Hello it's Missy! Thank you for watching. Today I wanted to share this braided hairstyle. Let me know what you think down below in the comment section. Be sure to subscribe and click that bell if you're new and let's get started! With my hair parted near the middle, I'm going to begin by creating a dutch braid on the left side of my head.  I'm going to pick up a section of hair on the left side of the part and divide it into three smaller pieces. Since I'm doing a dutch braid I'm going to be crossing the side strands under the middle strand so the braid sits out on top of my head. So I'm crossing one side under the middle then crossing the other side under the middle and after the first stitch I'm going to begin incorporating new sections of hair into the braid. So I'm crossing one side under the middle picking up a new section of hair crossing it under and into the middle strand as well then I'm crossing the other side strand under the middle strand picking up a new section of hair and crossing it under bringing it into the braid and I'm just going to repeat those steps working down the left side of my head. I brought in about four sections of hair and I'm going to create the braid along the left side of my head bringing in hair from the part line as well as from the hairline. Once the braid reaches the top of my ear I'm going to stop adding in additional pieces and I'm just going to continue braiding the hair in a dutch braid crossing the side strands under the middle strand continuing the braid down to the ends. Once the braid reaches the bottom I'm going to spray the braid with hair spray and then smooth down the edges before pulling it apart in order to make it look bigger and more full. So I'm just going to carefully pull the hair up and out of the braid so that it widens it. This will also make it a little bit flatter so it looks fuller. Then I'm going to slide a bobby pin over the bottom of the braid so it doesn't unravel. Now I'm going to repeat the same steps as before and create another dutch braid along the right side of my head. So the steps are the same as the previous braid.  I'm going to pick up a section next to the part and divide it into three smaller pieces. I'm going to cross the side strands under the middle strand and after the first stitch of the braid I'm going to begin incorporating new sections of hair into the braid as well. So I'm crossing one side under the middle picking up a new section of hair and bringing it into the braid crossing it under and into the middle strand. Then I'm crossing the other side strand under the middle picking up a new section of hair crossing it under and into the middle strand as well and I'm going to create the braid along the right side of my head bringing in hair from along the part line and from along the hairline. So again I'm crossing the side strand under the middle picking up a new section of hair and crossing it under and into the middle strand then I'm crossing the other side strand under the middle picking up a new section of hair and crossing it under and into the middle strand as well. Then once the braid reaches my ear I'm going to stop adding in additional pieces and continue braiding the section down to the ends in a regular three strand braid so I'm still crossing the side strands under the middle strand alternating between the left and the right side strands without incorporating new sections of hair into the braid and once the braid reaches the bottom I'm going to spray it with hairspray and then go back over the braid and gently pull the edges up and out slightly so the braid looks wider and more full. Then I'm going to slide a bobby pin over the bottom of the braid so it doesn't unravel. Once both braids are done I'm going to pin them against my head so I'm going to lay the left braid over the right braid and I'm going to slide my bobby pins into the middle of the braid grabbing only a few pieces of the braid with each bobby pin and then slide them upwards along the braid so they're hidden underneath the hair. I slid a couple into the center of the cross braids one on the top part and one on the bottom. A good rule of thumb is to pin wherever you're holding the braids in place and I just keep pinning until they feel nice and secure and aren't going to fall loose. Once that's done I'm going to divide off two sections of hair underneath both braids on the left and the right side. I'm going to bring these two sections together at the back of my head and tie them off using a clear elastic band. Then I'm going to flip the elastic band upwards and around itself so the two side sections are now twisted and then I'm going to repeat those same steps and create another twisted section so I'm taking a small section of hair from the left side and a small section from the right side underneath the previous twist and I'm going to bring the hair together at the back of my head and tie them off using a clear elastic band. Then I'm going to flip the elastic around itself so the two side sections are twisted again. Now I'm going to create the elastic style braid so I'm going to divide off two new sections again. These are going to be a little bit bigger than the previous sections but I need a section from both the left side and the right side of my head underneath the previous twist. I'm going to bring these two sections over the top of the rest of the hair and tie them together using a clear elastic band. Then I'm going to go back over the hair right above the elastic and I'm going to gently pinch and pull the hair slightly up and out of the elastic and this will create the first puffy section of the braid. Now I'm going to divide off two new sections of hair from underneath the previous section on both the left and the right side. I'm going to bring the two sections over the rest of the hair like before and tie them together with another elastic band. Again I'm going to gently pull on small sections of hair above the elastic so the two sections are bigger and look more full and I'm just going to repeat those steps and continue the braid down the length of my hair dividing off two sections of hair from both sides of the ponytail. Tie them over the top of the other hair and then make each section puffier by gently pulling the hair slightly up and out of the elastic. I ended up creating about six sections of the braid. I just went down the hair until I really couldn't reach anymore. You can do as many as you'd like or just a few. It's however you prefer your style to look. I think this is a really cool spin on a traditional braid and it's a lot easier to do since it's done with elastics. Let me know what you think down below in the comments. Thank you so much for watching. I hope you enjoyed today's video. Let me know what you think down below in the comment section, like and subscribe, click that notification bell as always and I will see you next time.


All right. Good morning. This is the Senate Health and Welfare Committee meeting of January 12th, 2022. Thank you all for being here. This morning we're going to be taking up as 74 and act relating to modifying the Vermont's patient choice at end of life law. Then we'll be looking at S91 related to parent child centers. And finally, we're going to pick up on COVID issues at 11 o'clock. And we have some hard stops that we're going to have to make to ensure that folks who are available for testimony can get their testimony in. One correction that was made to the agenda. I see it's already been made. Thank you, Aaron. Mary Han Beerworth is unable to testify this morning. We'll try to get her in as early as Friday so we can finish the work that we need to do on S74. Good morning. We have with us. Diana Barnard.  I think we have some things. And we've seen you in this committee before and it's a pleasure to see everyone back. It's great to see familiar faces, I have to say, though. I'm just sorry we're not in the state house all cramped together in that little tiny room of ours under better conditions. Diana, welcome. Thank you. It's great to see some familiar faces and also some new ones. So I want to just briefly remind you of the qualifications that bring me here today. I am a lifelong Vermonter and I've spent my entire clinical career taking care of Vermonters. I'm board certified in family medicine, and also in hospice and palliative care. So my role in my clinical work is as the lead physician at the University of Vermont Health Network Porter Medical Center Palliative Care Service and I also work as a hospice physician. I was as Jenny was indicating actively involved in the efforts to pass our initial medical aid and dying law. I continue to be on the patient choices Vermont board, and I am also on the clinical advisory board of the Academy of Medical Aid and Dying which is based out of California. I've been working in medicine for 28 years and the last 12 years of my practice has been focused exclusively on taking care of people living with serious illness. I just feel the need to start by reminding you that how we die matters, and that we only get to do it once, and that you enter it with no previous experience. And this is true for the person who dies and it's also true for the bereaved and the loved ones that are left behind, because the experience of witnessing somebody dying has an effect on how you approach your own death and that ripple effect can go through generations so it is imperative that we continue to refine and explore ways to meet the needs of people who are dying. As many of you know we've just had a recent report from the Vermont Department of Health that has clarified our experience in Vermont over the past six years has been as expected. The numbers show that the vast majority of patients who access our law are living with cancer more than 75% of them. The next most common diagnosis is ALS, followed by other neurodegenerative diseases. We have an average of 14 to 15 people a year who are completing the process for medical aid and dying, and those numbers from the Vermont Department of Health do not show any instances of abuse, which is very important to keep in mind. So our law is working very well, however