signatory authority as physicians on all health care documents was noted to be
“too broad and non-specific” to be evaluated by the legislative auditor.
An exhaustive list of documents for global signatory authority was neither practical nor conceivable. The listed documents such as Do Not Resuscitate, death certificates, and others reflect the documents paramount to the timely and cost-effective delivery of care. The request for global signature for APRNs is a crucial part of the proposed legislation to allow APRNs to provide full and complete services to the citizens of WV. There are several patient care
documents previously discussed as examples in the original PERD application that are currently not allowed in WV code for APRNs to sign. This burdensome regulatory barrier must be
rectified and codes updated with the proposed global signature legislation. The inability to complete necessary documents for patient care and services by the patients’ chosen primary care provider is convoluted and confusing. The global signature proposal has been the solution to problems associated with transparency and inclusion of direct providers of care in many states that have already adopted it. The specific wording of the proposed code was obtained directly from Rhode Island (RI Gen L § 5-34-42, 2012) for its simplicity and exact solution to the same barriers. The global signature concept has been used multiple times across the country to prevent discrimination in services and to provide necessary documentation to the primary patients of APRNs.
The intent of the request is to eliminate unnecessary steps that cause delays to patients and agencies while awaiting physician signatures. It aims to improve health care accessibility and affordability for WV citizens by reducing duplication of services, unnecessary paperwork,
and the regulatory burden. In addition, according to Safriet (2011) national health policy expert and IOM Committee member, “The cost of care is increased and much time is wasted by unnecessary physician supervision, and by duplication of services resulting from required
‘confirming’ visits with a physician and co-signatures for prescription orders.”
The current law, while allowing APRNs to practice, also creates unnecessary burdens on patients, physicians, ARPNs, other health care professionals, agencies, and the state of West Virginia. The current law unnecessarily misaligns the recognized scope of practice with restricted ability to provide necessary documentation. To resolve this bureaucratic barrier will improve the efficiency of the APRN providing care to WV citizens. It will improve access to health care services since most patients can receive appropriate primary care from one provider, often in one visit. It will allow APRNs to honor existing state and federal laws and best practice guidelines in a timely manner. It will allow APRNs to more effectively and responsibly treat their clientele. It will decrease unnecessary and duplicative paperwork.
Physicians will also benefit as it will reduce the potential of vicarious liability,
unnecessary time demands, and unfulfilling paperwork burdens not related to their direct care practice. Citizens will benefit with a reduction of the overall cost; through reduction in
paperwork, time, and additional health care visits, and improved transparency of care.
Global signatures for APRNs will improve the overall health care of citizens since it will eliminate inefficiency in the current system. It will also help to fill the gaps created by the current physician shortage, and demands on physician time, especially in rural areas. Several states across the nation have solved the exhaustive problem by implementation of global document signatures, for individual patient paperwork processed through the primary care provider closest to the individual.
The specific issue of signing a death certificate is paramount to providing care in the state of WV. Funeral directors and WV families have voiced distress and concern with obtaining a signed death certificate in a timely manner. It seems apparent that in times of distress this bureaucratic documentation and compliance should be a smooth transition from the health care provider closest to the care of the deceased. But in WV this is not the case. This causes many problems with timely burial planning and collection of death benefits. Physicians often do not feel comfortable with the urgency to complete paperwork for deceased patients for whom they have no previous personal knowledge, leaving families to wait for services,
programs, or monies that may seriously affect their life, health, and livelihoods after the loss of a loved one. For reference regarding death certificate signatory authority, please see the national map outlining this, cited on page 90 of the original PERD application, “Nurse Practitioners Authority to Sign Death Certificates.”
Current WEST VIRGINIA CODE §16-5-19. Death registration, (5), (1) states: in the absence of the physician or with his or her approval, the certificate may be completed by his or her associate physician, any physician who has been placed in a position of responsibility for any medical coverage of the decedent, the chief medical officer of the institution in which death occurred, or the physician who performed an autopsy upon the decedent, provided inquiry is not required pursuant to chapter sixty-one, article twelve of this code. In 2007, Senate Bill (SB) 184 was proposed to address this barrier to care by adding APRNs through “…or the APRN who was placed in a position of responsibility for the nursing care of the decedent.” At that time, it was determined that this specific change should be addressed in a legislative study resolution, which never came to fruition.
