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.