Legislature(2021 - 2022)BARNES 124
04/20/2022 03:15 PM House LABOR & COMMERCE
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| Audio | Topic |
|---|---|
| Start | |
| SB131 | |
| SB174 | |
| SB151 | |
| HB276 | |
| HB176 | |
| HB392 | |
| Workers' Compensation Appeals Commission | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| += | SB 131 | TELECONFERENCED | |
| += | SB 151 | TELECONFERENCED | |
| += | HB 276 | TELECONFERENCED | |
| += | HB 176 | TELECONFERENCED | |
| + | HB 392 | TELECONFERENCED | |
| + | TELECONFERENCED | ||
| + | TELECONFERENCED | ||
| + | SB 174 | TELECONFERENCED | |
HB 392-EXPAND ADV. PRAC. REG. NURSE AUTHORITY
4:07:14 PM
CO-CHAIR FIELDS announced that the next order of business would
be HOUSE BILL NO. 392, "An Act relating to advanced practice
registered nurses and physician assistants; and relating to
death certificates, do not resuscitate orders, and life
sustaining treatment." [Before the committee was CSHB
392(HSS).]
4:07:55 PM
REPRESENTATIVE SNYDER, as the prime sponsor, introduced HB 392.
She stated that CSHB 392(HSS) would give advanced practice
registered nurses (APRNs) and physician assistants (PAs) the
signature authority for death certificates, do not resuscitate
(DNR) orders, and physician orders of life sustaining treatment
(POLST). She explained that APRNs are registered nurses with
additional education and specialized training that adequately
prepares them for this authority. She said APRNs have had the
authority to practice independently in Alaska since 1984 and are
recognized as primary care providers. Similarly, she continued,
PAs have master's degrees, plus additional clinical training,
and work as part of a health care team to examine, diagnose, and
treat patients. She stated that both APRNs and PAs frequently
oversee end of life care, but current statute does not allow
APRNs or PAs to sign the official papers documenting and
finalizing these decisions, only physicians can do so. This
creates an unnecessary paperwork bottleneck that can cause
additional delays and stress for families during an already
stressful time, she pointed out. She noted that the bill has
received broad support since its introduction, is narrow in
scope in that it simply allows APRNs and PAs to sign off on the
care they have provided, and it helps a vulnerable population
through difficult times.
4:10:22 PM
ALLIANA SALANGUIT, Staff, Representative Liz Snyder, Alaska
State Legislature, on behalf of Representative Snyder, prime
sponsor, provided the sectional analysis for CSHB 392(HSS). She
paraphrased from the document in the committee packet titled
"SECTIONAL ANALYSIS HB 392: EXPAND ADV. PRAC. REG. NURSE
AUTHORITY Ver. B," which read as follows [original punctuation
provided]:
Sec. 1: Amends AS 08.68.700(a) Determination of death
by registered nurse by allowing a Registered Nurse
(RN) to pronounce or determine a death of a person if
a physician or an advanced practice registered nurse
(APRN) or physician assistant (PA) has documented in
the person's medical or clinical record that the
person's death is anticipated.
Sec. 2: Amends AS 08.68.700(b) by allowing an RN to
sign a determination of death if a physician, APRN, or
PA has previously documented the person's condition.
Sec. 3: Amends AS 08.68.700(c) by allowing an APRN or
PA to certify a death determined by an RN within 24
hours of the determination of death.
Sec. 4: Amends to 08.68.700(d) by adding "an advanced
practice registered nurse, or a physician assistant"
and physician assistant as a conforming change to
statute regarding health care facilities' policies and
procedures for determination and pronouncement of
death by a registered nurse.
Sec. 5: Amends AS 13.62.065 Do not resuscitate
protocol and identification requirements (a) by
allowing APRNs and PAs to issue a do not resuscitate
order.
Sec. 6 & 7: Adds conforming language to AS 13.62.065
Do not resuscitate protocol and identification
requirements to ensure APRNs and PAs are subject to
the same rules and protocols as physicians.
Sec. 8: Adds language to AS 13.62.065(f) Do not
resuscitate protocol and identification requirements
allowing APRNS and PAs to revoke a do not resuscitate
order.
Sec. 9: Adds "or an advanced practice registered
nurse, or a physician assistant" to 13.52.080(a)(5)
Immunities as a conforming change.
Sec. 10: Amends AS 13.52.100(c) Capacity by adding "an
advanced practice registered nurse, or a physician
assistant" to language regarding protocols and how do
not resuscitate orders govern decisions regarding
cardiopulmonary resuscitation and other life-
sustaining procedures.
Sec. 11: Amends AS 13.52.300 Optional Form by adding
"an advanced practice registered nurse, or physician
assistant" to the Advanced Health Care Directive Form.
