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Nurses Making Life and Death Determinations

By Susan Kreimer, MS, contributor

How much authority should nurses have when it comes to life and death? Although currently a role reserved for physicians, Ohio lawmakers are evaluating measures that would allow registered nurses to pronounce patient deaths.

The proposals stem in part from a shortage of physicians in hospitals and hospice care, especially in rural and underserved areas. About 20 states have enacted similar laws, granting nurses the power to make life and death decisions.

"There are so many situations, particularly in long-term care and nursing homes and skilled nursing facilities, where physicians are not readily on site and a patient has expired," said Jacalyn R. Golden, MSN, CRNP, co-chair of the legislative committee at the Ohio Association of Advanced Practice Nurses. "The pronouncement of death is delayed and causes undue stress on family members and staff."

The current Ohio law, which requires doctors to make death determinations, has been in place for decades. It was adopted before the training of registered nurses and advanced practice nurses broadened significantly. Over time, nurses have undertaken increasing responsibilities in patient care.

"Many years ago, nurses were seen primarily as handmaidens of physicians," Golden said. "All clinical decisions were made only by physicians."

An amendment to the Ohio law may include stipulations that RNs could pronounce death only in specific circumstances, such as when a physician is not available. A second possible amendment would require RNs to consult with a physician before pronouncing death.

While some nursing decisions call for greater urgency than others, all of them hinge on life or death to some degree. Nurses must be able to assess and act quickly, sometimes after detecting subtle changes in a patient's condition, said Malinda Markowitz, RN, president of the California Nurses Association/National Nurses Organizing Committee.

The California Board of Registered Nursing states it is within the registered nurse's scope of practice to determine that a patient has expired, as long as the RN is knowledgeable and competent in this regard. Even so, Markowitz said, each hospital has its own policy for nurses to follow. Rules also vary by care setting. A registered nurse in a hospice may pronounce death, but a physician must sign the death certificate.

In hospitals, "we see death on all units whether it's a med/surge area or an ICU or even an oncology unit," she said. "The reason is that patients are much sicker with multiple medical problems."

Many patients don't have health insurance or are denied care by their plan, so by the time they reach a hospital, their condition has worsened, said Markowitz, who works on a med/surge unit at Good Samaritan Hospital in San Jose.

Pronouncement of death typically occurs with the absence of blood pressure, pulse and respiration. All patients are given resuscitation unless they or a legal guardian have signed an advanced directive against it, said Golden, who works in internal medicine at the Cleveland Clinic.

Nurses talk with patients, families and physicians regularly about whether or not a treatment is futile. They weigh the benefits and the burdens. Often, they present the full picture of what may happen during resuscitation, said Beverly Paukstis, RN, MS, CHPN, CHPCA, director of hospice operations at The Washington Home and Community Hospices serving Washington, D.C., Virginia and Maryland.

These types of interactions take place on every unit of an acute or long-term care facility. In the case of an Alzheimer's patient, for instance, a registered nurse may discuss with the family whether it is in their best interest to insert a feeding tube, she said.

"They give the menu and let the patient and family make the decision about what they want from that menu," Paukstis said.

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