretary shall ensure that, of the funds
appropriated to carry out this section for each fiscal year--
(1) at least two-thirds are used for establishing or
developing new programs for orders regarding life sustaining
treatment; and
(2) one-third is used for expanding or enhancing existing
programs for orders regarding life sustaining treatment.
(d) Definitions.--In this section:
(1) The term ``eligible entity'' includes--
(A) an academic medical center, a medical school, a State
health department, a State medical association, a multi-State
taskforce, a hospital, or a health system capable of
administering a program for orders regarding life sustaining
treatment for a State or locality; or
(B) any other health care agency or entity as the Secretary
determines appropriate.
(2) The term ``order regarding life sustaining treatment''
means, with respect to an individual, an actionable medical
order relating to the treatment of that individual that--
(A) is signed and dated by a physician (as defined in
section 1861(r)(1) of the Social Security Act (42 U.S.C.
1395x(r)(1))) or another health care professional (as
specified by the Secretary and who is acting within the scope
of the professional's authority under State law in signing
such an order) and is in a form that permits it to stay with
the patient and be followed by health care professionals and
providers across the continuum of care, including home care,
hospice, long-term care, community and assisted living
residences, skilled nursing facilities, inpatient
rehabilitation facilities, hospitals, and emergency medical
services;
(B) effectively communicates the individual's preferences
regarding life sustaining treatment, including an indication
of the treatment and care desired by the individual;
(C) is uniquely identifiable and standardized within a
given locality, region, or State (as identified by the
Secretary);
(D) is portable across care settings; and
(E) may incorporate any advance directive (as defined in
section 1866(f)(3) of the Social Security Act (42 U.S.C.
1395cc(f)(3)) if executed by the individual. .
(3) The term ``program for orders regarding life sustaining
treatment'' means, with respect to an area, a program that
supports the active use of orders regarding life sustaining
treatment in the area.
(e) Authorization of Appropriations.--To carry out this
section, there are authorized to be appropriated such sums as
may be necessary for each of the fiscal years 2009 through
2014.

PART II--PROVIDER EDUCATION

SEC. 10121. PUBLIC PROVIDER ADVANCE CARE PLANNING WEBSITE.

(a) Development.--Not later than January 1, 2010, the
Secretary, acting through the Administrator of the Centers
for Medicare & Medicaid Services and the Director of the
Agency for Healthcare Research and Quality, shall establish a
website for providers under Medicare, Medicaid, the
Children's Health Insurance Program, the Indian Health
Service (include contract providers) and other public health
providers on each individual's right to make decisions
concerning medical care, including the right to accept or
refuse medical or surgical treatment, and the existence of
advance directives.
(b) Maintenance.--The website, shall be maintained and
publicized by the Secretary on an ongoing basis.
(c) Content.--The website shall include content, tools, and
resources necessary to do the following:
(1) Inform providers about the advance directive
requirements under the health care programs described in
subsection (a) and other State and Federal laws and
regulations related to advance care planning.
(2) Educate providers about advance care planning quality
improvement activities.
(3) Provide assistance to providers to--
(A) integrate advance directives into electronic health
records, including oral directives; and
(B) develop and disseminate advance care planning
informational materials for their patients.
(4) Inform providers about advance care planning continuing
education requirements and opportunities.
(5) Encourage providers to discuss advance care planning
with their patients of all ages.
(6) Assist providers' understanding of the continuum of
end-of-life care services and supports available to patients,
including palliative care and hospice.
(7) Inform providers of best practices for discussing end-
of-life care with dying patients and their loved ones.

SEC. 10122. CONTINUING EDUCATION FOR PHYSICIANS AND NURSES.

(a) In General.--Not later than January 1, 2012, the
Secretary, acting through the Director of Health Resources
and Services Administration, shall develop, in consultation
with health care providers and State boards of medicine and
nursing, a curriculum for continuing education that States
may adopt for physicians and nurses on advance care planning
and end-of-life care.
(b) Content.--
(1) In general.--The continuing education curriculum
developed under subsection (a) for physicians and nurses
shall, at a minimum, include--
(A) a description of the meaning and importance of advance
care planning;
(B) a description of advance directives, including living
wills and durable powers of attorney, and the use of such
directives;
(C) palliative care principles and approaches to care; and
(D) the continuum of end-of-life services and supports,
including palliative care and hospice.
(2) Additional content for physicians.--The continuing
education curriculum for physicians developed under
subsection (a) shall include instruction on how to conduct
advance care planning with patients and their loved ones.

