The Florida Senate
BILL ANALYSIS AND FISCAL IMPACT STATEMENT
(This document is based on the provisions contained in the legislation as of the latest date listed below.)
Prepared By: The Professional Staff of the Committee on Health Policy
BILL: SB 998
INTRODUCER: Senator Calatayud
SUBJECT: Physician Assistant and Advanced Practice Registered Nurse Services
DATE: March 31, 2025
ANALYST STAFF DIRECTOR REFERENCE ACTION
1. Smith Brown HP Pre-meeting
2. AHS
3. RC
I. Summary:
SB 998 authorizes advanced practice registered nurses (APRNs) providing hospice care,
pursuant to a written protocol with a licensed physician, to file a certificate of death or fetal
death, to certify the cause of death, and to correct information on a permanent certificate of death
or fetal death.
The bill also authorizes physician assistants (PAs) and autonomous APRNs (A-APRNs),
providing hospice care pursuant to a written protocol with a licensed physician, to perform
certain functions currently limited to physicians only. Specifically, the bill:
• Includes PAs and such A-APRNs in the definition of “hospice care team;”
• Authorizes those practitioners to diagnose terminal illness as a condition of admission to a
hospice program;
• Permits those practitioners to prepare and maintain a patient’s hospice plan of care and
manage the patient’s hospice services; and
• Authorizes those practitioners to sign a patient’s order not to resuscitate.
The bill provides an effective date of July 1, 2025.
II. Present Situation:
Vital Statistics and Death Certificates
Florida law requires the registration of all deaths and fetal deaths with the Department of Health
(DOH) through the Office of Vital Statistics. Section 382.008, F.S., governs the filing of death
and fetal death certificates. The funeral director who first assumes custody of the body is
responsible for electronically filing the certificate.
1
In the absence of a funeral director, current
1
Section 382.008(2)(a), F.S.
REVISED: BILL: SB 998 Page 2
law permits a physician, physician assistant, advanced practice registered nurse registered for
autonomous practice (A-APRN), or the district medical examiner to file the certificate.
2
The “medical certification of cause of death” must be completed by the decedent’s primary or
attending practitioner or the district medical examiner within 72 hours of receipt of the death
certificate.
3
Under current law, a “primary or attending practitioner” is defined as a physician,
PA, or an A-APRN who treated the decedent during the 12 months preceding death.
4
These
practitioners are also authorized to note corrections on permanent death or fetal death
certificates.
5
Hospice Care Teams and Plans of Care
Part IV, of chapter 400, F.S., establishes requirements for hospice programs. A hospice is a
centrally coordinated program offering a continuum of palliative and supportive care for
terminally ill patients and their families.
6
Admission to hospice care requires a diagnosis of
terminal illness by a physician licensed under ch. 458 or ch. 459, F.S., and the patient’s informed
consent.
7
For purposes of hospice programs, a “terminal illness” is defined as a condition with a
life expectancy of 12 months or less if the illness runs its normal course.
8
Hospice programs are required to employ multidisciplinary hospice care teams responsible for
establishing and reviewing patients’ plans of care and supervising the delivery of hospice
services. A hospice care team may also withhold or withdraw cardiopulmonary resuscitation
(CPR) if presented with a do-not-resuscitate (DNR) order executed under s. 401.45, F.S.
9
Pursuant to s. 400.6105, F.S., each “hospice care team”
10
must include, at a minimum:
• A physician licensed under ch. 458 or ch. 459, F.S.;
• A nurse licensed under part I, of ch. 464, F.S.;
• A social worker; and
• A pastoral or other counselor.
Do-Not-Resuscitate Orders
A DNR is a written instruction, recognized under Florida law, to withhold or withdraw
cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. The DOH
maintains the required DNR order form, also known as a DNRO form, (Form DH 1896).
11
A
patient’s physician or PA and the patient must sign the form.
12
2
Id.
3
Section 382.008(3), F.S.
4
Id.
5
Section 382.008(5), F.S.
6
Section 400.601, F.S.
7
Section 400.6095(2), F.S.
8
Section 400.601(10), F.S.,
9
Section 400.6095(8), F.S.
10
See also s. 400.601(4), F.S.
11
Florida Department of Health, Do Not Resuscitate Order (DNRO), available at:
https://www.floridahealth.gov/about/patient-rights-and-safety/do-not-resuscitate/index.html (last visited Mar. 28, 2025).
12
Section 401.45(3)(a), F.S. BILL: SB 998 Page 3
APRNs, A-APRNs, and PAs
13
Advanced practice registered nurses (APRNs) are regulated under part I, of ch. 464, F.S., the
Nurse Practice Act. The Florida Board of Nursing establishes eligibility criteria for APRN
licensure and regulatory standards for APRN practice. APRNs may only perform medical acts
that are directly related to the performance of authorized nursing or medical acts performed
pursuant to a physician’s protocol. The scope of practice includes administering medications and
treatments as prescribed or authorized by a licensed practitioner, starting and managing IVs, and
monitoring and responding to patient reactions, provided these actions occur within a protocol
agreement with a supervising physician or dentist licensed under chs. 458, 459, or 466, F.S.