Sec. 12: Amends AS 13.52.390(12) Definitions by adding
"an advanced practice registered nurse, or physician
assistant" to language defining "do not resuscitate
order."
Sec. 13: Amends AS 13.52.390(23) Definitions by adding
"an advanced practice registered nurse, or physician
assistant" to language defining "life-sustaining
procedures."
Sec. 14: Adds a new paragraph to AS 13.52.390(38)
defining an "advanced practice registered nurse" and
"physician assistant" by referring to the definition
in AS 08.68 Nursing and AS 08.64.107 Regulation of
Physician Assistants and Intensive Care Paramedic
respectively.
Sec. 15: Amends AS 18.15.230(c) by adding "advanced
practice registered nurse, or the physician assistant"
to the instructions for completing a death
certificate.
4:12:12 PM
REPRESENTATIVE SNYDER explained that the bill does not break new
ground, it updates Alaska statute to reflect current practices
elsewhere to improve access to care. The bill would bring
Alaska in line with 34 other states and the District of Columbia
where APRNs have full practice authority and are allowed to sign
DNR and POLST forms; 37 other states and the District of
Columbia where APRNs have full practice authority and can sign
death certificates; 30 states where PAs can sign DNR and POLST
forms; and 28 other states where PAs can sign a death
certificate. She added that nothing in the bill would change
practice protocol or guidelines with respect to patients wishes
for any of these actions, it would simply add APRNs and PAs to
the list of medical professionals who can sign the final
paperwork reflecting a patient's wishes.
4:13:20 PM
CO-CHAIR FIELDS opened invited testimony on CSHB 392(HSS).
4:13:38 PM
MARIANNE JOHNSTONE-PETTY, DNP, APRN, FNP-C, ACHPN, Alaska APRN
[advance practice registered nurse] Alliance, provided invited
testimony in support of CSHB 392 (HSS). She noted that she
holds a doctorate degree and specializes as an advanced
certified hospice and palliative nurse (ACHPN). She stated that
the bill would decrease costs, barriers, obstructions, and
inefficiencies in the care of the seriously ill. She said the
bill would simply update Alaska statutes to align with the APRN
state practice and licensing laws. She noted that APRN is an
umbrella term that includes certified nurse mid-wives, clinical
nurse specialists, certified registered nurse anesthetists, and
certified nurse practitioners, but that today's focus is
specifically on nurse practitioners.
DR. JOHNSTONE-PETTY pointed out that since 1984 nurse
practitioners in Alaska have had full practice authority as
independent practitioners. She said Alaska's practice and
licensing laws permit independent practitioners to diagnose,
order, and interpret diagnostic tests, and initiate and manage
treatments, including prescribing medications, meaning
independent practitioners do all this without having to have a
collaborative or supervisory agreement. In being able to do
this, she explained, APRNs have serious illness conversations
with patients and their families to help better care for them.
Part of those conversations need to lead to the completion of
forms, including POLST forms, death at home forms, DNR forms,
and death certificates. But at this time, she continued, APRNs
must rely on physician colleagues to come in and review what
they've done to take care of their patients.
DR. JOHNSTONE-PETTY conveyed that this is ongoing across the
nation - it is to align current practice with the statute and
ensure that APRNs can complete the forms for the practice that
they are providing for their patients. The best care of the
seriously ill, she said, requires that APRNs have signature
authority for medical orders and forms, such as DNR orders and
Alaska POLST and death certificates. That signature authority
is lacking right now, and the bill would simply update the
statutes to better align current practice.
4:16:26 PM
SHANNON HILTON, DNP, AGACNP, American Association of Nurse
Practitioners, provided invited testimony in support of CSHB 392
(HSS). She noted that she holds a doctorate degree in nursing
practice and is a board-certified adult gerontology acute care
nurse practitioner (AGACNP) and board-certified adult health
nurse practitioner. She stated that with their advanced
education, APRNs provide a tremendous amount of care for
Alaskans throughout the state. But, she continued, the statutes
that were written before nurse practitioners were providing the
level of care that they are today have not been updated to
include APRN signature on these very important documents. These
challenges for nurse practitioners and patients have caused
significant delays in care and unnecessary conversations during
very sensitive times in patient care, she related.
DR. HILTON pointed out that the documents in CSHB 392(HSS) serve
as an important guide and source of communication between health
care providers and their patients and the families of their
patients prior to a patient's advanced illness. For example,
she related, she may be the clinician directing the course of
treatment for a patient and facilitating difficult conversations
with family members, but the law does not recognize her
extensive knowledge and advanced care planning discussions on
this necessary paperwork. As a result of that, patients are
left with alternatives. The first is to locate and establish a
new patient relationship with another health care provider who
is recognized to complete these standard patient care forms.
