Doctors, Advanced Practice Nurses Spar Over Authority to Sign Death Certificates

Andrew Kitchenman | March 11, 2015 | Health Care
Physicians sound alarm on diluting quality of healthcare; APNs contend they’re qualified and often deal more directly with patients

Assemblywoman Nancy F. Munoz (R-Morris, Somerset and Union)
Advanced practice nurses are seeking the authority to sign death certificates– a move that’s being met with pushback from doctors’ groups

Advocates for the bill allowing APNs – also known as nurse practitioners – to sign the certificates say it isn’t a radical change. They say it builds on APNs’ existing legal authority to make nursing diagnoses.

But doctors call it an unjustified expansion of what nurses can do. They see it as another in a series of encroachments on duties best performed by doctors.

The bill reflects some of the larger debate involving expanding the role of nurses, which centers on whether nurses should be allowed to operate their own practices without agreements with doctors.

APNs – who receive graduate education in diagnosing and treating illnesses – argue that they’re frequently in the best position to address routine patient needs, while consulting with physicians about thornier problems. Broadening their scope, they contend, will help address a growing need for primary care providers.

Doctors argue that giving nurses more authority will inevitably lead to a decline in the quality of care, since doctors receive more extensive education and training, and that team-based healthcare should always be led by a doctor.

The bill would let nurses sign death certificates when a doctor isn’t available. The Assembly passed the bill by a 69-5 vote on Monday, after the Senate passed an earlier version unanimously last June. A similar measure was passed by the Legislature in January 2014, but it received a “pocket veto” from Gov. Chris Christie, which occurs when a bill goes unsigned at the end of a session.

Bill sponsor Assemblywoman Nancy F. Munoz (R-Morris, Somerset and Union) noted that APNs already diagnose terminal illnesses, and that sometimes doctors’ only interaction with patients for whom they sign death certificates is asking the nurse what to write down as the cause of death.

‘Professional chauvinism’

“There’s opposition to any changes,” Munoz said of doctors’ approach to APNs. She described the attitude of doctors as “professional chauvinism — it’s ‘We know better than you do.’ ”

Doctors argue that APNs are recognized and respected as an essential part of healthcare teams – but that role just shouldn’t be extended to signing death certificates.

“They take very good care of the patients. That being said, there are many instances where they need to refer to a physician for perhaps what to me seems like very simple issues,” said Dr. Joseph Costabile, a surgeon in a 21-doctor practice in Camden County that employs five APNs.

Costabile drew a parallel between what APNs do and what his wife does as a paralegal whose work is regarded as “excellent” by lawyers at her firm.

“She’s not going to trial, she’s not going to try that case, even if she’s done the preparation for it,” Costabile said.

Long waits for certificates

APNs said that patients’ families must sometimes wait unnecessarily for death certificates when doctors aren’t available, even though the APN served as the dead person’s primary care provider. Bill supporters said this will become increasingly common as more patients die at home, after receiving palliative care from APNs.

These time delays are particularly sensitive for families whose religions require burial within 24 hours of death.

“Our inability to sign causes delay and anxiety for families,” said Sandra Morrison, an APN and principal of Sparta-based practice New Perspectives Health Care.

Like other APNs who operate their own practice, she has an agreement with a collaborating physician that allows her to write prescriptions as long as they meet once a year to review at least one patient’s records. Morrison said it wouldn’t be appropriate for this doctor to sign the death certificates of patients he never treated, “nor does he want to.”

John Indyk, vice president of nursing-home trade group the Health Care Association of New Jersey, said the bill makes sense, since nursing homes increasingly rely on APNs when doctors aren’t available.

But Claudine Leone of the New Jersey Academy of Family Physicians pointed out that it’s become easier for doctors to issue death certificates remotely since the state implemented an electronic death registry.

“We have talked to funeral directors, we have talked to hospice providers and essentially they are not identifying this as problematic,” Leone said.

Mishael Azam, chief operating officer of the Medical Society of New Jersey, said that if APNs and their collaborating physicians aren’t communicating, the problem isn’t with current state requirements, but rather that they should increase their collaboration.

“If the physician and nurse are not talking, then that is a disservice to the patient,” she said. She noted that doctors receive more extensive education and training than APNs.

Munoz said she agrees that collaboration benefits patients, but that doesn’t mean that doctors must lead the collaboration.

Collaboration “doesn’t mean, ‘I’m in charge and you’re not,’ it means: ‘Let’s work together,’ ” she said.

Since the Assembly amended the bill, the Senate must vote on it again before it heads to Christie’s desk.