Current WV code is regulated under §16-30C-6. Issuance of a do-not-resuscitate order;
order to be written only by a physician. In 2007 SB 176 and followed by SB 82 in 2008, proposed the addition of Advanced Nurse Practitioners: ARTICLE 30C.
DO-NOT-RESUSCITATE ACT. §16-30C-6. Issuance of a do-not-resuscitate order; order to be written by a physician or advanced nurse practitioner.
(a) An attending physician or advanced nurse practitioner may issue a do-not-resuscitate order for persons who are present in or residing at home or in a health care facility if the person, representative or surrogate has consented to the order. A do-not-resuscitate order shall be issued in writing in the form as described in this section for a person not present or residing in a health care facility. For persons present in health care facilities, a do-not-resuscitate order shall be issued in accordance with the policies and procedures of the health care facility or in accordance with the provisions of this article: Provided, That notwithstanding any other provision of this article to the contrary, no health care facility may restrict an advanced nurse practitioner from signing do-not-resuscitate orders.
(b) Persons may request their physicians to issue do-not-resuscitate orders for them.
End-of-life (EOL) planning forms have different applications and acronyms such as Do-Not–Resuscitate (DNR) or more extensive forms like the Medical Orders for Life Sustaining Treatment (MOLST) or Physicians Orders for Life Sustaining Treatment (POLST forms), which guide end-of- life health care. These applications assist individuals to establish self-determined treatment in writing through an informed decision making process. Thus, allowing health care providers to document treatment their patients with serious or progressive illnesses prefer. These forms help establish the
extent of life-sustaining measures patients are willing to accept when facing challenging personal health care decisions.
Currently, most APRNs are performing the process of informed decision-making with their own patients, but then, as required by WV code, a physician, in most cases unknown to the patient, must provide the signature. To leave this signatory authority to a physician provider who has not been involved in the patient’s care, does not have a relationship with the patient, and furthermore does not have intimate knowledge of the patient’s preferences is unethical and not best practice.
According to AARP, EOL planning forms such as the DNR, MOLST, or POLST carry more weight within the health care community than a living will, which expresses a person's desires for care, but is not a medical order (AARP, 2013). Since the EOL planning forms are treated as orders they must be signed and directed by a health care provider. In WV this
signature must be a physician’s, even if the primary provider relationship is established with an APRN. Often, the time - end of life - in which these determinations are being made, a patient would understandably be very vulnerable and emotional. This is not the time to then ask a physician, again, who does not have an established relationship with the patient, to discuss end of life care decision-making. Existing and trusting relationships are of tremendous value, whereas establishing a relationship for the purpose of determining end-of-life decisions would not be of significant value during a patient’s most vulnerable time.
Unfortunately, several studies have found that patients who face life-threatening
illnesses may have difficulty gaining access to a discussion with their physician for a variety of reasons, one being the physicians’ inability to predict accurately and consistently survival or death. A study by White, Engelberg, Wenrich, Lo, and Curtis (2007) also notes concerns that a
physician who is unfamiliar with or new to the patient often demonstrates discomfort and lack of personal patient relationship established to promote discussions and education on the personal expectation of the individual’s diagnosis.
The aforementioned are some of the reasons that have created a lack of utilization of this personally effective self-determining life quality planning tool. Even though most Americans say they would prefer to die at home, for instance, only 24% of those over 65 do so, according to Medicare federal data (Wang, 2012). The rest spend their last days in hospitals or nursing homes. The DNR decision is paramount to individual self-determination of life-sustaining care.
The ANA (2012) proposed that “The DNR decision should reflect what the informed patient wants or would have wanted. This demands that communication about end-of-life wishes occur among all involved parties (patient, health care providers, and family; the latter as defined by the patient) and that appropriate DNR orders be written before a life-threatening crisis occurs.”
