Legal and Ethical Considerations Ch 6

˜Explain the legal role in psychiatric nursing. Discuss the basic standards by which nurses are held in practice, policies and procedures, and associations.

˜Differentiate voluntary admission versus involuntary commitment.  - Ex. Look at a pt and know , ex. If you went in voluntary- you can voluntary check yourself out if youre not a danger to yourself or others. Have to initiate a court order to keep them.

˜Describe laws relevant to psychiatric care including torts, negligence, and malpratcie, relevant to psychiatric care.

˜Describe patients’ rights and legal concerns with regard to restraint and seclusion.

˜Identify the steps a nurse is advised to take if negligence or illegal activity is found in healthcare.- 

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What is ethics

•Ethics: The study of philosophical beliefs about what is considered right or wrong in a society

•Bioethics: Used in relation to ethical dilemmas surrounding health care. study of specific ethical questions that arise in healthcare.

•Ethical dilemma: Conflict between two or more courses of action, each with favorable and unfavorable consequences

Ethical principles help healthcare providers make decisions for care and evaluate care that has been given. This is also what helps drive evidence-based practice. Ex. pregnant woman w schizophrenia and parents are telling her to get an abortion.

What are the six principles of bioethics

Autonomy: Respecting the rights of others to make their own decisions. Ex. acknoweledging the pts right to refuse med

2. Beneficence: The duty to act to benefit or promote the health and well-being of others. Ex. spending more time to help calm and anxious person

3. Nonmaleficence: Doing no harm to the patient. Ex. protecting confediental info about a pt

4. Justice: The duty to distribute resources or care equally, regardless of personal attributes. Ex. An ICU nurse devoted equal time to someone who attempted suicide and someone who has a brain anuersym.

5. Fidelity: Maintaining loyalty and commitment; doing no wrong to a patient. Ex. continuing education

6. Veracity: The duty to communicate truthfully ex. explain side effects of meds

Must learn and understand these terms. Many of these terms are in healthcare oaths.

What are the admission procedures

•Voluntary admission—sought by patient or guardian. when pts apply in writinf for admission in the facility. if under 16- have to get authority form legal gaurdian. if 16-18 can seek admission independently or through an angency. they have the right to request and obtain a release. revaluate the pt- the dr can decide if they need involuntary commitment.

•Involuntary commitment—without patient’s consent. aka assisted inpatient psych tx- court ordered admission.

–Mentally ill

–Danger to self or others

–Unable to acquire basic necessities- like food, clothing, shelter- diabled

–Mental illness itself prevents voluntary help-seeking

Before a patient can be admitted to a psychiatric facility, he/she must be deemed either voluntary or involuntary, and must have documentation supporting the admission status. All psych facilities are locked units, therefore the admission status must be legal. Holding someone against their will is illegal. The appropriate documentation allows the facility to hold an involuntary admission for safety reasons. 

What is due process in involuntary commitment

•Writ of habeas corpus – “formal written order” to “free the person”

•Least restrictive alternative doctrine – mandates that care providers take the least drastic action to achieve a specific purpose

Patient who think they are being held again their will must file a write of habeas corpus, which pushes it to the courts to decide if the patient has been denied due process.

Least restrictive alternative doctrine: Example given in book – if one can be treated with depression medication on an outpatient basis, then they do not need to be hospitalized (restrictive and unnecessary)

Pt has the right to access legal counsel and present it before a hudge who can order a release. if the pt thinks they are being held without a judte caus ethey can do a petition for writ of habeus corpus- formal written order.

pts can challenge the hospital- for a least restrictive doctrine- this is where the dr does the least invaise tx . for example w depression- they can do outpatient instead of hospitalization.

What is emergency commitment

a.k.a. temporary admission or emergency hospitalization

1. Person so confused they can not make decisions on their own

2. So ill they need emergency admission

•Driven by state laws, and court system- in some states anyone can initiate this through the court setting. other states providers or APN can initiate a temporary admission.

•Admission ranges from 24 – 96 hours, court decision is made for discharge, voluntary, or involuntary commitment

•purpose is to observe, diagnose, and treat pts who have mental illness or are a danger to themseleves.

a court hearing is held and a decision is made for dischrge, voluntary admission, or involuntray commitment.

The JP- spuse, mom, relative-

Idenitfy a pt in crisis- need emergency admission.

Which individual may need involuntary hospitalization?

A.A person with alcoholism who has been sober for 6 months but begins drinking again

B.An individual with schizophrenia who stops taking prescribed antipsychotic drugs

C.An individual with bipolar disorder, manic phase, who has not eaten in 4 days

D.Someone who repeatedly phones a national TV broadcasting service with news tips

A.Incorrect – not threat to themselves or others            ex. If they were drinking and driving- red flag

B.Incorrect – no signs or symptoms noted at this time, not a threat to themselves or others                  that doesn’t mean that theyre in crisis red fla– ex. The voices are telling them bad things, if they isolate themselves- red flags

C.Correct – states “manic phase” and not eaten in 4 days; patient not able to care for self at this time     

D.Incorrect – not a threat

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Figure out whos a red flag,

What are discharge procedures

•Unconditional release- termination of legal patient-institution relationship (if clinician determines patient is safe with self and others)- for ex if a patient wants to be released due to not being satisfied w care, lack of insurance coverage, or need to return to work. when the pts requests- the dr can agree- if they have doubts then they can be held involuntray admissions. theres a 72hr holding period for professional evaluation.

