Specially Trained Nurses May Pronounce Death

The Virgin Islands is a step closer to simplifying the process for making a pronouncement of death.

Health Commissioner Justa Encarnacion invites input on draft regulations governing circumstances for nurses to make pronouncement of death. (Submitted photo)

The Health Department has drafted regulations governing how and when a nurse – in lieu of a physician – can make a legal death pronouncement.

In the past decade or so, facing shortages of doctors as well as other medical staff, many states have enacted legislation expanding the type of health professionals who are considered qualified to make official determinations of death. Generally, they are limited to acting only under specific, narrow circumstances.

The V.I. Legislature enacted such a law in May 2021 and called on Health to write the regulations to implement the change.

While some jurisdictions authorize physician assistants or other medical personnel to pronounce death, others limit the authority only to registered nurses, and some even require two RNs to make the determination together.

The draft regulations for the Virgin Islands limit the authority to an RN or a registered nurse practitioner working in a certified nursing home or licensed hospice program, and then only under certain circumstances.

In a joint interview with the Source Friday, Department of Health officials discussed the reasons for, and the ramifications of, the change.

Currently, with a medical doctor the only one allowed to make an official pronouncement, there can be long delays for grieving families who want to make arrangements for deceased loved ones.

By expanding the authority to make a death pronouncement, “the wait time is reduced dramatically,” said Health Commissioner Justa Encarnacion.

Dr. Tai Hunte-Ceasar added, “This is something that is going to expand access to health care.”

The officials said the rules were drafted in consultation with various stakeholders, including the territory’s single hospice care service. “So they know exactly what the law provides,” Hunte-Ceasar said.

Under the proposed regulations, a nurse or nurse practitioner must have specialized training handled by the nursing facility or hospice program for which they work. The RN can only pronounce death if the patient’s death was anticipated and if there was first a “reasonable effort” to contact the attending physician or the medical examiner.

The nurse must report the death on a form approved by the health commissioner.

A nurse is not allowed to pronounce death for anyone under age 18; for someone who is to be cremated or whose organs are to be donated for medical or scientific purposes; for someone who died at home unless they were under hospice care; or if the circumstances of the death make it one that must be referred to the medical examiner, such as from a new injury.

The draft regulations also spell out the method the nurse or nurse practitioner must use to make a determination: the absence of a carotid pulse and the absence of heart sounds for more than one minute; the absence of respiratory movements and breath sounds for over one minute; the presence of dilated or fixed pupils; unresponsiveness to bright lights and to painful stimuli.  “All signs must be present before death is pronounced.”

As a further safeguard, the regulations stipulate that the body of the decedent may not be removed until the pronouncement has been given to the attending physician or the medical examiner.

The department has posted the draft regulations on its website.

Public comments on them should be sent via email to dohregulatory@doh.vi.gov or by post to:
Department of Health, Regulatory Division at Charles Harwood Complex
3500 Estate Richmond
Christiansted, VI 00820-4370.

Comments must be received by March 11 to be considered in the final regulations.

Health officials were unable to give an estimate of how soon the regulations will go into effect.

The department’s legal counsel, Mackiesh Taylor-Jones, said, “It has to go through processes.”  That means that the department will consider the public comments and possibly make some adjustments before finalizing the regulations. Then the final regulations will go to the Department of Justice to be studied for legal sufficiency, to the Lieutenant Governor’s Office for review and then be published in the government’s listing of Rules and Regulations.

Attempts to determine how many states currently allow non-physicians to pronounce death were unsuccessful. Taylor-Jones said her research online indicated there are “many.” One article from 2020 gave the number as 20 at that time, and there were indications that more states were considering the move.