ANA has also included statements in the Nurses Code of Ethics in regard to end-of-life decision-making for more than 20 years (ANA, 2014). This code has included since 2001
"Nursing care is directed toward meeting the comprehensive needs of patients and their families across the continuum of care. This is particularly vital in the care of patients and families at the end of life to prevent and relieve the cascade of symptoms and suffering that are commonly associated with dying. Nurses are leaders and vigilant advocates for the delivery of dignified and humane care. Nurses actively participate in assessing and assuring the responsible and appropriate use of interventions in order to minimize unwarranted or unwanted treatment and patient suffering (ANA, 2010, p.7)."
APRNs are positioned to facilitate these EOL discussions and care planning. In order to provide for the continuum of care with the transparency and accountability that our health care
system and patients deserve, APRNs must be allowed to sign the EOL planning documentation to provide the best care possible with our patients.
The US Gallup poll has consistently ranked nursing as the profession they think is the most honest and ethical, Americans regularly rank nursing No.1. Nursing has topped Gallup’s annual poll consistently, since the profession was first included in 1999 (Gallup Poll, 2013).
Therefore it is easy to conclude that at a critical decision-making time in one’s life, the person they choose and feel most trusted should be discussing these difficult decisions and signing the documentation, allowing transparency and trust of completing this well-defined but
underutilized health care document.
The Coalition to Transform Advanced Care (C-TAC) co-founder Bill Novelli, a former CEO of AARP, characterized end-of-life planning and care as “the most significant and most human challenge we face in health care. It intersects with religion, spirituality, family life and our national conscience. I have worked on many big social change issues and I believe that this one is ripe for reform” (Taylor, 2013).
The high cost of this current and unacceptable health care status is crippling the health care systems of many states by simply not documenting a patient’s wishes. One in four
Medicaid dollars currently support end of life treatments according to the 2009 CMS estimates.
This means that more than $125 billion is spent on services for the 5% of beneficiaries during their last year of life (Wang, 2012).
In addition, according to Pasternak (2013), “Any debate about health care policy isn’t complete without adequately addressing its third rail—end-of-life care—and the financial stress it puts on the Medicare budget. Total federal spending on health care eats up nearly 18 percent of the nation’s output, about double what most industrialized nations spend on health care. In
2011, Medicare spending reached close to $554 billion, which amounted to 21 percent of the total spent on U.S. health care in that year. Of that $554 billion, Medicare spent 28 percent, or about $170 billion, on patients’ last six months of life”.
In closing, regarding Finding 4 the legislative auditor’s assessment regarding global signature authority, we respectfully request that the legislature evaluate and allow global signature authority as outlined above. As mentioned, an exhaustive list of
documents for global signatory authority was neither practical nor conceivable. At the very least, it is imperative that allowance for signatures of the listed documents such as Do Not Resuscitate and death certificates by APRNs be granted. The request for global
signature by APRNs is a crucial part of the proposed legislation to allow APRNs to provide full and complete services to the citizens of WV.
Finally, in response to the entire PERD findings and recommendations, it is important to again note that none of the requested changes to WV code for APRNs allows any practice outside the current professional educational scope and standards for APRNs. The APRNs of WV are proposing a retirement of outdated codes and regulations that limit practitioners from practicing to their full scope which results in decreased access to care of West Virginia’s
growing health care needs. We further emphasize that standards for all health care professionals never recommend practice at any level without collaboration and consultations with other health care professionals. This application is simply a retirement of the outdated barriers in the written, legally liable, time intensive, and cost prohibitive collaborative regulatory statute.
State Law Changes RE: APRN Full Practice Authority since filing Sunrise Application:
● Kentucky: First bill passed and signed into law of 2014 session relaxed some practice restrictions on APRNs including retiring APRN written collaborative agreement requirement for experienced APRNs (Kentucky Revised Statute section 314, 2014).
