Nurse Practitioners and Advanced Directives in Florida – Legal Responsibilities and Practical Approaches
Responding to Sita
Hello Sita,
Thank you for your enlightening post. It’s critical to understand the laws and regulations in your state that govern nurse practitioners’ roles and obligations, especially when it comes to advanced directives (ADs). In Florida, it is clear that nurse practitioners work under the overall supervision of a physician, and the signing of AD paperwork is normally the physician’s domain (Katz et al., 2020). However, if NPs practice autonomously, they may have the right to sign ADs, which is consistent with the trend of governments broadening NP practice privileges.
The example you described demonstrates the vital role that palliative and hospice care may play in improving a patient’s quality of life and minimizing suffering, especially in cases like the one you encountered. These services can give comprehensive assistance, symptom management, and emotional care to individuals suffering from severe or terminal illnesses. It is critical for NPs to approach this topic with sensitivity and empathy, concentrating on teaching the patient and family about available services rather than conveying a sense of therapeutic failure.
Two main recommendations stand out for improving access to palliative and hospice care for vulnerable and marginalized groups. First and foremost, improving NP understanding and training on these services is critical. NPs should be skilled in identifying patients who may benefit from palliative or hospice care and communicating these alternatives effectively. Utilizing community-based resources, such as collaborating with churches to educate communities such as the African-American population, can efficiently spread knowledge and develop trust (Odhiambo et al., 2022). This method acknowledges the impact of cultural influences and community dynamics on healthcare decisions. Second, NPs must improve their communication abilities. Incorporating these suggestions into your practice as an NP can help improve patient outcomes, particularly in vulnerable and underserved groups, and ensure that clients receive treatment consistent with their beliefs and preferences.
References
Katz, P. R., Ryskina, K., Saliba, D., Costa, A., Jung, H.-Y., Wagner, L. M., Unruh, M. A., Smith, B. J., Moser, A., Spetz, J., Feldman, S., & Karuza, J. (2020). Medical Care Delivery in US Nursing Homes: Current and Future Practice. The Gerontologist, 61(4). https://doi.org/10.1093/geront/gnaa141
Odhiambo, L. A., Ezinne Anaba, Stephens, P. C., Cheruvu, V. K., & Zullo, M. D. (2022). Community-Based Approach to Assess Obstructive Respiratory Diseases and Risk in Urban African American Churches. Journal of Immigrant and Minority Health, 25(2), 389–397. https://doi.org/10.1007/s10903-022-01405-w
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Question 
Legal Responsibilities and Practical Approaches
Discuss the laws in your state related to the nurse practitioner’s (NP) role and responsibility in creating and signing advanced directives (ADs). Indicate if the NP can independently complete AD documents or if a physician is required to sign or cosign the documents.
In the state of Florida, nurse practitioners (NPs) must have general supervision by a physician (AMA, 2017). The patient and family are encouraged to communicate with the physician about their advance directive in Florida (Online Sunshine, 2023). NPs in Florida cannot sign advanced directives. Only a physician can sign these documents. However, if the NP practices autonomously, they can sign advance directives (NCSL, 2023).
Consider clients you’ve encountered in practicum (or in your practice as a registered nurse). Identify at least ONE client who may have benefited from a referral to hospice or palliative care. Indicate why this client would have benefited from these services. Describe how, as an NP, you might approach the conversation with the client.
One patient I encountered in clinical was going through radiation treatment for endometrial cancer. The patient did not tolerate the treatment well and would have ongoing nausea and vomiting with poor nutrition and fluid intake. The patient would come to the clinic often between radiation sessions to receive IV fluids. The patient was also admitted to the emergency room multiple times to manage symptoms as well. The patient got to the point where she did not have enough energy to eat or move. This patient would have benefited from palliative and hospice services to help promote quality of life and decrease suffering.
Bringing up palliative and hospice care is a sensitive topic, and the NP should communicate with the patient and family in a respectful and kind manner. The conversation should be geared towards educating the patient about the many resources pallitive care and hospice provides to the patient and the family instead of making the patient and family feel like we are giving up or the patient is dying soon. In addition, a lack of cultural understanding between the patient and the NP can placed a barrier that can hinder care. The NP must develop their cultural competence and assess their own attitudes and biases and how they influence the relationships with many different patient populations. Expanding knowledge related to vulnerable groups, such as the LGBTQ population, will allow the NP to be more aware of their beliefs and needs in order to provide safe and accepting communication and care for these patients (Kuzma et al., 2019).
Discuss at least TWO recommendations you have for improving palliative and hospice care access to vulnerable and underserved populations in your community.
Nurse practitioners must increase their knowledge about hospice and palliative care services in order to be able to identify patients who may benefit from these services and effectively present these options to the patient and family. It is important for the NP to communicate with the patient and the family about their goals of care and wishes for treatment options as well (Carpenter et al., 2021). Vulnerable and underserved populations experience many barriers to palliative and hospice care, such as misunderstanding what the definitions of these services are, lack of information or health literacy, lack of health care insurance, mistrust in health care providers, and avoiding the topic of death.
African Americans are one of the most vulnerable patient populations with poor involvement with advanced care planning. Since many individuals from this patient population are very religious. One recommendation to improve palliative and hospice care access would be to partner with the churches to help communicate hospice education to the African American community. Community-based approaches can be more effective in promoting advance care planning among African Americans rather than from health care providers who this patient population may not entirely trust. Another recommendation to improve palliative and hospice care access to vulnerable populations involves improving communication with the patients in order to build a better rapport with the patient and the family. This involves active listening, providing empathy and respect, engaging the patient in their care, being friendly, and connecting with the patient to help develop a bond. When a strong rapport is established, the NP can more effectively provide the patient with hospice and palliative care education to increase their engagement (Bazargan & Bazargan-Hejazi, 2021)
References
American Medical Association [AMA]. (2017). State law chart: Nurse practitioner practice authority. https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/specialty%20group/arc/ama-chart-np-practice-authority.pdf
Bazargan, M., & Bazargan-Hejazi, S. (2021). Disparities in palliative and hospice care and completion of advance care planning and directives among non-Hispanic Blacks: A scoping review of recent literature. American Journal of Hospice and Palliative Medicine, 38(6), 688-718. DOI: 10.1177/1049909120966585
Carpenter, J. G., & Ersek, M. (2021). Developing and implementing a novel program to prepare nursing home-based geriatric nurse practitioners in primary palliative care. Journal of the American Association of Nurse Practitioners, 34(1), 142. doi: 10.1097/JXX.0000000000000565
Kuzma, E. K., Pardee, M., & Darling-Fisher, C. S. (2019). Lesbian, gay, bisexual, and transgender health: Creating safe spaces and caring for patients with cultural humility. Journal of the American Association of Nurse Practitioners, 31(3), 167-174.DOI: 10.1097/JXX.0000000000000131
National Conference of State Legislatures [NCSL]. (2023). State overview: Florida. https://scopeofpracticepolicy.org/states/fl/?fbclid=IwAR2VD5em6RDnJbL7E-V051Ero4xyRNQgfE0xe9q5oN8GondUIIWLU6VSImM_aem_AdDz3OJ9ccIHyufHvrS7dsnX4kBDz0q3N2b4AtUmT5ltdZBo-Oz4tVeNFQrqIs0JbT0
Online Sunshine. (2023). The 2023 Florida Statutes: Title XLIV: Chapter 765. http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&URL=0700-0799/0765/0765.html#:~:text=(2)%20A%20health%20care%20provider,of%20the%20patient%27s%20medical%20record.