Amending Regulation 1094 (General) made under the Vital Statistics Act
Summary of Proposal:
The regulation amendment proposes to allow registered nurses to complete and sign a Medical Certificate of Death if:
- the nurse had a nurse-patient relationship with the deceased;
- the death was expected;
- there was a documented medical diagnosis of a terminal disease; and
- there was a predictable pattern of decline for the deceased with no unexpected events or unexpected complications.
This proposed amendment supports increased access to care for patients and interprofessional collaboration between health professionals. It also supports the Patients First: Action Plan for Health Care by delivering better coordinated and integrated care in the community, closer to home.
The Medical Certificate of Death (MCD) is often needed by funeral directors before accepting a body and to register deaths with the local municipal clerk’s office.i Enabling registered nurses (RN) to sign Medical Certificates of Death will accelerate this process as they are likely providing direct care to patients at the time of their death. ii This will provide dignity to deceased persons and their families, friends and caregivers. RNAO regularly hears from our members and the public significant concern around process delays to receive a MCD, especially in residential settings. This is both unnecessary and disturbing. This regulatory change is timely given efforts already underway by the Ministry of Health and Long-Term Care to put patients first and by extension, their family, friends and caregivers, as well as to expand RN scope of practice to include independent prescribing authority.
While RNAO fully supports authorizing RNs to certify a death, there is one proposed regulatory criterion that is unnecessarily restrictive.
- There was a documented medical diagnosis of a terminal disease
The focus of the regulatory change should be on progressive life limiting illnesses and expected deaths in circumstances whereby a person in the care of an RN experiences a predictable pattern of decline. This definition would include someone in the advanced years of life with (or without) established health challenges, that has not been diagnosed with a “terminal disease”. However, the death is expected. Restricting an RN’s ability to certify death by having the criterion of a documented medical diagnosis of a “terminal disease” reduces their ability to provide timely services. RNAO is also concerned that the need for diagnosis of “terminal disease” will create unnecessary ambiguity, possibly duplicate health system resources, blur accountability between providers and ultimately limit the utilization of RNs to certify a death in expected circumstances. Therefore, RNAO urges that the criterion for a medical diagnosis of a terminal disease be removed.
Second, the time has come to expand nurse practitioners’ (NP) authority to certify death beyond the current eligibility criteria. Thus, RNAO calls for corresponding changes to Regulation 1094 by repealing all of section 35(1)(3) and expanding section 35(1)(2) to include a qualified medical practitioner or NP. This will further support the dignity and well-being of deceased persons and their loved ones. It also ensures that the regulation keeps pace with the significant evolution in NP utilization in Ontario as NPs are now serving as most responsible provider across sectors, including attending NPs in long-term care homes.
First and foremost, RNAO wants to steadily advance regulatory amendments to authorize RNs to certify a death and expand NPs’ existing authority. There is no reason to delay. However, we also cast our vision forward to identifying both organizational and system level enablers to promote the best outcomes for patients and their loved ones. These considerations include:
- Amending other regulations to ensure there are no implementation barriers (e.g. Public Hospitals Act Regulation 965, Section 17 – Report of Death).
- Promptly advancing legislative and regulatory enhancements to deliver the government’s commitment to independent RN prescribing.
- Facilitating strong provider communication and ready access to information about health status. This can be achieved through electronic health records and enabling care co-ordination within primary care.
- Providing education and direction to health service providers, to ensure that organizational policies adopt evolving scopes of practice.
- Providing health providers with clarity around the conditions under which an RN and/or NP can certify a death. A handbook for RNs comparable to the document previously created for NPs through the Office of the Registrar General may be useful.
- Ensuring that RNs and NPs are aware of the conditions necessitating notification of the coroner.
- Providing clear communication to the funeral industry about changes.
In conclusion, enabling RNs and NPs to sign Medical Certificates of Death (with distinct conditions depending on their category) will enable more timely access to the completion of death registrations. RNAO recommends that the government proceeds in authorizing RNs to certify death in abidance of the conditions proposed in the regulatory proposal, except for the requirement for a ‘terminal diagnosis’. Moreover, RNAO calls for an urgent expansion to NPs’ authority to certify death, by expanding the conditions in which they can exercise this authority.
- ServiceOntario. (2016). How to get a copy of an Ontario death certificate online. Retrieved from: https://www.ontario.ca/page/how-get-xopy-ontario-death-certificate-online
- Registered Nurses Association of Ontario. (2011). End-of-life Care During the Last Days and Hours. Retrieved from: http://rnao.ca/bpg/guidelines/endoflife-care-during-last-days-and-hours