Subtitle B--Portability of Advance Directives; Health Information
Technology

SEC. 10131. PORTABILITY OF ADVANCE DIRECTIVES.

(a) Medicare.--Section 1866(f) of the Social Security Act
(42 U.S.C. 1395cc(f)) is amended--
(1) in paragraph (1)--
(A) in subparagraph (B), by inserting ``and if presented by
the individual, to include the content of such advance
directive in a prominent part of such record'' before the
semicolon at the end;
(B) in subparagraph (D), by striking ``and'' after the
semicolon at the end;
(C) in subparagraph (E), by striking the period at the end
and inserting ``; and''; and
(D) by inserting after subparagraph (E) the following new
subparagraph:
``(F) to provide each individual with the opportunity to
discuss issues relating to the information provided to that
individual pursuant to subparagraph (A) with an appropriately
trained professional.'';
(2) in paragraph (3), by striking ``a written'' and
inserting ``an''; and
(3) by adding at the end the following new paragraph:
``(5)(A) An advance directive validly executed outside of
the State in which such advance directive is presented by an
adult individual to a provider of services, a Medicare
Advantage organization, or a prepaid or eligible organization
shall be given the same effect by that provider or
organization as an advance directive validly executed under
the law of the State in which it is presented would be given
effect.
``(B)(i) The definition of an advanced directive shall also
include actual knowledge of instructions made while an
individual was able to express the wishes of such individual
with regard to health care.
``(ii) For purposes of clause (i), the term `actual
knowledge' means the possession of information of an
individual's wishes communicated to the health care provider
orally or in writing by the individual, the individual's
medical power of attorney representative, the individual's
health care surrogate, or other individuals resulting in the
health care provider's personal cognizance of these wishes.
Other forms of imputed knowledge are not actual knowledge.
``(C) The provisions of this paragraph shall preempt any
State law to the extent such law is inconsistent with such
provisions. The provisions of this paragraph shall not
preempt any State law that provides for greater portability,
more deference to a patient's wishes, or more latitude in
determining a patient's wishes.''.
(b) Medicaid.--Section 1902(w) of the Social Security Act
(42 U.S.C. 1396a(w)) is amended--
(1) in paragraph (1)--
(A) in subparagraph (B)--
(i) by striking ``in the individual's medical record'' and
inserting ``in a prominent part of the individual's current
medical record''; and
(ii) by inserting ``and if presented by the individual, to
include the content of such advance directive in a prominent
part of such record'' before the semicolon at the end;
(B) in subparagraph (D), by striking ``and'' after the
semicolon at the end;
(C) in subparagraph (E), by striking the period at the end
and inserting ``; and''; and
(D) by inserting after subparagraph (E) the following new
subparagraph:
``(F) to provide each individual with the opportunity to
discuss issues relating to the information provided to that
individual pursuant to subparagraph (A) with an appropriately
trained professional.'';
(2) in paragraph (4), by striking ``a written'' and
inserting ``an''; and
(3) by adding at the end the following paragraph:
``(6)(A) An advance directive validly executed outside of
the State in which such advance directive is presented by an
adult individual to a provider or organization shall be given
the same effect by that provider or organization as an
advance directive validly

[[Page S13272]]

