Docs Must Supervise Delegation to CRNAs, TMA Tells Attorney General
By Joey Berlin

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Texas Attorney General (AG) Ken Paxton should state that certified registered nurse anesthetists (CRNAs) require physician supervision when a physician delegates medical acts to them, the Texas Medical Association told the attorney general in response to a request for opinion.

The Texas Medical Board (TMB) asked for the AG’s opinion on supervising CRNAs last month, saying it was making the request “to unequivocally clarify that Texas law requires supervision of CRNAs by physicians” under the state’s Occupations Code, which includes the Texas Medical Practice Act.

TMA weighed in with a letter last week largely supporting the medical board’s arguments.

“There are certain individuals and groups, promoting self-interests, who are creating confusion over the relationship and legal obligations between delegating and supervising physicians and CRNAs,” TMB wrote in its request. “Specifically, CRNAs claim they have ‘independent’ practice in the field of anesthesia. While there is a great latitude in utilizing these professionals and their skills, it is legally incorrect and misleading to claim they have independent practice, not to mention impossible, as CRNAs cannot anesthetize patients without a physician order or authorization.”

TMB asked the attorney general to comment on two questions:

  • Does state law require any physician supervision of CRNAs?
  • Is the liability of the delegating physician limited to the determination of the physician’s competency to initially delegate to the CRNA, or does it include liability for all delegated medical acts?

In its Sept. 14 brief, TMA agrees with the medical board that the state’s Medical Practice Act “requires some level of physician supervision over the medical acts delegated to a CRNA.” However, TMA notes, direct supervision over the CRNA’s performance of those acts isn’t required.

TMA argues that the level of supervision depends on the physician’s professional judgment in accordance with other federal and state laws, medical staff bylaws, facility policies, and ethical standards.

TMA also notes the law does not limit the supervision requirement based on practice setting or type of licensure. It states that physicians may delegate “to a qualified and properly trained person acting under the physician’s supervision any medical act” of sound medical judgment, if the physician believes the person can perform the task properly and safely; if it is “performed in its customary manner” without violating any law; and if the person isn’t representing that they’re authorized to practice medicine.

On the liability question, TMA asserts that physicians may generally be held liable for any medical acts delegated to a CRNA, subject to other legal limitations.

“The physician’s liability for any medical acts delegated to a CRNA depends, generally, on whether the alleged violation is based on the physician’s direct negligence (for delegation or appropriate supervision), the negligence of his or her employee delegate, or the negligence of a delegate employed by a third party,” TMA’s brief explains.

It adds that under the Medical Practice Act, a physician can’t be held responsible solely because of the physician’s supervisory relationship with an advanced practice registered nurse (such as a CRNA) unless the physician had “reason to believe the nurse lacked competence to perform the act – but the physician can be held liable for other reasons, such as failure to provide appropriate supervision.”

The medical board originally asked Attorney General Paxton for the opinion on Aug. 12.

Attorney General Paxton issued an opinion last year – at the request of TMA – that keeps CRNAs from administering anesthesia without physician delegation.

While not binding law, opinions of the attorney general are considered persuasive authority. Interpretation of state law is ultimately left up to courts.

Last Updated On

September 21, 2020

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Joey Berlin

Associate Editor

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Joey Berlin is associate editor of Texas Medicine. His previous work includes stints as a reporter and editor for various newspapers and publishing companies, and he’s covered everything from hard news to sports to workers’ compensation. Joey grew up in the Kansas City area and attended the University of Kansas. He lives in Austin.

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