at the same time the past six years of experience has shown us that like with many laws, it's an opportunity to tidy it up and to fix some unintentional issues with the law, which I would like to briefly review with you today. The first issue is one of immunity. Other people will speak more to this, but I will simply say that our law somewhat unintentionally only focused on immunity for the physician participating in the process, and explicitly they are the only ones who are protected, even though there is implicit understanding that others would be protected. This has proven to be an issue, particularly with pharmacists who would want to participate, but worry about protecting understandably their license. And so we are asking you to make that protection for pharmacists and other members of the health care team explicit. The second issue which we are asking you to address is the final 48 hour waiting period. We have waiting periods built into our law to assure that patients have adequate time to consider their treatment options and are not rushing to a decision. It's really important to have safeguards, and it's also important to recognize that sometimes safeguards can actually become barriers. And I believe we have a mismatch in that balance in our law, which we are asking you to address today. You know, the almost every patient I meet wants to live as well as possible and as long as possible. And particularly in the setting of a serious illness. Most patients are focused like a laser beam on their illness and the treatments that are available to them to help them live well and live longer. And at the same time, as your illness becomes more advanced, your physical and emotional energy can rapidly decline. And so by the time patients are realizing that their treatments are no longer working as well as they had thought, time is short and physical and emotional energy is short at a time when people have very important issues that they want to be focused on in bringing their life to a close. I can tell you that virtually everybody that's been diagnosed with a terminal illness has thought about dying and has wishes for how they want to die, even as they're focused on living. Oftentimes those wishes have not been explicitly talked about unless the patient has had the services of an expert person to bring out those worries. And so those worries about how we die often come to the table very late in an illness. Most people who have interest in medical aid and dying have talked about it and thought about it for a long time and many times family is aware, but they haven't started the formal official process because they are focused on living and getting treatment. So what happens is by the time people realize that treatment is not working and their time is short. Energy is also short. So just to briefly review the process that patients go through for medical aid and dying, they have to make a formal request to the prescribing physician.  There has to be a consulting physician to confirm the patient's eligibility. And that patient also has to take the time to put their wishes in writing and have that wish witnessed. Our law requires at this time, after all of those steps have been completed, an additional 48 hour waiting period before the prescription can actually be written. There are no other of the 11 states, 10 other 11 states in jurisdiction that allow medical aid and dying have such a requirement. And in my experience and the experience of other clinicians that I talked to this 48 hour period offers no meaningful benefit and has created a burden. The patients have thought about the process, they've made their requests, and they are by and large by that point, ready to move forward with having that medication access in their back pocket. So we are asking you to eliminate this final 48 hour waiting period, knowing that the other safeguards will remain in place. And the other issue of course that we're addressing today is the issue of telemedicine. Telemedicines are constantly changing science. We're always learning new things. And when our law went into place, you know, frankly, telemedicine was just not at the forefront. We know that telemedicine has been used in other areas for for a number of years quite successfully. Now the best example of that is really within the VA system. I suppose, thanks to the pandemic over the past two years, we've really seen in Vermont how telemedicine can be effectively used in order to provide timely and high quality medical care to Vermonters. And, and we believe that telemedicine should be incorporated into medical aid and dying as it is in any other area of medicine. I also want to say just as an aside that in my practice as a palliative care physician and a hospice physician.  My eyes to evaluate the patient and my ears to listen to suffering and actually in my clinical work. It's very common for me not actually ever to have to lay eyes on the patient. Excuse me lay my hands on the patient. So my hands are useful in some clinical situations, but largely not in my clinical work. It's useful just to kind of run through what would a telemedicine visit look like. So, if I were going to see a patient to explore suffering and their end of life wishes, I would start by reviewing their medical record. I would look at all of their notes, their lab results, their x-rays. I would look for those specialty notes to tell me how the disease has progressed. I would look for prognostic data that lets me know that the patient's illness is in its final phase. Then when I'm on the telemedicine visit I would start with introductions. I would begin by getting to know my patients by exploring their values by learning who they are how have they lived their life. What has been their experience with illness. What are their biggest fears. I would always be listening for sources of suffering. What is bothering the patient most and what could possibly I do to address that suffering. So always looking for therapeutic interventions. I would be listening to their request for medical aid and dying. All of the requirements of the law in particular focusing on their understanding of the illness and their capacity to move forward with the law. During that visit I am continually looking for anything that tells me that this telemedicine visit is not accurate and I need an in-person visit and that could happen at any time. Maybe there are technical issues. Maybe there are communication challenges over the technology. All of those things would encourage me to pivot to an in-person visit. If I was continuing with the telemedicine visit I would use what I do in an in-person visit which is my ears and eyes to assess the patient. I can hear if somebody short of breath. I can hear if their voice is very weak because they're living with serious illness. I can hear them cough. With my eyes I can see if they have signs of advanced illness. Are they thin? Are their clothes loose fitting? If needed I could even have them use the camera to show me any tubes or accoutrements that are part of their body to look at their tummy, to look at their edema. It's very effective as a way to assess what's going on with the patient and continually my biggest clinical skill are my ears in listening to the patient's worries and their understanding and my words to assure them that we're going to do anything possible. At the end of that visit if all went well I would close and schedule a follow-up. So I believe that telemedicine could absolutely be effectively used to help assess the patient's eligibility to move forward with law. I think I want to close by just telling a story. This is the story of Lynn Achay who was a woman in her 60s from Arlington, Vermont. And unfortunately her case actually articulates all three of the issues that we are talking about with our law. Lynn was a competitive athlete. She actually was the first woman to bicycle to the top of Mount Washington. And she was incredibly healthy and had no risk factors for the disease which she would get in late winter of 2019 she developed a cough that was eventually diagnosed as pneumonia and she had treatment but she had a lingering cough that lasted several weeks, which prompted a more extensive evaluation which unfortunately revealed evidence of widely metastatic lung disease. As you can imagine Lynn was in shock and she and her husband Tony immediately began to explore their treatment options and preparing for the end of her life because her disease was at such an advanced stage at the time of diagnosis. In that previous experience with dying her father had had a very difficult painful final phase of life, which had really traumatized her as a daughter, and she was very clear and articulate in her desire to not experience such a terrible situation for herself. And because of the waiver that our willing pharmacist requires physicians to sign. She could not find a willing prescriber in her area. Eventually she reached out to me in June of 2020 and I agreed to see her. This was in the middle of the pandemic and I was balancing so many clinical needs that I did not have the time to be able to travel to her. And then Tony had to drive an hour and 45 minutes each way to come to my office, and they had to do that on two occasions. I learned only after the fact that for that second visit Lynn, who remember was a competitive athlete who had a very high bar for how she wanted to live her life, actually beg Tony to call an ambulance because she was so exhausted and uncomfortable to lay down on the way to my office. And I will never forget going out to the car on that second visit to help Lynn get out of the car and Tony had fashioned a camping mattress on top of the reclining front seat in a desperate effort to get Lynn to be as comfortable as possible. During those two visits, despite advanced physical illness, Lynn's mind was very sharp and she was very clear in her wishes and clearly qualified for the law. Our last visit happened to be on a Friday. While Lynn was still interested in living as long as possible because remember she had only been diagnosed in April. And this was June so she still had things she was