● New York: The Nurse Practitioners Modernization Act (NPMA) will become law as part of the 2014-2015 enacted budget. The NPMA takes effect on January 1, 2015. It retires the written collaborative agreement for experienced certified nurse practitioners (3600 hours in practice). It recognizes collaboration as a natural part of the profession of advanced practice nursing and requires an attestation that the certified nurse practitioner collaborates when necessary but the attestation does not require a physician signature nor does it have to be filed with any regulatory body. Attestations will be complete by 1/2015. Midwives have already been practicing under such laws (New York Executive Budget, 2014-2015).
● Connecticut: Full practice authority passed in May 2014 for certified nurse
practitioners after completing three years of practice under a collaborative relationship with a physician.
● Minnesota: Became the 19th state to pass full practice authority for APRNs as of May 2014, providing patients full and direct access to APRN care by modernizing
regulations.
● North Carolina: National CNM Policy Update 4/3/14: North Carolina Joint
Legislative Committee on Health and Human Services Subcommittee on Midwives met to consider the issue of independent practice for nurse-midwives and their final report
was released on March 11, 2014. The committee recommendation is to support a bill to update and modernize the Midwifery Practice Act, which was originally enacted in 1983. In lieu of supervisory requirements, the bill would (1) allow the independent practice of midwifery by the CNMs who have at least 2,400 hrs and 24 months
experience in the practice of midwifery under the supervision of a physician or a CNM with more than 4 years of experience, and (2) provide for a 90-day grace period for a CNM to obtain a written practice agreement when the CNM’s existing practice agreement is terminated. If accepted by the committee, a bill will be introduced in the upcoming short session.
Additional Updates of News & Research Re: APRN’s Practice:
● Currently 25 states allow certified nurse practitioners to sign death certificates (Barton and Associates, 2014)
● 19 states plus Maryland (which only requires an attestation statement that APRNs will collaborate when necessary) now have full practice authority (AANP, 2014)
● The number of certified nurse practitioners in Hawaii has doubled since passage of full practice authority, increasing access to care for Hawaiians. (RWJ Campaign for Action Update, 2014).
● Veterans Health Administration (VHA), at a time of intense scrutiny for access to care for the US military veterans, the VHA plans to move forward with the recognition of certified nurse practitioners and other Advanced Practice Registered Nurses (APRNs) to practice within their full scope, as the Institute of Medicine has recommended, so that our veterans have access to the high quality health care they need. This proposal would
remove the individual state barrier to providing care to state VHA recipients (ANA, 2014).
● The Federal Trade Commission (2014) released a new report stating: “When APRNs are free from undue supervision requirements and other undue practice restrictions, they can more efficiently fulfill unmet health care needs… APRN scope of practice limitations should be narrowly tailored to address well-founded health and safety concerns, and should not be more restrictive than patient protection requires. Otherwise, such limits can deny health care consumers the benefits of competition, without providing significant countervailing benefits.” (FTC, 2014).
● The RAND Corporation published information that much of the shortage of primary care physicians could be eliminated if certified nurse practitioners were allowed to practice at full authority (RAND, 2013).
● The RAND Corporation conducted the study for the Commonwealth of Massachusetts.
It suggests concrete savings that might be associated with expanded APRN (and PA) scope of practice, due to the lower costs and prices that tend to be associated with APRN-delivered services: " between 2010 and 2020, Massachusetts could save $4.2 to
$8.4 billion through greater reliance on certified nurse practitioners and PAs in the delivery of primary care (Eibner, et al. 2009).
● A California report by the Bay Area Council Economic Institute (Weinberg &
Kallerman, 2014) estimates that expanded use of APRNs and PAs, facilitated by scope of practice and reimbursement reform, should result in a "health care expenditure decrease of between $1.4 billion and $1.8 billion in current-year dollars from 2013-2022," in that state.
● Health care experts Thomas Bodenheimer and Mark Smith wrote in the November (2013) issue of Health Affairs that American physicians have flooded into subspecialties in recent decades, leaving a dearth of internists and family practitioners to help people
● Health care experts Thomas Bodenheimer and Mark Smith wrote in the November (2013) issue of Health Affairs that American physicians have flooded into subspecialties in recent decades, leaving a dearth of internists and family practitioners to help people