Nurses, Doctors Skirmish Over Authority to Issue Death Certificates

Andrew Kitchenman | March 18, 2014 | Health Care
APNs cite difficulties encountered by primary caregivers, while doctors assert their continued lead role is essential

Cynthia Riemer, left, says advanced practice nurse Meshell Mansor, right, had to scramble to track down to sign the death certificate on a timely basis.
When a patient dies, the medical practitioner treating the patient at the time generally determines the cause of death and signs the death certificate – unless that provider is an advanced practice nurse.

In yet another debate about the limits of authority awarded APNs, doctors groups are opposing a bill advancing in the Legislature that would expand this authority to APNs who are serving as patients’ primary caregivers.

Doctors argue that they
play an essential role in making sometimes-complicated determinations about the cause of death. Nurses, however, contend that doctors sometimes aren’t available to sign these documents in a timely manner, complicating funeral arrangements.

The debate is one of several centered on the scope of practice for APNs, who are playing an increasingly important role in primary care treatment for many patients. Doctors groups say that giving APNs more authority runs contrary to a trend of emphasizing team-based care, a contention that APNs reject.

Advanced practice nurses – also known as nurse practitioners — hold graduate degrees and are trained to diagnose and treat acute and chronic illnesses; take health histories; order and interpret lab tests and X-rays; and provide physical examinations, immunizations, and supportive counseling. They must pass an exam to receive state certification.

APNs have the education and training to determine the cause of death, and frequently treat patients who die at home or in hospices, according to
Judith Schmidt, the New Jersey State Nurses Association’s president and interim CEO.

Giving these nurses this authority “will help expedite the process for an already grief-stricken family,” she said.

Dr. Kennedy Ganti of Virtua Family Medicine in Mansfield said that while doctors value APNs, physicians are in a better positionto diagnose the cause of death in light of the increasing complexity of these decisions in light of evolving technology and ethics.

“We want them on the front lines, but we want to make sure that we have accuracy of diagnosis,” said Ganti, who was speaking on behalf of the Medical Society of New Jersey and not Virtua.

In addition, Ganti said the bill “seems to be going against” the movement toward collaborative, team-based care that is overseen by doctors.

Bill supporter Sen. Joseph F. Vitale (D-Middlesex) expressed skepticism about this argument, saying that APNs routinely work closely with doctors and other healthcare providers.

Ganti said the pressure to emphasize care given by APNs is part of the larger problem of patients not having enough access to doctors.

“We don’t want to insult our APN colleagues, but at the same time we don’t think that substituting one for another is necessarily equivalent,” Ganti said.

APN Meshell Mansor said that when her patients die, she sometimes can’t reach the doctor who signed the agreement – or joint protocol – that allows her to operate a primary care practice in Turnersville. She added that while this doctor does sign some death certificates based on the information she provides to him, he doesn’t treat or even see her patients.

Cynthia Riemer said Mansor’s practice treated two of her family members who died. She said that both relatives wanted to be cremated. Since her grandfather died on a weekend, this created a dilemma, since state law requires that cremation occur within 48 hours of death or additional costs – such as those for embalming — must be incurred without a death certificate. Mansor had to go to a doctor’s house to have the certificate signed, Riemer said. If a doctor wasn’t available, Riemer said, it would have cost her an additional $1,000.

“You might as well take that $1,000 and put it in the crematory with them,” Riemer said, adding: “You shouldn’t have to worry about whether the death certificate is getting signed or not.”

The Senate Health, Human Services and Senior Citizens Committee released the bill yesterday. A similar bill earned a “pocket veto” from Gov. Chris Christie when the last legislative session ended in January, meaning that he allowed it to expire without signing it. Vitale said it was possible that Christie didn’t oppose the measure, but that his staff didn’t have time to review it before the deadline to make a decision.

Doctors and APNs also differ on whether APNs should be able to establish their own practices without signing agreements with doctors and whether APNs should have the same authority as doctors to prevent utilities from shutting off electricity to patients.