trying to do but also desperately wanting to plan for a death that was not going to be like her fathers. So she wanted to have the prescription waiting at the pharmacy and ready. We discussed how I had to wait the 48 hours it was a Friday. And so I said you know very first thing the next week I'm going to send the prescription off. Unfortunately, over the weekend, Lynn's condition first began to deteriorate which told her she wanted to move forward as soon as possible with the law. But second over just those two short days, her condition further deteriorated and she lost the capacity to be able to participate. And by early next week she was left in the condition and lived for 11 additional days, exactly in the kind of situation she did not want with Tony as her caregiver and witness. Despite his grief, Tony was frustrated and quite frankly angry about the ways in which Lynn had faced these barriers to the law, and he wrote many people to talk about his experience and some of you have actually probably heard this story before. I am haunted by that experience. I think anybody who knows my clinical work knows that my bar is very high and I have high expectations of my ability to offer people comfort in their dying process. And in this case, I was not adequately able to address Lynn's issues and from that time I became determined to move forward with fixing the law so that others would not have to suffer the fate that Lynn did. I actually called Tony this week to check in and see how he was doing. It's been about 18 months since Lynn died, and he was the one who encouraged me to share her story. So I think I will stop there I really appreciate you listening and I would be very happy to take any questions now or later. Thank you very much Dr Barnard. And I'm going to ask you if you can send us some written comments. If you have a few minutes, I know you're busy but if you could get that to us because I don't see it on our webpage. Yes, there's been a lot going on but I will get my written comments by the end of today. Okay, that would be terrific. Thank you so much. Committee unless you have a significant question of clarification. I'm going to suggest that we move right along in our testimony. Senator Hooker. Dr Barnard, you mentioned other members of the health team besides the, what do I want to say, besides the pharmacist. Could you just elaborate on that please. I was referring to other people who may be involved in the care of the patient. I actually need to say that I just now I'm having a little brain cramp and can't remember the specific language of the law. But we know that there are others helping to care for patients living with serious illness and I would hope that other members of my team could address that issue. We'll hear more about that. I know we're going to hear more about that particular section so that's a very good question Senator Hooker thank you. All right. Why don't we move ahead and we'll ask Betsy Walkerman thank you for being here. Why don't you introduce yourself for the record and I, and I do know that we have your testimony on our webpage. Yes, I submitted some back up documents, but if you want. Betsy, we're having difficulty hearing you. You're going in and out as you speak. Let's get this close. That was better as soon as you moved a little closer. And just moving closer to where my actual speaker is. Is that all right? Yes, it is. That's fine. Thank you. So, I. Yeah, so thank you. Good morning. Thank you for the opportunity to testify on making some improvements back 39. I'm president of patient services Vermont and I'm a lawyer. I've worked on medical aid in time for the past 20 years. Since I started work with my parents, many of you know that Walters and any Walters to law patient services Vermont. Can you all hear me all right. Yes. Okay. When you when you face directly into your, or whatever the mic wherever the microphone is we hear you perfectly. Okay, great. Yeah, that's good. I thought I had all this setup exactly right. That's good right there. Right there. Okay. So, as I mentioned, I had a patient choices Vermont. PCV is a nonprofit organization and we're focused on educating Vermont residents and the medical and caregiving communities about medical aid and dying and our volunteers answer. Oh, about 6 to 10 calls per month from patients and doctors. And we connect any doctor who has not participated in act 39 before with knowledgeable colleagues such as Diana Barnard, and we train hospice and medical personnel. And the PCV website, patient choices.org has extensive resources, including videos of Vermonters who have used medical aid and dying. I would encourage you to listen to the voices of the people who made this choice. It's made such a huge difference for people working. We're working with terminal illness. You know, there's a real family and a real person behind every one of the 116 people who have filed for medical aid and dying since 2013. We've received a lot of notes of gratitude, which actually really should be forwarded to all of the legislators who made this possible. Vermont now has experienced doctors and hospice nurses and an excellent pharmacy, a compounding pharmacy, which is what's needed to develop the drugs and the medications that are used in medical aid and dying. And that pharmacy delivers the prescriptions where needed all over the state. In parallel, I would say that hospice use in Vermont increased 26% since 2013. I know this was a topic of discussion when the law was being considered. So there's been a very big increase in hospice use and so that today almost half of the people dying in Vermont are using hospice services. I would like you to hear directly from the patient. So I'm going to play a short clip from a young cancer patient named Karen Olschlager. So let me just hit the go button. And I knew that right now is like it's thicker and thicker. It looks more likely to that would be true. I'll actually need a lot. But I've been grateful to have it there in the two books on the left. I am so grateful this is something I worked through mentally and emotionally two years ago. I think there can be a lot of pressure in our society to keep fighting, keep fighting, keep fighting, especially as a young cancer patient. And I think what folks don't always realize is sometimes that keep fighting is really just a lot of so long physical suffering. I am just I am grateful for all the providers who have agreed with me that this is a valid option, you know, to take some control during this process, which is such a profound law. I hope you can hear that. Yeah, so, so Karen's whole video is on our website under the video section. And it's really, it's really enlightening about what actually goes on for for a patient who's considering act 39. So when act 39 was drafted legislators gave a lot of attention to preventing improper use of the law. And as a result, there's quite a list of requirements. There are five qualification requirements. There's an eight step procedure that the patient and the doctor have to go through and there's full documentation that is filed with Vermont Department of Health. Every person qualifying for eight and dying has to go through must be diagnosed by two doctors as having a terminal illness with six months or less to live and they must be capable of making their own medical decisions. And participation in the law is completely voluntary. So just by way of background I filed with in the written testimony a graphic flow chart which shows the procedure for your reference. Medical aid and dying is much more established across the country than it was in 2013 and Kim Kalin and from compassion is twice this is going to speak to that. In our eight years of experience PCV has not received a single report of suspected abuse. Yet we do know how onerous the process is for dying people. So we really think it's time to make improvements and appreciate your consideration. So I'm going to just run through the three aspects of the law and perhaps fill in any gaps that that there might be an understanding. The first the first change is that it would remove the requirement that request for eight and dying be in the physical presence of the doctor. And we have included in our testimony and a table comparing the the laws in the 11 states across the country and looking at the specific provisions that are in Senate bill 74. And you can see that Vermont is the only state among the 11 where requests for eight and dying have to be made in the physical presence of the doctor. And it can you just give me a thumbs up or a thumbs down I would I would play a quick clip from Karen all schlager again about her experience trying to get to the doctor when she was so debilitated.  So I was profoundly malnourished and dehydrated and vomiting pretty much constantly. So it's rough to drive 45 minutes and sit in a waiting room and, you know, have to get dressed and engage with someone who you know you might keep in front of the time of talking to the actual position I thought about it for literally years. So I yeah I think the removal of that requirement would be just a huge relief. Yeah, I having listened having had conversations with Karen through this whole process it's, it hits me pretty hard and I think it you'll find the same if you listen to Karen's video on our website on the video page, as well as the recording from the Allen who you may know she was the Resolutions clerk at the State House for many years, and she used after 39 last year. So then, so then the second part of Senate bill 74 which fixed the technical error that Diana Barnard mentioned, which provides explicit legal immunity only for the doctors in the process, and it would clarify that all the parties who act in accordance with the law which could be family members it could be hospice workers and it and of course the pharmacist would be free from claims of immunity. So, I'm going to take just a minute more on the pharmacist because that's where the real issue has come up. Because the, the, the law is just implicit not explicit about their immunity, the principal pharmacist who who fills prescriptions in Vermont requires doctors to sign an indemnification agreement. And many doctors are not willing to sign it is a very unusual requirement for a doctor. So this has reduced the number of physicians who are willing to prescribe and it's created pockets in the state, especially in southern Vermont and up in the Northeast Kingdom, where patients have trouble finding, finding a doctor who will prescribe and who will work with you at 39 with the Senate bill 74 amendment, the indemnification agreement would no longer be required and the pharmacist has confirmed to us that that is the case. And so we would expect the number of participating doctors to increase and especially local doctors and doctors who might have longer relationships with the patient. So you'll see in the table that compares the state laws, all of the other state laws provide immunity for all the people who are involved in the process in compliance with the law. The third part of Senate 74 would adjust the steps required to get a prescription. The proposed amendment keeps the 15 day period between the two request. It keeps the requirement for two doctors and a written request, but it removes this unnecessary and burdensome last 48 hour delay. 