Section 464.0123, F.S., establishes minimum qualifications for an APRN to register for
autonomous practice. An autonomous APRN (A-APRN) is not subject to supervision by a
physician or required to work under a protocol. These practitioners may only provide care in
primary care, which includes: physical and mental health promotion, assessment, evaluation,
disease prevention, health maintenance, counseling, patient education, diagnosis and treatment of
acute and chronic illnesses, inclusive of behavioral and mental health conditions, services such
as physical and mental health promotion, disease prevention, patient education, and treatment of
acute and chronic conditions, including behavioral and mental health conditions.
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Autonomous APRNs are also authorized to admit and discharge hospice patients and manage
their care independently. As of February 2025, there are 64,953 licensed APRNs in Florida,
including 13,470 with the autonomous designation.
A physician assistant (PA) is a health care practitioner who practices under the direct or indirect
supervision of an allopathic or osteopathic physician. PAs are authorized to perform medical
services such as conducting physical exams, diagnosing and treating illness, counseling on
preventive care, assisting in surgery, and prescribing medication. Supervising physicians may
only delegate tasks and procedures to a PA that are within the physician’s own scope of practice,
and the supervising physician must ensure that the PA is qualified to perform any delegated
tasks. PAs must disclose to patients that they are not physicians and must inform patients of their
right to consult the supervising physician before a prescription is issued or dispensed. PAs are
authorized to sign certain medical documents, including death certificates, Baker Act
commitments, and school physicals.
III. Effect of Proposed Changes:
Section 1 amends s. 382.008, F.S., to expand the list of individuals authorized to file a certificate
of death or fetal death and to note corrections on permanent certificates. Under current law, in
the absence of a funeral director, a physician, physician assistant, A-APRN, or the district
medical examiner may file the certificate. The bill expands this authority to include APRNs
providing hospice care pursuant to a written protocol with a licensed physician. These
practitioners are responsible for completing the medical certification of cause of death within 72
13
Department of Health, Senate Bill 998 Legislative Analysis (Mar. 28, 2025) (on file with the Senate Committee on Health
Policy).
14
Rule 64B9-4.001(12), F.A.C BILL: SB 998 Page 4
hours of receipt of the death or fetal death certificate and signing it to the best of their knowledge
and belief.
Similarly, under the bill, APRNs providing hospice care under a written protocol with a licensed
physician may correct information on a permanent certificate of death or fetal death, alongside
funeral directors, physicians, PAs, A-APRNs, and medical examiners.
Section 2 amends s. 400.601, F.S., to revise the definition of “hospice care team” by replacing
the term “primary or attending physician” with “primary or attending practitioner.” The term
“primary or attending practitioner” is defined as a physician, PA, or an A-APRN practicing
pursuant to a written protocol with a physician.
The bill also revises the definition of “primary or attending practitioner” to include APRNs
providing hospice care pursuant to a written protocol with a licensed physician, in addition to
physicians, PAs, and APRNs registered under s. 464.0123, F.S.
Section 3 amends s. 400.6095, F.S., to revise the roles and responsibilities of the
interdisciplinary plan of care teams in hospice programs. Under current law, a hospice plan of
care is developed and reviewed by a primary or attending physician and other members of the
interdisciplinary team. Through the definition established in section 2, the bill authorizes non-
physician practitioners, A-APRNs providing hospice care pursuant to a written protocol with a
physician and PAs (who practice under the supervision of a physician), to assume the
responsibilities previously reserved for a physician, including development and review of the
plan of care, certification of terminal illness for purposes of hospice admissions, and
management of admission, transfer, and discharge from hospice.
Section 4 amends s. 401.45, F.S., to authorize A-APRNs providing hospice care pursuant to a
written protocol with a physician, to sign a patient’s order not to resuscitate (DNR order), in
addition to physicians and PAs.
Section 5 provides an effective date of July 1, 2025.
IV. Constitutional Issues:
A. Municipality/County Mandates Restrictions:
None.
B. Public Records/Open Meetings Issues:
None.
C. Trust Funds Restrictions:
None. BILL: SB 998 Page 5
D. State Tax or Fee Increases:
None.
E. Other Constitutional Issues:
None.
V. Fiscal Impact Statement:
A. Tax/Fee Issues:
None.
B. Private Sector Impact:
None.
C. Government Sector Impact:
None.
VI. Technical Deficiencies:
None.
VII. Related Issues:
The DOH notes that it is unclear whether the authority to sign a DNR, as provided in the bill,
falls within the scope of practice for APRNs under s. 464.012(3), F.S. The DOH recommends
amending that section to expressly include the authority to sign a DNR order within the APRN
scope of practice to ensure the bill’s provisions are fully effectuated.
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VIII. Statutes Affected:
This bill substantially amends the following sections of the Florida Statutes: 382.008, 400.601,
400.6095, and 401.45.
IX. Additional Information:
A. Committee Substitute – Statement of Changes:
(Summarizing differences between the Committee Substitute and the prior version of the bill.)
None.
15
Department of Health, Senate Bill 998 Legislative Analysis (Mar. 28, 2025) (on file with the Senate Committee on Health
Policy). BILL: SB 998 Page 6
B. Amendments:
None.
This Senate Bill Analysis does not reflect the intent or official position of the bill’s introducer or the Florida Senate.