You’ve taken care of Mrs. King for many years, and you have excellent rapport with her family as well. Mrs. King and her family trust you and rely on your clinical judgment. When people ask who her doctor is, Mrs. King tells them you are even though you’ve made it clear that you are a nurse practitioner or physician assistant, not a doctor. The important thing is that Mrs. King is your patient and that she is now dying. You have promised her and her family that you will be present for this final journey with them.

After much discussion with the family about her prognosis, everyone agrees that when Mrs. King’s time comes, trying to resuscitate her would serve no purpose. You write the Do Not Resuscitate (DNR) order. But then you are informed by nursing staff that they cannot accept a DNR order from you. As a professional, you do what NPs and PAs always do, you save the fight for later and get one of your physician colleagues to sign because it’s important that your patient’s needs are met.

It’s 2 am when you get a call from the nursing staff that Mrs. King is not doing well and that the family has asked for you. You get up, dress, and go in to support the family through Mrs. King’s final moments. As promised, you are there when she takes her last breath. The family looks to you for confirmation. You remove your stethoscope from your pocket and listen for heart sounds. There are none. You tell the family she is gone.


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You note the time: 2:47 am. Then you proceed to the nurse’s station and inform them that you have just pronounced Mrs. King as deceased. The nursing staff says that by law, you cannot do that. Again, you must call on a physician colleague for assistance.

The next day, during your busy clinic, you get a call from your physician colleague asking for information to complete and sign Mrs. King’s death certificate. That’s right; you’re not allowed to fill out the death certificate either.

Are you familiar with the laws pertaining to these final privilege issues in your state? Unfortunately, there is no uniformity from one state to the next. If you work in a state where you can perform any or all of these duties, you may not be aware of the struggles faced by your PA and NP colleagues elsewhere.

According to the American Association of Nurse Practitioners, NPs may sign a death certificate in only 12 states; the organization has no information regarding NPs’ eligibility to sign DNR orders or pronounce death. According to the American Association of Physician Assistants, PAs can sign DNR orders in just two states: South Dakota and Vermont. And things get really confusing when it comes to pronouncing death and signing death certificates. In some states, PAs may pronounce death but cannot sign the death certificate; in others, PAs may pronounce death and sign the death certificate only if the death is anticipated, while in still others PAs may sign any form a physician can sign as long as they are acting as the physician’s agent.

The bottom line is that NPs and PAs have proven track records as qualified, competent clinicians, and we should have the legal authority to write DNR orders, pronounce death, and sign death certificates for our patients in every state in the land.

Lobby your states’ governing bodies and legislators. Encourage your patients and their families to do the same. We deserve the final privilege, but we must speak out, for only then will change happen.

Melody A. French, Ph.D., PA, FNP, is a primary-care nurse practitioner and correctional health specialist at High Desert State Prison in Susanville, Calif.