48 hours may not seem like much but the severely ill patient can make the difference between being able to qualify or not. And Vermont's timeline again looking at the comparison of the state. We were early in the process, you know we Vermont was the first state that that passed an aid in dying law through legislative action. So now that they're 11. There's really much more experience across the country and our process is one of the longest. If you look at the other laws, some of them do have a 48 hour period during the process but they overlap with the 15 days, whereas ours is tacked on to the end. So that makes our process a month the longest across the country. So, Betsy I'm going to ask if you could get to some closure simply because we're going to be pressed for time. And we and we may be able to come back with questions or further testimony going forward. Yes, yes, I certainly can. I would just add to that comment. I'm going to read these words of D Allen son, whose video is on her website, and he calls the last 48 hours, a nightmare. And that pretty much says it all for her case I won't go into more details you can listen to it if you like. So, please consider removing that last barrier. And we certainly appreciate all the consideration that you're giving we think that s dot 74 would remove needless suffering while keeping at 39 strong and consistent with best medical practice across the country. So thank you for your consideration. Thank you and thank you for your work on this I know it's been a long, a long time, including with your parents who many of us know when worked with. Thank you. Questions of clarification. Okay. All right. So next on our list is charity Clark of the Attorney General's office and charity thank you for being here. I know you have some specific comments to make about the bill and I think that's going to be helpful to the committee. Sure. Thanks for inviting us to testify on this bill today. Just a couple of things we were asked to testify as to the immunity portions of the bill. So I see those as the, the good faith section and see that was added. I first wanted to comment on the change in telehealth which we fully support and it's actually really wonderful to hear the testimony today about that. We would just suggest that safeguards be put in place. Obviously, it's, it's different to be in the room with the patient versus on on the screen, and would be happy to work with you on this or legislative council thinking about what those safeguards might look like. But also with telehealth wanted to lag an issue that I probably came up in 2013, but maybe with telehealth is going to be more of an issue that you might want to think about, which is the potential implications for where the healthcare provider charity or frozen if you can hear us. And sometimes it helps to turn off the video. It's probably the, the windy weather. Okay, so what I'm going to suggest is that we move to Kim Kalan and Kim you're not frozen. I'm good. Okay, Aaron is maybe you could communicate with charity and let her know that we know she's frozen and we'll try and get her back in. We'll do. Okay, thank you. Kim wanted to go ahead. Great. Thank you so much for being here today for allowing me to be here today. My name is Kim Kalan and and I lead compassion and choices, and we are the largest national organization that works to improve care and expand options at the end of life, including working with different states to authorize and then implement medical aid and dying laws and we worked closely with patient choices Vermont on the authorization of this law along with of course the legislature, as well as the early implementation efforts. So I'm delighted to be here today and my specific unique role will be to be able to share with you the experience in the other authorized states where we work across the vast majority of them. And what I thought I would do is start out and share with you. Oh, it looks like I cannot share my screen so I'll just in my testimony I think there are some slides you can refer to them there and I will just go ahead and and talk through them. So, first, just to give you guys some context and Betsy went into this a little bit in her testimony. But right now, across the United States, one in five adults have access to the option of medical aid and dying across 10 states and Washington DC. Vermont has played a very important role in the authorization of medical aid and dying be the being the very first state legislature to authorize the option in the states that became came before you, or again in Washington were authorized by ballot, and Montana was authorized through the courts and it looks like Aaron told me I can share my screen now so I'm going to go ahead and do that. Can everybody see that okay. Yes, great. So you can see that after Vermont authorized the option that right after that a flurry of other states followed suit. So California authorized by the legislature Colorado was another ballot initiative but then DC Hawaii New Jersey Maine and New Jersey all authorized through the legislature so on behalf of all of those other states I would like to profoundly thank the lawmakers of Vermont for your leadership. You've really not just brought a compassionate end for the residents of Vermont but you've helped pave the way in other states as well. It's important to know that while this option for brings a profound peace of mind to lots of terminally ill residents that very small numbers are going to choose to use the option and this is true in the other authorized states that already have the policies that we're hoping that the Vermont legislature will pass today. So, as Betsy mentioned it's 116 residents of Vermont have used the option across the years it's been authorized in Vermont but across all of the authorized jurisdictions all 11 jurisdictions in many many years decades combined, just over 5000 terminally ill adults have used the option. It's important though to know that what the data shows us is even those small numbers of people are using the option it's bringing peace of mind to lots of other people. And it also as you've seen in Vermont it improves end of life care across the board by creating better conversations between doctors and patients and encouraging earlier enrollment into hospice care as well. In terms of who uses the law data is collected across the vast majority of the authorized states, and we see pretty consistently the same trends and patterns. So you have about three quarters of the people who are using the option are over the age of 65 with the median age being in the mid 70s. There's an equal percentage of male and female which I always find to be particularly interesting and people give a large number of reasons why they're choosing to use the law we really think about it as being the entire experience of what something what happens to somebody at the end of life. It's everything from the loss of autonomy to fear about suffering to reduced quality of life. And the totality is why people are choosing to use the option. And as Dr Barnard said in her testimony the vast majority of people who use this option. Well before they were terminally ill were already clear that they wanted to be able to die on their own terms and that this is the option that they wanted so people don't come to this and make the decision lightly.   And generally speaking the family is very involved in the decision people who do choose the option tend to be have advanced education and the vast majority are insured. So that's just a little bit about what the data across the other authorized state shows about who chooses to use the option in terms of the specific provisions that you're talking about doing here in the state of Vermont. And I think what's most important to understand is that those are already the law across all of these other authorized jurisdictions so you're not asked we're not asking for changes here that are outside the practice that's taking place across all these other jurisdictions just like in Vermont there aren't you know substantiated incidences of abuse or coercion. What we do know is there are a lot of regulatory road box that 12 step process that somebody has to get through to be able to access the law when a person is terminally ill. It's quite an extensive process and the changes that we're making here are not going to make it any so that patients have more vulnerable populations are it doesn't change the experience for them. So specifically in terms of telehealth it's important to remember that all of the laws that govern the practice of medicine also govern medical aid and dying. So by removing the language within your provision related to telehealth what you're simply saying is the laws in place that govern telehealth in general will also be in place to govern medical aid and dying. And so what does this mean it means that video only appointments will have to be used in order to establish a relationship for