Legislature(2021 - 2022)BUTROVICH 205
05/03/2022 01:30 PM Senate HEALTH & SOCIAL SERVICES
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| Audio | Topic |
|---|---|
| Start | |
| HB392 | |
| SB191 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| += | SB 183 | TELECONFERENCED | |
| *+ | HB 382 | TELECONFERENCED | |
| *+ | HB 392 | TELECONFERENCED | |
| *+ | HB 297 | TELECONFERENCED | |
| *+ | SB 191 | TELECONFERENCED | |
| + | TELECONFERENCED |
HB 392-EXPAND ADV PRC REG NURSE, PHYS ASSIS AUTH
1:36:52 PM
CHAIR WILSON announced the consideration of CS FOR HOUSE BILL
NO. 392(HSS) am "An Act relating to advanced practice registered
nurses and physician assistants; and relating to death
certificates, do not resuscitate orders, and life sustaining
treatment."
1:37:12 PM
REPRESENTATIVE LIZ SNYDER, Alaska State Legislature, Juneau,
Alaska, sponsor of HB 392, introduced the legislation speaking
to the sponsor statement that read as follows:
HB 392 updates statute so Advanced Practice Registered
Nurses (APRNs) and Physician Assistants (PAs) can
provide more support for the seriously ill and their
families. APRNs are Registered Nurses (RNs) with a
master's degree in nursing and additional specialized
education and training. Physician Assistants also have
a master's degree and additional clinical training.
In 1984, Alaska became one of the very first states to
give APRNs full practice authority. Full practice
authority means APRNs can use their expanded knowledge
and skillset to prescribe, diagnose, or treat patients
independently within their specialization. A common
example of this is Nurse Practitioners (NP), a type of
APRN, working as primary care providers for many of
us.
APRNs are authorized to independently oversee end of
life care, including assisting with Do Not Resuscitate
(DNR) orders and the Physician's Order for Life
Sustaining Treatment (POLST). Similarly, PAs examine,
diagnose, and treat patients, including participating
in end-of-life care discussions, as part of a health
care team. However, statute does not allow APRNs or
PAs to sign and finalize these documentsonly
physicians can. This can cause administrative delays
and unnecessary additional stress for families if a
physician is unavailable.
Additionally, current statute allows a registered
nurse to declare a death but only if a physician
documents the anticipated reason for the death. A
registered nurse can also sign a death certificate,
but it must be certified by a physician within 24
hours. HB 392 revises statute so APRNs and PAs can
also certify a death certificate. While the bill is
narrow in scope, it helps many and especially those at
vulnerable times.
Passage of HB 392 brings 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 form; 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 a
PA can sign a death certificate.
1:41:19 PM
ALLIANA SALANGUIT, Staff, Representative Liz Snyder, Alaska
State Legislature, Juneau, Alaska, presented a summary of the
sectional analysis for HB 392 that read as follows:
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.
MS. SALANGUIT noted that Section 5 was further amended on the
House floor requiring the written consent of the patient or the
parent or guardian of a minor for a DNR order to be issued.
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.
1:43:31 PM
CHAIR WILSON turned to invited testimony.
1:44:04 PM
CHRISTINE KRAMER, DNP and APRN, Anchorage, Alaska, testified by
invitation on HB 392. She stated that she has been practicing
for 23 years, primarily in hospitals. She reviewed her
credentials and specific work history and advised that she would
talk from perspective of an APRN about how this bill impacts
practice. She recounted that when a patient is admitted from the
emergency department, their code status must be determined
through discussion with the patient and their family. This is
documented in the admission notes and orders are written to
reflect those wishes. The NP is an integral part of the
treatment team throughout the patient's hospitalization. If the
patient passes, that is documented in the death summary. The NP
provides all this documentation but cannot sign the death
certificate. Under the current process a physician must sign the
death certificate even though they may not be familiar with the
patient care and case, and this may delay the signing. HB 392
changes this practice and would allow the NP to sign the death
certificate. She offered her professional opinion that this
legislation would improve care for patients who are critically
ill and facing end-of-life issues.
1:46:59 PM
SENATOR COSTELLO referenced Section 5 and offered her
understanding that an Alaskan can sign a DNR form and have it on
file in anticipation of needing it someday. She asked Dr. Kramer
to comment.
DR. KRAMER said that's correct, but what frequently happens is
that family members are aware of the document but don't know
where it is filed. If the document is on file at Providence
Hospital she can look it up, but frequently that is not the
case.
CHAIR WILSON said he didn't believe she tailored her answer to
Section 5.
1:48:58 PM
SENATOR COSTELLO said her reading is that the DNR may have been
written and signed in advance or the parent or guardian of a
minor can make the decision when the need arises. It also says
the nurse or physician shall document the grounds for the order
in the patient's medical file.
DR. KRAMER asked if she was talking about the amendment [that
passed on the House floor].