Or, in the instance of critical care, [Alaska's] current health
care system is obligated to provide care that patients did not
want initially and that patients had prior indicated to their
primary care nurse practitioner that they did not want. The
disconnect between treating patients and signing paperwork, she
advised, contributes to costly unnecessary interruptions in care
and to delays at a very trying time.
DR. HILTON urged support for the bill because it would authorize
APRNs who are already treating the patients to also treat the
paperwork and to protect the autonomy of patients and respect
patient choices. She reiterated that similar reforms have
already been successfully implemented in other states.
4:19:59 PM
REPRESENTATIVE KAUFMAN, regarding the forms embedded in the
bill, stated that there is probably a variety of ways to create
the templates for the forms. He inquired whether the prime
sponsor wants these forms embedded in the bill.
REPRESENTATIVE SNYDER replied that those forms are already in
statute and are not embedded [in the bill].
REPRESENTATIVE KAUFMAN asked whether the prime sponsor is sure
that that is how to do this.
REPRESENTATIVE SNYDER deferred to the medical professionals to
answer the question.
4:21:04 PM
CO-CHAIR FIELDS relayed Representative Kaufman's question to the
witnesses and asked whether there should be further changes to
the underlying statute that CSHB 392(HSS) would change.
DR. JOHNSTONE-PETTY responded that as a hospice and palliative
care nurse practitioner she doesn't have a strong opinion one
way or another whether it is in statute, but her understanding
is to minimize statutes as much as possible. She said there are
multiple templates for advanced care planning documents in the
community that can be used and are readily available.
REPRESENTATIVE SNYDER drew attention to page 5, Section 11, of
the bill and said the form provided there is an optional sample
form that may be used. She agreed it may be worth having
discussion on the necessity of that since it isn't something
that is addressed in this specific bill.
MS. SALANGUIT related that in conversations with Legislative
Legal Services during the bill's drafting, the form was added as
a conforming change to make it line up with the rest of the
statutory changes.
4:22:51 PM
CO-CHAIR SPOHNHOLZ noted that her own advanced healthcare
directive is included with her legal documents, including her
will, which have been submitted to the court system to have on
file. She said a confidential paper copy has also been
submitted to local hospitals in Anchorage so her wishes can be
known should she arrive at the hospital while unconscious.
REPRESENTATIVE KAUFMAN responded that he understands the
function and that it is optional, but he is trying to determine
whether there is a more optimal place to park a template.
4:24:11 PM
REPRESENTATIVE NELSON inquired about the conversations that
happen in relation to a DNR.
DR. JOHNSON-PETTY replied that she has these conversations every
day as a hospice and palliative nurse practitioner. She said it
is not a situation of a patient wanting DNR and the practitioner
just hands the paper to the patient. Rather, she explained, it
is an in-depth conversation discussing who the patient is, what
the patient hopes to gain from it, what are the goals of the
patient's medical care, and why the patient would want something
like a DNR. Then it is a conversation about the forms that are
to be used and that are the legal forms in Alaska to protect the
patient from having procedures that the patient does not want.
The POLST form, she stated, is to ensure that the patient's and
family's wishes are abided.
4:25:36 PM
REPRESENTATIVE NELSON noted that not all APRNs specialize in
hospice care. He asked whether other APRNs would be qualified
to have that in-depth conversation about the various options,
especially the DNR option.
DR. JOHNSON-PETTY answered that she believes they do. She
pointed out that there are many nurse practitioners and PAs
across Alaska who are caring for patients and families,
including patients in rural and remote settings. She noted that
there is a lengthy amount of training through the website of
akpolst.org. She further pointed out that all physicians, not
just physicians with hospice training, are able to complete
these forms and there haven't been issues with that. She also
noted that other states have not made it just for a specific
type of APRN, it has been for all APRNs to ensure that the
patient has access to these documents.
REPRESENTATIVE NELSON related his understanding that while in
medical school physicians must take classes in ethics, end of
life care, and DNR. He inquired about the training for APRNs.
DR. JOHNSON-PETTY replied that nurse practitioners receive
extensive training in advanced physiology, ethics, and
pharmacology, along with completing clinical hours, to become an
APRN. She said APRNs therefore have the training to have these
types of conversations.
4:28:06 PM
CO-CHAIR SPOHNHOLZ pointed out that advanced health care
directives are developed in consultation with health care
practitioners and in estate planning conversations. She said it
is a form used by many professionals who have this expertise so
it can be acted upon if the person becomes unable to make those
decisions for himself or herself. The bill, she continued, is
referencing a form that is used by a broad group of providers
who are trained in having these conversations with folks.
[CSHB 392(HSS) was held over.]