the person, which gives that you know experience that Dr Barnard was talking about. It means that you know a person can't get through that whole process without those video appointments and it means that you're treating the practice of medical aid and dying in the same way we're treating other medical practices. This is what is done across all the other authorized jurisdictions and again what the experience has been especially in the time of COVID is it has actually helped to protect vulnerable populations because you haven't forced them to risk getting COVID and leaving their homes, which actually is a pretty horrific death in order to access the option that they want. So I would say it brings a lot greater compassion, especially for a person in a state like Vermont that has lots of rural areas. It takes away the burden of having to travel several hours in order to be able to get the care and the experience that they want. The second provision around the 48 hour timeframe, the trend across the country is actually to move. I don't want to interrupt, but we're running into some time issues this morning, and your, your written testimony that you have provided us is very clear. So if you could just give a couple of sentences about the last provisions and then wrap up that would be terrific. Great. I will do 30 seconds on the, on the immunities again they're across all of the other authorized states and in the 48 time period. This is just consistent with the other states so you know happy to answer any questions of people have them and I appreciate the opportunity to be here. Thank you. And thank you that you're the information that you provide is extremely helpful. And we greatly appreciate it. We have a question of clarification from Senator Hardy. Thank you madam chair. Kim you, you brought up an issue that I hadn't. Unfortunately, I hadn't thought about before in that in your statistics about who accesses medical aid and dying. Specifically people who tend to be more educated and and insured. And I'm wondering if there are provisions in other states that could improve that we might consider that would improve sort of health equity and access to this medical care. Yeah, that's a great question. I think from an access perspective. First of all I do think it's important we want to get these changes through so I wouldn't want to do anything to the bill this time around that would slow things down in any way. But some of the other states their state Medicaid program covers the law and that does help to bring about greater access to the law. Thank you that's helpful and one does our state not does our Medicaid program not cover it. I will defer to Betsy on that. Right. After the nine patients in general have to pay for the medication. You know what I'm going to suggest Betsy thank you. Yeah, I think we'll get clarity from our legislative council. Okay, yeah, that I think that that would help and and Ruth is a great Senator Hardy is a great question so we'll try to get some clarity on that. Great. Thank you. Thank you. Sure. All right. Yes, thank you for your testimony. So charity Clark is with us by telephones charity. Why don't you go right ahead with your testimony. And I know. Yeah, go ahead. I'm going to keep my camera off one because I'm on my camera and you always look gigantic when you turn your camera on but also I'm nervous about the connection maybe because of the wind. So I was just flagging I hope that you heard me start this but to think about what the implications might be for where the health care providers physically located. In other words, are they out of state in a state that does not have a law that would provide the immunity. So I wanted to flag that as an issue. And then the second kind of main topic is this prevent this addition to a paragraph dealing that that references good faith. So currently as others have discussed there is this regimented process for facilitating patient choice at end of life, and any good faith is implied in that. So the new section makes good faith explicit and from a criminal perspective the current process is very strict is regimented so long as these steps are taken. The report is made the Department of Health, the physician isn't subject to criminal liability. The proposed subsection introduced introduces explicitly this new element of good faith. So I'm wondering if this might raise questions about the process, because it does introduce this new element, and you know for prosecutors or the Office of Chief Medical Examiner Department of Health. I'm not sure if there was, it sounds like the reason for the section relates to making sure that pharmacists are explicitly included in the immunity, and it might be simplest just to add pharmacists or others to the list with physicians to the new section which I think does raise some questions about the paradigm right now as the law exists. I'm happy to speak with legislative council about particulars on this but those are the, you know, couple of things I wanted to flag for the committee, and I'm sorry again for my connection issues but glad I was able to finish the testimony today thank you. Thank you and and again this this sounds like something that our ledge council may be interested in helping us understand so we will. It would be helpful to have you connect with ledge council and we'll work through that and try and make that happen. Great happy to thank you. All right, thank you. Who is next on our list, I think it's Sarah teach out a blue cross and blue shield and Sarah thank you for being here. Great, thank you Sarah teach out the government and media relations person for blue cross and blue shield of Vermont. I will be quite brief. Blue cross supports the passage of s 74. And in particular we believe that the provision about immunity that applies more broadly is very important for this bill what we've noticed in trying to support our members who are looking to fill the prescription is that there's only one pharmacy in the state of Vermont that can do so right now, or is willing to do so. And we believe that this is one of the reasons that pharmacists have not been participating. And so if you broaden this immunity piece, there might be more options for patients for filling the script, and that's something that we work on with our members when they've requested it. And again, we really do try to support our members with all of their health care choices and we believe that this will make the law work better for patients in Vermont. Thank you. Thank you. Okay. So we'll move along unless there's a question of clarification. And David Englander is here from the Department of Health. Welcome. Madam chair it's wonderful to see you. Good morning members to see you. My name is David Englander I'm the senior policy and legal advisor to the Department of Health. I think we're a little short on time so I will uncharacteristically try to be brief, the Department of Health supports these proposals for the reasons articulated earlier. Actually, this is the act 39 in 2013 was the first piece of legislation that I worked on. I'm in my role the Department of Health. So I built long the department has a long history so folks know the role the Department of Health is to collect the information provided by doctors and patients. That information is held confidentially, and then we produce a buy in report that I've provided my testimony. We also provide support to doctors and patients, the extent that they have questions regarding the law, although largely this is, you know, decisions made between, between doctors and patients. With that, I'm happy to take the communities questions. I do have a question and you've you've given us the full report which is terrific it's four pages long so we won't have any difficulty getting through it. And then you've also given some other information, but I guess my question for you is there anything in the report or the reporting that you have seen that was a surprise to the department in terms of how the process is going or the data collection. A surprise. No, it has been, it has been so I would say I've been surprisingly smooth from the department's perspective understanding that doctors and patients are leading that the complex lives involved with with end of life decisions. There certainly has been. There's a lot of work on the department side trying to gather this information sometimes there's a misunderstanding about how the law works so we do a lot of outreach to providers. The law is so familiar with the law know it lays out a stepwise process that doctors and patients have to go through the Department of Health did produce forms so that all providers can use those rather than trying to generate them themselves. So, on the whole it's been it has been a fairly smooth the the calls with questions regarding the law tends to ebb and flow with reporting.  