executed under the law of the State in which it is presented
would be given effect.
``(B)(i) The definition of an advance directive shall also
include actual knowledge of instructions made while an
individual was able to express the wishes of such individual
with regard to health care.
``(ii) For purposes of clause (i), the term `actual
knowledge' means the possession of information of an
individual's wishes communicated to the health care provider
orally or in writing by the individual, the individual's
medical power of attorney representative, the individual's
health care surrogate, or other individuals resulting in the
health care provider's personal cognizance of these wishes.
Other forms of imputed knowledge are not actual knowledge.
``(C) The provisions of this paragraph shall preempt any
State law to the extent such law is inconsistent with such
provisions. The provisions of this paragraph shall not
preempt any State law that provides for greater portability,
more deference to a patient's wishes, or more latitude in
determining a patient's wishes.''.
(c) CHIP.--Section 2107(e)(1) of the Social Security Act
(42 U.S.C. 1397gg(e)(1)), as amended by sections 2101(d)(2),
2101(e), and 6401(c), is further amended--
(1) by redesignating subparagraphs (G) through (N) as
subparagraphs (H) through (O), respectively; and
(2) by inserting after subparagraph (F) the following:
``(G) Section 1902(w) (relating to advance directives).''.
(d) Study and Report Regarding Implementation.--
(1) Study.--The Secretary shall conduct a study regarding
the implementation of the amendments made by subsections (a)
and (b).
(2) Report.--Not later than 18 months after the date of
enactment of this Act, the Secretary shall submit to Congress
a report on the study conducted under paragraph (1), together
with recommendations for such legislation and administrative
actions as the Secretary considers appropriate.
(e) Effective Dates.--
(1) In general.--Subject to paragraph (2), the amendments
made by subsections (a), (b), and (c) shall apply to provider
agreements and contracts entered into, renewed, or extended
under title XVIII of the Social Security Act (42 U.S.C. 1395
et seq.), and to State plans under title XIX of such Act (42
U.S.C. 1396 et seq.) and State child health plans under title
XXI of such Act (42 U.S.C. 1397aa et seq.), on or after such
date as the Secretary specifies, but in no case may such date
be later than 1 year after the date of enactment of this Act.
(2) Extension of effective date for state law amendment.--
In the case of a State plan under title XIX of the Social
Security Act or a State child health plan under title XXI of
such Act which the Secretary determines requires State
legislation in order for the plan to meet the additional
requirements imposed by the amendments made by subsections
(b) and (c), the State plan shall not be regarded as failing
to comply with the requirements of such title solely on the
basis of its failure to meet these additional requirements
before the first day of the first calendar quarter beginning
after the close of the first regular session of the State
legislature that begins after the date of enactment of this
Act. For purposes of the previous sentence, in the case of a
State that has a 2-year legislative session, each year of the
session is considered to be a separate regular session of the
State legislature.

SEC. 10132. STATE ADVANCE DIRECTIVE REGISTRIES; DRIVER'S
LICENSE ADVANCE DIRECTIVE NOTATION.

Part P of title III of the Public Health Service Act (42
U.S.C. 280g) is amended by adding at the end the following:

``SEC. 399X. STATE ADVANCE DIRECTIVE REGISTRIES.

``(a) State Advance Directive Registry.--In this section,
the term `State advance directive registry' means a secure,
electronic database that--
``(1) is available free of charge to residents of a State;
and
``(2) stores advance directive documents and makes such
documents accessible to medical service providers in
accordance with Federal and State privacy laws.
``(b) Grant Program.--Beginning on July 1, 2010, the
Secretary, acting through the Director of the Centers for
Disease Control and Prevention, shall award grants on a
competitive basis to eligible entities to establish and
operate, directly or indirectly (by competitive grant or
competitive contract), State advance directive registries.
``(c) Eligible Entities.--
``(1) In general.--To be eligible to receive a grant under
this section, an entity shall--
``(A) be a State department of health; and
``(B) submit to the Director an application at such time,
in such manner, and containing--
``(i) a plan for the establishment and operation of a State
advance directive registry; and
``(ii) such other information as the Director may require.
``(2) No requirement of notation mechanism.--The Secretary
shall not require that an entity establish and operate a
driver's license advance directive notation mechanism for
State residents under section 399Y to be eligible to receive
a grant under this section.
``(d) Annual Report.--For each year for which an entity
receives an award under this section, such entity shall
submit an annual report to the Director on the use of the
funds received pursuant to such award, including the number
of State residents served through the registry.
``(e) Authorization.--There is authorized to be
appropriated to carry out this section $20,000,000 for fiscal
year 2010 and each fiscal year thereafter.

``SEC. 399Y. DRIVER'S LICENSE ADVANCE DIRECTIVE NOTATION.

``(a) In General.--Beginning July 1, 2010, the Secretary,
acting through the Director of the Centers for Disease
Control and Prevention, shall award grants on a competitive
basis to States to establish and operate a mechanism for a
State resident with a driver's license to include a notice of
the existence of an advance directive for such resident on
such license.
``(b) Eligibility.--To be eligible to receive a grant under
this section, a State shall--
``(1) establish and operate a State advance directive
registry under section 399X; and
``(2) submit to the Director an application at such time,
in such manner, and containing--
``(A) a plan that includes a description of how the State
will--
``(i) disseminate information about advance directives at
the time of driver's license application or renewal;
``(ii) enable each State resident with a driver's license
to include a notice of the existence of an advance directive
for such resident on such license in a manner consistent with
the notice on such a license indicating a driver's intent to
be an organ donor; and
``(iii) coordinate with the State department of health to
ensure that, if a State resident has an advance directive
notice on his or her driver's license, the existence of such
advance directive is included in the State registry
established under section 399X; and
``(B) any other information as the Director may require.
``(c) Annual Report.--For each year for which a State
receives an award under this section, such State shall submit
an annual report to the Director on the use of the funds
received pursuant to such award, including the number of
State residents served through the mechanism.
``(d) Authorization.--There is authorized to be
appropriated to carry out this section $50,000,000 for fiscal
year 2010 and each fiscal year thereafter.''.

