Opinion ID: 1038649
Heading Depth: 3
Heading Rank: 2

Heading: The Medical-orders Exception.

Text: The medical-orders exception provides in full as follows: “This chapter [the NPA] does not prohibit: [¶] . . . [¶] (e) The performance by any person of such duties as required in the physical care of a patient and/or carrying out medical orders prescribed by a licensed physician; provided, such person shall not in any way assume to practice as a professional, registered, graduate or trained nurse.” (Bus. & Prof. Code, § 2727, subd. (e), italics added.) The meaning of the first clause and its application to this case are clear: Unlicensed school personnel acting pursuant to section 49423 and its implementing regulations “perform[] . . . 13 duties as required . . . in carrying out medical orders . . . .” (Bus. & Prof. Code, § 2727, subd. (e).) What the italicized proviso means is less clear, especially in its use of the word “assume.” On this point the legislative history is uninformative, reflecting only that section 2727 was added as part of the original NPA (Stats. 1939, ch. 807, § 2, p. 2349), and that the medical-orders exception was added on the Assembly floor for unrecorded reasons (Assem. J. (1939) p. 515). The Nurses argue a person “assume[s] to practice as a . . . registered . . . nurse” (Bus. & Prof. Code, § 2727, subd. (e)) simply by performing any health care function that falls within the NPA‟s definition of nursing practice (id., § 2725, subd. (b)). But this cannot be what the proviso means, as it would vitiate the medical-orders exception. A person who carries out a physician‟s medical orders with respect to a patient does not need an exception from the laws prohibiting unauthorized practice unless his or her conduct would otherwise violate those laws. To adopt the Nurses‟ interpretation would thus render the exemption entirely meaningless — a result we would hesitate to accept “unless absolutely necessary.” (E.g., People v. Arias (2008) 45 Cal.4th 169, 180.) But we need not accept it. The statute‟s language, broader statutory context and interpretive history all point to a different meaning: To “assume to practice as a professional, registered, graduate or trained nurse” (Bus. & Prof. Code, § 2727, subd. (e)), means to hold oneself out, explicitly or implicitly, as being a nurse in fact. We begin with the language. To “assume” to do a thing has two possible meanings in the present context. It might mean to “undertake” to do a thing, or “[t]o take [a thing] upon oneself” — in effect simply to do it. (Oxford Eng. Dict. Online (2013) definition II.4.a; see Webster‟s 3d New Internat. Dict. (2002) p. 133, definition 2.) Alternatively, to “assume” might mean “[t]o put forth claims or pretensions,” to do a thing “in appearance only, . . . to pretend, simulate, feign.” (Oxford Eng. Dict. Online, supra, definition III.8, 9; see Webster‟s 3d New 14 Internat. Dict., supra, at p. 133, definition 4.) Building upon the former definition (“undertake”), the Nurses contend a person “assumes to practice as a . . . nurse” (Bus. & Prof. Code, § 2727, subd. (e)) by undertaking to perform — in other words, simply by performing — any of the patient care functions listed in the NPA‟s definition of nursing (id., § 2725, subd. (b)(2)). This interpretation, as noted, cannot be correct as it would leave the medical-orders exception without meaning. In contrast, the medical-orders exception does have meaning if one “assume[s] to practice as a . . . nurse” (Bus. & Prof. Code, § 2727, subd. (e)) by holding oneself out, explicitly or implicitly, as being a nurse in fact. The broader statutory context supports this interpretation. The list of statuses an unlicensed person who carries out medical orders may not “assume” — “professional, registered, graduate or trained nurse” (ibid.) —indicates that one may not evade the rule against falsely posing as a registered nurse by substituting a vaguer term such as “professional,” “graduate” or “trained.” A penal provision enacted by the same Legislature in the same bill as the medical-orders exception similarly declared it “unlawful for any person or persons not licensed as provided in this chapter to impersonate in any manner or pretend to be a professional nurse, or to use the title „registered nurse,‟ the letters „R.N.,‟ or the words „graduate nurse,‟ „trained nurse,‟ or any other name, word or symbol in connection with or following his [or her] name so as to lead another or others to believe that he [or she] is a professional nurse.” (Id., former § 2796, added by Stats. 