Okay, thank you. And you have your frequently asked questions there which is very helpful. Senator Hardy, I think Senator Hooker you had your hand up first and then Senator Hardy. Actually, Senator Hardy did. Okay, thank you. This is not necessarily a question for David but a charity who is not on the screen anymore. Raise this question and maybe Dr Barnard knows the answer about telehealth and medical licensure. My assumption is that that just like with any physician they would have to be licensed in the state of Vermont to provide telehealth for this for this service. So it seems to me that it would be covered already under medical licensure law in another part of the statute. Maybe this is a question for our legal counsel as well but is that your understanding Dr Barnard. I guess listen I'll let Dr Barnard answer but I think the Department of Health can answer that based on the board of professional regulation but go ahead Dr Barnard. Yes, I agree with what you said Ruth about the issues being guided and and deferred to others with more expertise in the legal realm. Okay. I agree Senator Hardy that is the case. Okay, so there's not like we don't need another separate provision for this new telehealth it's already covered under the fact that physicians have to be licensed to practice in Vermont. Well, cherry and I haven't spoken in detail with regard to the age of concerns so I so I wouldn't want to opine that broadly but certainly on its face that would appear to be the case. I just want to make sure we get clarity on that before we move the bill forward but it seems like it probably is already covered, but thank you. Right, so this is another let's let's I'll give that task to David Englander will I'm going to add that to our list of clarification with our ledge counsel. And also on my list is to determine whether Medicaid covers these services I've already reached out to my colleagues and we'll get the answer by the end of the day. Thank you so much. Senator Hooker. Thank you and actually Senator Hardy asked the question that's very similar to the one I had and I was just wondering if in the reporting you differentiate between doctors who are located in the state and those who are located in states. We don't they that the in order to participate they have to be Vermont license positions. Okay, and we will, we will, of course work with ledge counsel as we go through the bill again and look at some of the responses that we're getting. So once we get Medicaid that'll be helpful and then we'll learn further what language might be necessary on the pharmacists, how much language have been we'll have charity Clark, working with ledge council initially initially and then we'll bring it back into committee, talk and committee. And that's one point if I may, which is that the issue of concerns about liability coach for pharmacists arose immediately after passage of the bill, the department actually reached out to the office the attorney general. And you can see on the, the penultimate question of the FAQ we have the statement of the attorney general that if a pharmacist acts within the scope of her practice that actions of the law are covered by liability. So, what I 74 does is it makes explicit what has been implicit understood, I just want to be clear that that it codifies the status quo. In a way that that's we now have positive we would now have positive law, but it's not it doesn't represent a shift, legally speaking. Thank you. Thank you for that clarity helpful. Okay. Committee any other questions for the witnesses today. And just as I indicated earlier we do have one witness who's who is unable to be here because of a family emergency. And so we will add that testimony. As quickly as we can. And we'll try to get responses back on this legislation and go through it for some final discussion and markup as quickly as we can as well. Okay. Thank you all for being here I we're, we're, we're in a mode of switching gears and turning a corner. And we're going to be looking next at parent child centers and a bill called s 91. So I'm not sure you need to stay around but thank you all for your testimony has been excellent.


the next lecture in the topic thermal infrared remote sensing. In the last class we got introduced to the concept of thermal infrared remote sensing and also we started discussing about emissivity and its importance in understanding the thermal properties of object. So today we will continue with this particular topic. In the last class we defined spectral emissivity and its importance and based on spectral emissivity how objects can be classified. So what are some important factors that controls the spectral emissivity of objects we will see now. So spectral emissivity is influenced by the colour of the object. Darker objects typically has higher emissivity, chemical composition, the nature, chemical nature of the object, surface roughness like how rough or how smooth the surface is, moisture content, compaction of the object, wavelength of observation. This is important because that is why we repeatedly call emissivity as spectral emissivity. Emissivity varies with wavelength. With the viewing angle whether we are viewing it from nadir or whether we are viewing it from some other angle all these things will influence the emissivity of the object and hence emissivity has a directional property and sometimes the temperature of the object itself will influence the emissivity. But we may not worry much about this because for the normal temperature range we are seeing this may not be a major factor. But all these other factors colour, surface roughness, moisture content etc will change it. Say for example, if you compare like a dry soil under wet soil like after a rainfall or something. So after like when it rains over like dry soil it gets wet. So when it is dry it will have certain emissivity value. After it got wet the emissivity most likely would have increased if other conditions remain normal emissivity would have increased most likely. But this is applicable only in the thermal infrared range. In other wavelengths this relationship may not be valid emissivity may also decrease especially in microwave wavelengths. But in this particular thermal infrared wavelengths 8 to 14 micrometers for dry soil emissivity will be low. For wet soil emissivity will be high and similarly we also know that when we add water to soil when the soil get moist its reflectance goes down. We have already seen this the reflectance property of soil. So the reflectance decreases. So emissivity will increase. So normally it will appear dark and its emissivity will be high. So the colour, composition, moisture, surface roughness all these things will affect emissivity. So these are some of the common factors. So again in order to emphasis the importance of emissivity I have given like two examples here. So this is like a black body curve that is as given by Planck's equation the dark black line and this dotted gray line is for water at the same temperature 350 Kelvin. But water has emissivity less than 1 and as I told you at the wavelengths of that we are discussing like in the infrared range and all we can assume water to be of like a gray body and hence the emissivity can be treated more or less constant. So it will the radiation from water body will be 98% than what is given by Planck's equation. On the other hand let us consider a material called geonite it is a mineral. It has like it is a what to say selective radiator and its emissivity will be keep on varying. So at certain value or at a given wavelength we have to know the emissivity in order to properly change this Planck's equation value to the actual value emitted by it. Either we should measure this and we should bring it there in order to calculate it. So we should know the emissivity values. So what will be the typical emissivity values of real life objects in the wavelength that we are talking about that was between this 8 to 14 micrometers wavelength. The wavelength or the emissivity of most of the earth surface features will is fairly high above like 0.85 or above 0.9. Maybe we will look at this particular chart given in the slide. Say after this 8 micrometer even like we can start at 10 micrometers because as I said most of the earth observing satellites typically measures between 10 to 12 micrometers. So if you look here and if I draw something like this and if I project it here then we can observe that after like between this 10 to 12 micrometer range under where most of the thermal satellites observe the earth surface the emissivity of most of the commonly occurring earth surface features snow, sea water, ice, leaf, grass, etc. typically is fairly high above 0.9 range. So this is like more or less a general property of earth surface objects. In thermal infrared wavelengths 8 to 14 micrometers wavelength emissivity will be like pretty high and the values also will not vary very widely. Say maybe in the later part of lectures when we discuss about passive microwave remote sensing we will see that at such wavelengths at microwave wavelengths emissivity varies very widely. But in thermal infrared wavelengths emissivity variation is not as high as in that particular wavelength it is fairly high like above 0.9 and mostly it will lie in that particular range say 0.85 to 1 or 0.9 to 1 for most of the naturally occurring earth surface features like soil, vegetation, water and so on. So the emissivity of some commonly occurring objects on the earth surface is given in this slide. So under this 8 to 14 micrometer range of wavelength the emissivity of various factors like distilled water has extremely high emissivity, normal water occurring in our water bodies has emissivity of say 0.92 to 0.98, concrete has pretty low emissivity range like pretty low emissivity value. If you look at like vegetation say here you can all observe forest all these vegetation related thing has fairly high emissivity 0.95 or 0.96 and above. Whereas if you look at like metals all these things aluminum, stainless steel, polished metals etc all these things have very low emissivity values. So normally metals which are good conductors of heat and which can reflect a lot normally metal surfaces can reflect lot of energy such objects will have low emissivity. And almost all naturally occurring surfaces like soil, vegetation, water all has emissivity above 0.9 this is like a under normal conditions even human skin has very high emissivity. Snow has pretty low emissivity in this particular band so we have to take care of it if someone wants to observe snow. So now we have seen or we have got introduced to the concept of emissivity and the typical range of emissivity that we can expect in thermal infrared wavelengths or long wave infrared wavelengths. One important law that we should remember in remote sensing or thermal remote sensing especially is known as Kirchhoff's law. What Kirchhoff's law says Kirchhoff's law relates reflectance of an object with the emissivity of the object. So we all we know that whenever some object is kind of emitting or basically interacting with EMR three different processes can occur. Reflectance or reflection, absorption and transmission like let us say this is like some any earth surface feature. When some EMR is incident over it it can reflect a part of it or it can absorb a part of it or it can allow a portion of EMR to transmit to pass through it. These three things