SEC. 10133. GAO STUDY AND REPORT ON ESTABLISHMENT OF NATIONAL
ADVANCE DIRECTIVE REGISTRY.

(a) Study.--The Comptroller General of the United States
shall conduct a study on the feasibility of a national
registry for advance directives, taking into consideration
the constraints created by the privacy provisions enacted as
a result of the Health Insurance Portability and
Accountability Act of 1996 (Public Law 104-191).
(b) Report.--Not later than 18 months after the date of
enactment of this Act, the Comptroller General of the United
States shall submit to Congress a report on the study
conducted under subsection (a) together with recommendations
for such legislation and administrative action as the
Comptroller General of the United States determines to be
appropriate.

Subtitle C--National Uniform Policy on Advance Care Planning

SEC. 10141. STUDY AND REPORT BY THE SECRETARY REGARDING THE
ESTABLISHMENT AND IMPLEMENTATION OF A NATIONAL
UNIFORM POLICY ON ADVANCE DIRECTIVES.

(a) Study.--
(1) In general.--The Secretary, acting through the Office
of the Assistant Secretary for Planning and Evaluation, shall
conduct a thorough study of all matters relating to the
establishment and implementation of a national uniform policy
on advance directives for individuals receiving items and
services under titles XVIII, XIX, or XXI of the Social
Security Act (42 U.S.C. 1395 et seq.; 1396 et seq.; 1397aa et
seq.).
(2) Matters studied.--The matters studied by the Secretary
under paragraph (1) shall include issues concerning--
(A) family satisfaction that a patient's wishes, as stated
in the patient's advance directive, were carried out;
(B) the portability of advance directives, including cases
involving the transfer of an individual from 1 health care
setting to another;
(C) immunity from civil liability and criminal
responsibility for health care providers that follow the
instructions in an individual's advance directive that was
validly executed in, and consistent with the laws of, the
State in which it was executed;
(D) conditions under which an advance directive is
operative;
(E) revocation of an advance directive by an individual;
(F) the criteria used by States for determining that an
individual has a terminal condition;
(G) surrogate decisionmaking regarding end-of-life care;
(H) the provision of adequate palliative care (as defined
in paragraph (3)), including pain management;
(I) adequate and timely referrals to hospice care programs;
and
(J) the end-of-life care needs of children and their
families.
(3) Palliative care.--For purposes of paragraph (2)(H), the
term ``palliative care'' means interdisciplinary care for
individuals

[[Page S13273]]

with a life-threatening illness or injury relating to pain
and symptom management and psychological, social, and
spiritual needs and that seeks to improve the quality of life
for the individual and the individual's family.
(b) Report to Congress.--Not later than 18 months after the
date of enactment of this Act, the Secretary shall submit to
Congress a report on the study conducted under subsection
(a), together with recommendations for such legislation and
administrative actions as the Secretary considers
appropriate.
(c) Consultation.--In conducting the study and developing
the report under this section, the Secretary shall consult
with the Uniform Law Commissioners, and other interested
parties.

Subtitle D--Compassionate Care Workforce Development

SEC. 10151. EXEMPTION OF PALLIATIVE MEDICINE FELLOWSHIP
TRAINING FROM MEDICARE GRADUATE MEDICAL
EDUCATION CAPS.

(a) Direct Graduate Medical Education.--Section
1886(h)(4)(F) of the Social Security Act (42 U.S.C.
1395ww(h)(4)(F)), as amended by section 5503(a)(1), is
amended--
(1) in clause (i), by inserting ``clause (iii) and'' after
``subject to''; and
(2) by adding at the end the following new clause:
``(iii) Increase allowed for palliative medicine fellowship
training.--For cost reporting periods beginning on or after
January 1, 2011, in applying clause (i), there shall not be
taken into account full-time equivalent residents in the
field of allopathic or osteopathic medicine who are in
palliative medicine fellowship training that is approved by
the Accreditation Council for Graduate Medical Education.''.
(b) Indirect Medical Education.--Section 1886(d)(5)(B) of
the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)), as
amended by sections 5503(b)(2) and 5505(b), is further
amended by adding at the end the following new clause:
``(xi) Clause (iii) of subsection (h)(4)(F) shall apply to
clause (v) in the same manner and for the same period as such
clause (iii) applies to clause (i) of such subsection.''.

