Should APRNs Be Allowed to Pronounce Death or Certify Cause of Death?

Article Outline

• Support for APRNs to Pronounce Death or Certify Cause of Death
• Rationale Against APRNs to Pronounce Death or Certify Cause of Death
• Copyright

Karen Koozer Olson is a certified family nurse practitioner, professor of nursing, and FNP/DNP option coordinator for the University of Tennessee Health Science Center, College of Nursing. She is a member of Sigma Theta Tau, the American College of Nurse Practitioners, the American Academy of Nurse Practitioners, and the National Organization of Nurse Practitioner Faculties.

Christell Oberdorf Bray is a certified family nurse practitioner, coordinator of the family nurse practitioner program and associate professor at Texas A&M University-Corpus Christi. Bray is active in the American Nurses Association, the Texas Nurses Association, Sigma Theta Tau International, Delta Kappa Gamma (Outstanding Educators), Phi Kappa Phi, the National Organization of Nurse Practitioner Faculties, Texas Nurse Practitioners, the American College of Nurse Practitioners, and is a fellow of the American Academy of Nurse Practitioners.

As efforts to allow nurse practitioners (NPs) to practice to their fullest capacity continue, we realize that the legal acts of certifying death and completing death certificates are much more than signing pieces of paper. Information provided on death certificates about cause of death is an important source of health data for a variety of entities and may have a strong emotional impact on survivors.

This legal act demands accuracy and therefore specific knowledge. Some strategies to help NPs accurately perform this task include online death certificate educational modules or presentations by state medical examiners at state NP association meetings. Does the forensic nature of this task preclude accurate performance by NPs, or does the suffering inherent with loss of a loved one lessen when NPs are authorized to perform this final duty?

What do you think? Contact section editor Janet Selway at janet.selway@gmail.com if you would like to comment on this matter.

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Support for APRNs to Pronounce Death or Certify Cause of Death 

Karen Olson

Caring for all aspects of a person's health throughout his or her life is inherent in nursing. Part of caring for patients and their families in the dying process is pronouncing death and completing the death certificate. Advance practice registered nurses (APRNs) should have the legal authority to complete this final task.

Increasingly, APRNs are the primary care provider for the patient and his or her family, and have the best knowledge of the patient's medical condition(s). In this circumstance, the APRN has the necessary knowledge to complete the cause(s) of death. When the cause of death is difficult to determine, the APRN has the duty to collaborate with a physician or medical examiner to reach this determination. Likewise, if the APRN has been the primary health care provider, the physician or medical examiner can collaborate with the APRN to obtain the necessary data to certify the cause of death.

Graduate nursing education prepares APRNs with the background to understand the importance of accurate documentation in completing death certificates. With specific continuing education in forensics, the APRN not only has the knowledge and ability to determine the cause of death but also appreciates the significance of the data documented as it relates to development of public policy and the impact that information has to the surviving family.

Fewer numbers of primary care physicians and primary care medical residents causes more delays in death certificate completion. APRNs have extensive knowledge about patients and should be allowed to provide this public service.

The unnecessary restriction on completion of this important document is a barrier to the attainment of appropriate scope of practice. The APRN role is being an effective policy and patient advocate with an advanced knowledge base. This role is diminished when APRN skills are not fully used in all areas, including completing death certificates.

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Rationale Against APRNs to Pronounce Death or Certify Cause of Death 

Christell Bray

APRN education includes evaluation, diagnosis, and treatment of living patients across the lifespan. While the APRN education experience provides the skill and knowledge to pronounce death, in some settings, death may include additional data beyond observing absence of spontaneous movements, response to stimuli, heart sounds, respirations reflexes, and fixed or dilated pupils.

The APRN educational process does not develop sufficient knowledge or skills to complete the portion of the death certificate regarding cause(s) of death. Determination of cause of death or the details of accurately completing a death certificate are not taught in most APRN curricula. The cause-of-death component includes a multifaceted and often subtle cascade of comorbidities that contributed either directly or indirectly to demise. Currently, APRNs do not have the depth of background or skills to complete this section of the document. Possibly with additional pathophysiology content and specific forensics content within DNP programs, APRNs would be qualified to have this practice responsibility.

Death certificate data are compiled by the Centers for Disease Control and Prevention and used by the national government to influence and fund health care policy. Increasingly, death certificate data are being used for global health care planning, such as in the recent swine flu pandemic. The information on death certificates is complex and detailed and must be accurate to be of value. Death certificates require special skill and knowledge for accurate completion. To argue that, because some unqualified individuals can sign death certificates, APRNs also should be able to, is specious. Abilities to complete any document should be based on the provider's skills and ability to do the task accurately and in a timely fashion. If APRNs and any other professional want this responsibility or obligation, they should be required to document forensic content specific to cause of death.