will happen. Let us say absorption like first we will talk about this. If an object is a good absorber then it will be a good emitter like if we talk in this particular range 8 to 14 micrometer thermal infrared wavelengths. If an object absorbs well then theoretically speaking it should also emit well because we have learned in thermodynamics that all objects on the earth surface try to be in thermal equilibrium with its surroundings. Normally when you bring a hot body and a cold body near each other it will try to the hot body will transmit radiation or heat energy to the cold body they will try to become like one single equilibrium. Same thing is common for almost all naturally occurring objects. So if an object is a very good absorber like it is absorbing lot of energy then its temperature will be keep on rising right absorbing means taking in more energy. So if it wants to come to thermal equilibrium with its surroundings it also has to emit equally good then only it will emit radiation like it will be absorbing in one end it may be emitting from the other end such that it remains or it moves towards thermal equilibrium with its surroundings. So naturally all commonly found earth surface features if they absorb well they will also emit well. So absorption and emittance we can replace one with each other that is say in terms of like thermal infrared remote sensing we are dealing with emission of objects how much energy objects are emitting. So for our purposes we change this equation reflectance plus transmittance plus absorptance this is equal to one this this equation we have seen already in earlier classes. Now we replace this absorptance with emittance. So reflectance plus transmittance plus emittance equal to 1 because we all know that absorptance is equal to emittance that is our major assumption. And then again look at like commonly occurring earth surface features like sand vegetation etc most likely they will have zero transmittance to thermal infrared thermal infrared wavelengths they may not allow the thermal infrared radiation to pass through them either they may absorb it or reflect it or something okay. So naturally transmittance also will be zero under this wavelengths. So at 8 to 14 micrometer range this equation reduces to reflectance plus emittance is equal to 1 that means reflectance is equal to 1 minus emittance or emittance is equal to 1 minus reflectance. So this is what is given by Kirchhoff's law. So Kirchhoff's law basically tells us that good absorbers are good emitters that is why we have replaced absorptance with emittance first thing and second thing is good reflectors are poor emitters. So if an object reflects a lot of energy in this range 8 to 14 micrometer normally like there is no incoming radiation from sun in this 8 to 14 micrometer range. So if somehow let us say there is like some surface on the earth we are illuminating with some energy source that is radiating at this 8 to 14 micrometer range okay but even like atmosphere atmosphere also emits energy in that wavelength only. So if some energy is falling on an object at this 8 to 14 micrometer wavelength and if an object the land surface object if it is capable of reflecting a major portion of it then according to Kirchhoff's law that particular object will be a poor emitter. On the other hand if that object that is under this influence of this incoming radiation if it absorbs a major portion of it then it will be a very good emitter. So higher the reflectance lower will be the emissivity and vice versa. So this relationship we will quite often use reflectance is equal to 1 minus emissivity when we deal with data processing especially in thermal infrared remote sensing okay. We will now try to understand few or different definitions existing for temperature. Temperature is like a very common word but we can define it in several ways especially when we deal with remote sensing. So one of the commonly used definition of temperature is what is known as a thermodynamic temperature. So what exactly is thermodynamic temperature like loosely putting it or like commonly putting it let us say if you want to measure temperature of an object what we will normally do take a thermometer put the thermometer in contact with the object wait for few seconds take the thermometer out make a reading out of it we will measure the temperature of the object. So how this thing is happening basically we are taking the thermometer and we are bringing the thermometer in physical contact with the object of our interest let us say in olden days how doctors used to measure our body's temperature they will take a mercury thermometer put it underneath our tongue they will ask us to open our mouth put it below our tongue. So they are bringing a thermometer and making it or bringing it in physical contact with object of our interest that is our body. After coming into a contact they will wait for some time why are they waiting for some time they are allowing the time in order to bring our body and the thermometer to reach like a same temperature level that is they want the thermometer and our body to in thermal equilibrium. So the time they allow that few seconds of time they allow during that time our body's temperature will influence thermometer temperature and vice versa and both of them will come toward like one same temperature at that level and then they will take it out they will read a value. Hence thermodynamic temperature can be thought of or can be defined as the temperature which we can measure directly with the thermometer in physical contact with the object of interest and also there the object of our interest and the thermometer should come to like thermal equilibrium and then we measure the temperature of the object. So the temperature we measure in that particular way is known as thermodynamic temperature. So here that is what the definition is given a slide. So this definition is taken from one of the seminal papers by Becker and Lee in the year 1995. So it is defined for a medium in thermal equilibrium. So I said they will leave some time for the object or that is our body and thermometer to come to physical thermal equilibrium and it can be measured directly by a thermometer. So this is the common way of measuring temperature but there we are actually making an assumption. What is the assumption? The doctor is putting the thermometer underneath our tongue and doctor is taking a reading. Doctors assume our body's average temperature all across is very close to or equal to the temperature they measure underneath the tongue. That is the assumption they do but it need not be the case the temperature underneath the tongue may be that but it may change at different points of our body. It will change but that is the most representative measurement the doctors can make. Similarly if you take analogy of some commonly occurring earth surface features if you put thermometer over it measure temperature we are assuming that object is in thermal equilibrium and that particular object is homogeneous. Let us say there is like a water tank. Someone asks us to measure the temperature of water in the tank. What we will do if we take a thermometer and measure just at one particular point within the water tank it may not be representative. The temperature at different points of the tank may vary. Normally what we will do we will take at least some 4 or 5 different measurements we will take average out of it and present it. So what this means the measurement of this particular thermodynamic temperature also assumes the object is homogeneous and isothermal. Isothermal means it is in temperature is not changing it is in equilibrium with its surroundings it is homogeneous in nature. Under such circumstances only the point measurements that we make will be reliable but under normal conditions this may not be valid. Say in this water body example I just showed you I said even within a small tank of water body the temperature may change from point A to point B and also if we measure the temperature at different different depths temperature may change all these things will come into picture. So definition of thermodynamic principle is very simple. You take a thermometer put it in contact with the object of interest let they come to thermal equilibrium take temperature definition is simple but in practice or in reality measurement of thermodynamic temperature is a difficult task because most of the commonly occurring earth surface features they will not be in thermal equilibrium the temperature will be keep on changing they are not isothermal say even if you take like a small water pond you need to take multiple measurements at different different points you will get different temperatures. So these non-homogeneity and non-izothermal nature of earth surface features makes it difficult for us to measure thermodynamic temperature for our various application. Let us say you want to measure temperature of like whole city for some applications we will not be in a position to measure the temperature of each and every point in the city right it is like impossible. So definition of thermodynamic temperature is possible very simple but in reality measuring it is extremely difficult due to the very high level of in homogeneity or non-homogeneity of objects objects are non-homogeneous temperature will change at different different points for the same object and also objects will not be in isothermal conditions isothermal conditions means let us say take a land surface during daytime solar radiation will be keep on like illuminating the surface surface will be getting heated up it will be under like constant process of getting heated up similarly during like night times surface will be continuously cooling down. So it will never be in like isothermal conditions either it will be heating up or it will be cooling down. So the temperature will be either raising or falling continuously. So finding a proper commonly occurring so finding a proper earth surface feature under isothermal and homogenous conditions is bit difficult and hence measurement of thermodynamic temperature is also difficult. The next