SENATOR COSTELLO said yes. She added that she knows DNR forms
can be filled out in advance, she just wanted it on the record.
She called it prior consent.
DR. KRAMER offered her perspective that requiring a patient to
sign their consent to their DNR status when they're just coming
from the emergency department could be difficult to impossible
depending on the patient's condition.
1:52:08 PM
CHAIR WILSON asked if she understood that the discussion was
about an amendment that passed on the House floor.
DR. KRAMER answered yes.
REPRESENTATIVE SNYDER said a concern that she has with the floor
amendment is that a spouse may not be able to decide on what to
do with a DNR if the patient doesn't have paperwork on file and
is suddenly incapacitated. The other concern is what to do in
situations where it is not possible to obtain written consent
from the patient.
1:54:23 PM
DR. KRAMER said she didn't believe the floor amendment would
prevent a spouse from signing a DNR on the patient's behalf.
Alaska statutes make the spouse the decision maker in those
situations, but they would have to be present at the hospital to
sign the paperwork.
SENATOR HUGHES asked if she agreed that the part of Section 5
that requires written consent was a bit redundant because the
forms are by either the patient or the family.
1:56:54 PM
DR. KRAMER agreed it was redundant. She also emphasized that the
utmost attention is given to the patient's wishes when DNR
orders are made and no decision is made without consent from the
patient or the family.
SENATOR HUGHES asked if it's been a problem that DNR orders
aren't defined in AS 13.52.065. She said she'd also like
clarification on the record regarding what the sponsor brought
up about a person's ability to make a DNR decision if their
spouse is unable to do so.
1:59:19 PM
REPRESENTATIVE SNYDER asked Senator Hughes if she had seen the
definition for "do not resuscitate order" in Section 12 that
starts on page 18. She noted that there had been some discussion
about adding the word "surrogate" to the language in Section 5
about those who have the ability to make a decision about a DNR
order when the patient is unable to do so.
SENATOR HUGHES offered her perspective that the definition in
Section 12 makes it sound as though the health care provider
could issue a DNR order without advanced consent. She suggested
that should be clarified and she would speak with the sponsor
offline about whether that was a discussion to have with the
drafter.
REPRESENTAIVE SNYDER said there are good reasons that the
language in statute isn't as specific as the requirements and
policies at the health provider level where signatures are
required. She added that Ms. Salanguit would reach out to
Senator Hughes about whether it was appropriate to speak with
the drafter about this.
2:03:23 PM
At ease.
2:04:10 PM
CHAIR WILSON reconvened the meeting.
SENATOR HUGHES asked if there was any situation where a
physician, and potentially PAs and nurse practitioners, would
issue a DNR order without patient or family consent.
2:04:46 PM
DR. KRAMER answered yes, but it is highly unusual. It might
happen when an individual is gravely ill and all efforts to
locate the family have been unsuccessful. In that circumstance,
two physicians look at the situation, perhaps in consultation
with the Ethics Committee, consider the care options, and make a
DNR judgement call. She then reiterated her concern with the
change in Section 5 that resulted from the House floor
amendment.
2:06:55 PM
CHAIR WILSON clarified that Dr. Kramer was talking about a
change made to Section 5 when the bill was in the other body.
This committee was not considering an amendment.
2:07:14 PM
CHRISTOPHER DITTERICH, PA, Past President, Alaska Academy of
Physician Assistants, Palmer, Alaska, stated that he was a
practicing PA with Orion Behavioral Health Network and a
behavioral health and primary care services provider with the
Department of Corrections. He stated that NPs and PAs are
integrative leaders in patient care teams who are in a good
position and well able to provide end of life care decisions
with patients and their families. He continued to say that PAs
in particular are medical providers who diagnose illness,
develop and manage treatment plans, prescribe medications, and
often serve as the patient's principal health care provider.
They are also specifically prepared to complete death
certificates, provide life-sustaining treatment, and complete
the DNR orders with patients.
2:09:07 PM
CHAIR WILSON opened public testimony on HB 392; finding none, he
closed public testimony.
2:09:29 PM
At ease.
2:11:54 PM
CHAIR WILSON reconvened the meeting.
2:11:59 PM
SENATOR BEGICH directed attention to AS 13.52.065 related to the
do not resuscitate protocol and AS 13.52.100 related to capacity
[to make health care decisions]. He said it appears that the
lingering issue about responsible party could be addressed with
a minor amendment to the capacity statute.
2:12:33 PM
SENATOR HUGHES pointed out that PAs fall under the State Medical
Board but APRNs do not. According to the current statute, APRNs
have to comply with the protocol the department developed and
the State Medical Board approved, so that would be the rule
regarding DNR that APRNs would have to follow in the situation
where an individual either has no family or none can be located.
SENATOR BEGICH relayed that Senator Hughes was describing AS 13
52 065(d).
2:13:43 PM
CHAIR WILSON, finding no further questions or comments, held HB
392 in committee.