1939, ch. 807, § 2, p. 2356; see Bus. & Prof. Code, § 2796 [current version, adding “nurse anesthetist” to the list of titles one may not falsely assume].) The order in which the bill‟s provisions were drafted suggests the Assembly looked to the penal provision, and even borrowed some of its terms, in drafting the floor amendment that added the medical-orders exception. (Compare Assem. Bill No. 620 (1939 15 Reg. Sess.) § 2, p. 11, as introduced Jan. 13, 1939 [adding Bus. & Prof. Code, § 2796], with Assem. J. (1939) p. 515 [floor amend. of Mar. 13, 1939, adding Bus. & Prof. Code, § 2727, subd. (e)].) The broader statutory context provides additional evidence supporting our conclusion. The same section of the NPA that contains the medical-orders exception (Bus. & Prof. Code, § 2727, subd. (e)) also creates a narrower exception covering “[i]ncidental care of the sick by domestic servants or by persons primarily employed as housekeepers as long as they do not practice nursing within the meaning of this chapter.” (Id., subd. (b), italics added.) Read in the context of the whole statute, the italicized language expresses the thought that domestic servants and housekeepers caring for sick persons may not perform nursing functions, without regard to how they hold themselves out. The Nurses would interpret the medical-orders exception similarly, yet the same Legislature, in the same act and section, chose the different words — “assume to practice as a . . . nurse” — (ibid., italics added) to qualify the exception for unlicensed persons who merely carry out medical orders. The inescapable inference is that the Legislature, by using different words to define the two exceptions, intended them to have different meanings. The single prior interpretation of the medical-orders exception is consistent with our conclusion. The Attorney General has described that exception, and the NPA‟s related penal provisions, as “show[ing] a legislative intent to prohibit any person from holding out to the public that [he or] she is specially trained or registered in the nursing profession unless said person is licensed by the state of California in this field.” (Registered Nurse, 32 Ops.Cal.Atty.Gen. 159, 160 (1958), referring to Bus. & Prof. Code, §§ 2727, subd. (e) [medical-orders exception; unlicensed person carrying out medical orders may not assume to practice as a nurse], 2795 [unlawful to use any title, sign, card or device to indicate 16 nursing licensure], and 2796 [unlawful to use the titles “registered,” “graduate” or “trained nurse,” or the letters “R.N.”].) Thus, the Attorney General concluded, an unlicensed person employed by a physician as a “doctor‟s nurse” was forbidden to use titles confusingly similar to “registered nurse,” such as “ „Registered Doctor‟s Nurse‟ or the abbreviation „R.D.N.‟ or any title, or wear or display any pin that would indicate that said person is duly licensed as a registered nurse under the laws of the state of California.” (Registered Nurse, supra, at p. 159; cf. Kolnick v. Board of Medical Quality Assurance (1980) 101 Cal.App.3d 80, 84 [declining to construe the exception].) For all of these reasons, we conclude the medical-orders exception does permit a layperson to carry out a physician‟s medical orders for a patient, even orders that would otherwise fall within the definition of nursing practice, without thereby violating the rule against unauthorized practice. To fall outside the exception by “assum[ing] to practice as a . . . nurse” (Bus. & Prof. Code, § 2727, subd. (e)), one must go further by holding oneself out, explicitly or implicitly, to be a nurse in fact. This conclusion disposes of the issue, because unlicensed school personnel do not hold themselves out to be nurses simply by volunteering to act on behalf of particular students in accordance with the Education Code and its implementing regulations. We thus proceed to consider the Nurses‟ remaining objections to the conclusion that such personnel may administer medications.