definition is radiometric temperature. So this is what we are going to measure in remote sensing. So what exactly radiometric temperature is let us say this is like a land surface here we have our sensor. So land surface has a temperature let us say this is like Ts surface temperature and it is radiating some energy this is the radiance. So this will reach the sensor also we have our own atmosphere. So atmosphere has its own temperature T, Ta it will emit radiation towards the earth surface it will be reflected back towards the sensor. So this is the surface reflected atmospheric downwelling radiance. We have seen this already in earlier lectures. So these two terms actually carry the signal above the earth surface features. So the temperature based on the temperature there will be a radiance and similarly based on the reflectance of an object there will be a radiance. So these two paths will carry the signal above the surface. So if you take the radiance reaching the sensor let us neglect all other effects of atmosphere. So the radiance reaching the sensor is practically what is emitted by the object of interest itself and what is emitted by atmosphere. So this is atmospheric emitted term and 1 minus emissivity this is basically the reflectance. So here what is being reflected? So this term is reflection or reflectance of atmospheric emitted component. This is the surface emitted component. So the surface emitted component is equal to emissivity time the Planck's equation. So the emissivity is to correct for how well an object can radiate. So emissivity into Planck's law will give us the actual radiation emitted by the object at a given temperature Ts and this rho times radiance of atmosphere will tell us the surface reflected downwelling radiance terms. So you just kind of neglect this I want to get this Ts surface temperature. So what I should do the Ts surface temperature is equal to observed radiance divided by emissivity of the object when you give this value to the inverse Planck's function then we will get the temperature T. So what exactly inverse Planck's function is? Say Planck's function will tell if an object is at a given temperature T the object will emit a certain amount of radiation at a given wavelength. You reverse it now I observe radiance from remote sensing and using this radiance I know the wavelength in which I am observing and I know the emissivity of an object. So if I know the radiance if I observe the radiance if I know the emissivity and if I know the wavelength of our observation I will be able to substitute all these values in Planck's equation and calculate the temperature of the surface. So this way of measuring the surface temperature that is by observing radiance by knowing the emissivity and calculating temperature this way is known as measurement of radiometric temperature the temperature you are measuring in this way is known as radiometric temperature. So that is again given here in this particular slide. So the radiometric temperature under normal conditions will be the radiance observed by the satellite r lambda minus the surface reflected atmospheric emitted terms. There is also like a path radiance term we have seen it but here we are neglecting it. We assume it has already been removed. So purely speaking the radiance emitted by the surface object you correct for emissivity effect that is you divided by emissivity and then you invert it in plan invert the Planck's function to get the surface temperature and this is known as radiometric temperature. So this radiometric temperature and thermodynamic definition of temperature that we have earlier seen they will be equal only for homogeneous objects under isothermal conditions. Let us say we have like a water body and let us say like the satellite is observing like a small part of water body. So this is like 1 J FOV. So it is observing only that water body continuously. So if the entire pixel is occupied by water body let us assume the water body has a homogeneous temperature and somehow it is in thermal equilibrium. Let us say its temperature is not changing thermal equilibrium at isothermal conditions. Under such circumstances only the temperature we measure from remote sensing the radiometric temperature will be equal to the true thermodynamic temperature that you measure with a thermometer. So this is like a very stringent conditions. So under normal conditions the radiometric temperature that we measure from satellites will not be equal to the physical temperature of the objects on the earth's surface. Because as we have seen most of the objects are they are not homogeneous and they will not be under isothermal conditions and hence these two temperatures the radiometric temperature that we measure from a distance and the what to say thermodynamic temperature that we measure with a thermometer most of the conditions they will not be equal they will be equal only for homogeneous and isothermal surfaces. The next definition of temperature that we are going to see is brightness temperature. What exactly is brightness temperature? Let us say we have a satellite in space it is measuring the land surface it is observing the thermal radiance coming out of the earth's surface it has measured some value okay some L lambda value it has observed. Now if someone wants to calculate temperature they can just take the value put that value in Planck's equation because the wavelength is fixed a satellite once we send a satellite we know in which wavelength it will work. So take the radiance substitute that in Planck's equation invert it to get the temperature that is known as a black body sorry that is known as a brightness temperature sorry. So what exactly brightness temperature is brightness temperature of an object or the brightness temperature is defined as the temperature a black body would have in order to produce the same level of radiance as observed at the satellite sensor. Say I have a satellite sensor up in space some radiance L lambda it is measuring I just take the L lambda substitute this in Planck's equation invert it and I get a temperature. So this temperature is essentially a black body temperature because Planck's law is defined for black bodies. So brightness temperature is defined as that particular temperature that is the temperature a black body will have in order to emit the same amount of radiance observed at the satellite sensor. So this is known as a brightness temperature. We compare this definition with real world objects a satellite is in high up in space land surface is emitting energy it is passing through the atmosphere and my sensor is measuring radiance in order for me to calculate brightness temperature what I do I just take this radiance value substitute this in Planck's equation get a temperature out of it that is it I have not done any correction. So this temperature what I calculated just from mere satellite observation is actually not corrected for surface emissivity effect and atmospheric effect and also the sensor response function I already told you within a given wavelength within a given bandwidth the sensor may not have uniform response at certain each bandwidth or each each interval of wavelength the sensor may have a different response right we have already seen it when we define the concept of spectral resolution. So please go back to previous lectures about spectral resolution we have discussed this what a spectral response function of sensor is. So essentially when we calculate brightness temperature we just take the radiance from satellite put it in Planck's equation and invert it that is all we are not doing any correction. So the surface emissivity effect atmospheric effect and sensor spectral response effect all these things will be there when you calculate brightness temperature. So brightness temperature is kind of like a first hand information I can get just from radiance I am calculating the temperature we do not bother much about what effect atmosphere made how much surface emissivity or spectral emissivity object has all these things we do not care about. So this is another way of measurement but for most of the applications especially in the thermal infrared domain in the 8 to 14 micrometer wavelength normally we would not stop at brightness temperature we will we will correct it for effect of surface emissivity we will correct it for the effect of atmosphere and then we will convert it into radiometric temperature the definition we have already seen and then we will use it. So in today's lecture as a summary we have seen few examples or few ranges of emissivity of commonly occurring earth surface features and also we have defined 3 different temperatures thermodynamic temperature, radiometric temperature and brightness temperature. Thermodynamic temperature is the physical temperature you measure with the help of a thermometer and the object for which you are measuring the temperature we assume the object is isothermal and in thermal equilibrium. Second thing is radiometric temperature that is if there is an object I measure the radiance out of it from the radiance knowing the emissivity value of an object if I estimate the temperature that is known as brightness temperature sorry that is known as the radiometric temperature brightness temperature is a temperature of a black body that will produce the same amount of radiance as observed by a satellite sensor. So essentially the sensor when it absorbs the radiance in it will not be corrected for surface emissivity effect will not be corrected for surface or the atmospheric effects. So brightness temperature is roughly speaking temperature uncorrected for atmosphere and emissivity effect whereas radiometric temperature is if the brightness temperature after doing all the corrections emissivity atmosphere sensor response all these corrections after we do it the temperature we are going to get is radiometric temperature. So brightness temperature and radiometric temperature are kind of related okay so if we whether we do atmosphere correction whether we do emissivity correction all these things will tell us with this we end this lecture thank you very much.