SEC. 10152. MEDICAL SCHOOL CURRICULA.

(a) In General.--The Secretary, in consultation with the
Association of American Medical Colleges, shall establish
guidelines for the imposition by medical schools of a minimum
amount of end-of-life training as a requirement for obtaining
a Doctor of Medicine degree in the field of allopathic or
osteopathic medicine.
(b) Training.--Under the guidelines established under
subsection (a), minimum training shall include--
(1) training in how to discuss and help patients and their
loved ones with advance care planning;
(2) with respect to students and trainees who will work
with children, specialized pediatric training;
(3) training in the continuum of end-of-life services and
supports, including palliative care and hospice;
(4) training in how to discuss end-of-life care with dying
patients and their loved ones; and
(5) medical and legal issues training.
(c) Distribution.--Not later than January 1, 2011, the
Secretary shall disseminate the guidelines established under
subsection (a) to medical schools.
(d) Compliance.--Effective beginning not later than July 1,
2012, a medical school that is receiving Federal assistance
shall be required to implement the guidelines established
under subsection (a). A medical school that the Secretary
determines is not implementing such guidelines shall not be
eligible for Federal assistance.

Subtitle E--Additional Reports, Research, and Evaluations

SEC. 10161. NATIONAL MORTALITY FOLLOWBACK SURVEY.

(a) In General.--Not later than December 31, 2010, and
annually thereafter, the Secretary, acting through the
Director of the Centers for Disease Control and Prevention,
shall renew and conduct the National Mortality Followback
Survey (referred to in this section as the ``Survey'') to
collect data on end-of-life care.
(b) Purpose.--The purpose of the Survey shall be to gain a
better understanding of current end-of-life care in the
United States.
(c) Questions.--
(1) In general.--In conducting the Survey, the Director of
the Centers for Disease Control and Prevention shall, at a
minimum, include the following questions with respect to the
loved one of a respondent:
(A) Did he or she have an advance directive, and if so,
when it was completed.
(B) Did he or she have an order for life-sustaining
treatment, and if so, when was it completed.
(C) Did he or she have a durable power of attorney, and if
so, when it was completed.
(D) Had he or she discussed his or her wishes with loved
ones, and if so, when.
(E) Had he or she discussed his or her wishes with his or
her physician, and if so, when.
(F) In the opinion of the respondent, was he or she
satisfied with the care he or she received in the last year
of life and in the last week of life.
(G) Was he or she cared for by hospice, and if so, when.
(H) Was he or she cared for by palliative care specialists,
and if so, when.
(I) Did he or she receive effective pain management (if
needed).
(J) What was the experience of the main caregiver
(including if such caregiver was the respondent), and whether
he or she received sufficient support in this role.
(2) Additional questions.--Additional questions to be asked
during the Survey shall be determined by the Director of the
Centers for Disease Control and Prevention on an ongoing
basis with input from relevant research entities.

SEC. 10162. INSPECTOR GENERAL INVESTIGATION OF FRAUD AND
ABUSE.

In accordance with the recommendations of the Medicare
Payment Advisory Commission for additional data (as contained
in the March 2009 report entitled ``Report to Congress:
Medicare Payment Policy''), the Secretary shall direct the
Office of the Inspector General of the Department of Health
and Human Services to investigate, not later than January 1,
2012, the following with respect to hospice benefit under
Medicare, Medicaid, and CHIP:
(1) The prevalence of financial relationships between
hospices and long-term care facilities, such as nursing
facilities and assisted living facilities, that may represent
a conflict of interest and influence admissions to hospice.
(2) Differences in patterns of nursing home referrals to
hospice.
(3) The appropriateness of enrollment practices for
hospices with unusual utilization patterns (such as high
frequency of very long stays, very short stays, or enrollment
of patients discharged from other hospices).
(4) The appropriateness of hospice marketing materials and
other admissions practices and potential correlations between
length of stay and deficiencies in marketing or admissions
practices.

SEC. 10163. GAO STUDY AND REPORT ON PROVIDER ADHERENCE TO
ADVANCE DIRECTIVES.

Not later than January 1, 2012, the Comptroller General of
the United States shall conduct a study of the extent to
which providers comply with advance directives under the
Medicare and Medicaid programs and shall submit a report to
Congress on the results of such study, together with such
recommendations for administrative or legislative changes as
the Comptroller General determines appropriate.
______