•Release against medical advice (AMA)- when patient request discharge but would benefit from continuation of admission, but is not a danger to self or others. they are required to sign a form which becomes part of the electronic record. shows pt autonomy.

•Conditional release- usually requires outpatient treatment for a period of time, meeting medication regimen, basic needs, and ability to reintegrate into the community. an involuntary admitted pt who is conditionally release may be readmitted based on the original committment order.

WHat are patients rights under the law

•Right to Treatment

•Right to Refuse Treatment- if pt is determine to not be sound mind- then that right gets turned off but you have to document that you tried to reasons, threats pt made, mood in, delusions, right to be free from excessive or unecessary med, privacy and dignity, least restrictive enviornment, atorney, clergy, private care providers, right to not be subjected to lobotomies, elctroconvulsie tx- and other tx without consent

•Right to Informed Consent- us as nurses- its not our scope. Ex only the dr explains the risks and benefits- we dont

•Right Regarding Psychiatric Advance Directives- this is provided when they are well and it identifies in detail their wishes and tx choices. ex. preffered physicians, therapistis, appointment of someone to make mental health decisions, preferences of meds, ECT, admission to a psych facility, people who should not visit.

•Right Regarding Restraint – chemical- sedations, adavan, Geodon, and Seclusion. use the least restrive restraint for the least amount of time. in emergency situations, less restrivtive measures dont need to be tried. verbally intervene- ask the pt for cooperation, reduce stimuli, actively listen, provide distraction, offer PRN meds. chemical restraints can be a helpful alternative to physical- and is less restrictive. seclusion- putting patient alone and preventing them from leaving. this only for pts who are violent, or may hurt themselves or others. someone who is physically retained in an open room is not in a seclusion. seclusion is diff from a timeout bc in timeout- pt choosed when to leave.

•Right Regarding Confidentiality- only the pt can waive the legal privelage of confidentiality. Ex. should not talk about pts in elevators, clinical paperwork should not have names.

Rights are mandated to be covered upon admission and also posted on the wall within the facility, where patients can refer to them.

Comes first- talk, de-escalation techniques, seclude, chemical,

JS agrees to electroconvulsive therapy (ECT). Which member of the team is responsible for obtaining the client’s informed consent?

A. Case Manager

B. Prescriber

C. Registered Nurse

D. Social Worker

A.Incorrect – usually a nurse, who helps patients get ready for discharge

B.Correct

C.Incorrect – nurses usually provide the education regarding procedures

D.Incorrect – not involved with obtaining consents

What can you do to eliminate the need for restraints

•Chemical interventions are usually less restrictive than physical or mechanical (wrist restraints or seclusion)

•Addressing problems can reduce or eliminate the need for restraint, seclusion, or chemical intervention

–Verbally intervening (“Assisting Process”)

–Reducing stimulation, providing diversion

–Actively listening

–Offering prescribed or as needed medications

Chemical interventions are usually given IM and not part of the patients routine prescribed medications.

Chemical interventions impact the patient’s level of awareness and you have to monitor vital signs and watch for side effects.

Never, ever, ever say or document the words “CHEMICAL RESTRAINT”!!!! That is an illegal term and can cause litigation.

What is tort law

Tort—a civil wrong for which money damages may be collected by the injured party (plaintiff) from the responsible party (the defendant)

Intentional tort—willful or intentional acts that violate another person’s rights or property

• Assault – the intentional threat designed to make another person fearful that you will cause them harm

• Battery – the actual harmful or offensive touching of another person (e.g. shoving)- Battery- when you hit a patient

• False imprisonment – person is confined in a limited area or within an institution ex, spouse put them there, they weren’t meant to be there

• Invasion of privacy – breaking a person’s confidence or taking photographs with permission (must obtain a photo consent)

• Defamation of character – provider makes a false statement that causes some degree of harm (usually reputation)  ex. Wealthy ppl , always talk to pt themselves

Unintentional tort—unintended acts against another that produce injury or harm

• Negligence – most common, the failure to use ordinary care in any professional or personal situation when there is a duty to do so

• Malpractice – special type of professional negligence

All elementes have to be reached , board of nursing is not for you, its to protect the public

RESUME

WHat are the five elements to prove negligence/malpractice

•Duty

•Breach of duty

•Cause in fact

•Proximate cause

•Damages

Comes down to cause in fact and proximate cause.

“If it were not for what this provider did or didn’t do, would this injury have occurred?”

Was the even foreseeable?

WHat are the standards of nursing care

State Boards of Nursing- state agencies that regulate nursing practice and primary goal to protect public health

Professional Organizations – to elevate the practice of its members by setting standards of excellence, specialties

Institutional policies and procedures – criteria for care within the facility

Custom as a standard of care – e.g. no policy on use restrain, testimony might offer “customary” use of restraint (the norm)

Which of the following identifies the titles that registered nurses will use and what they are legally allowed to do?

A.State Boards of Nursing

B.Professional Organizations

C.Custom as a Standard of Care

Institutional Policies and Procedures

How do you act on questionable practice

•Duty to intervene and duty to report

–Incompetence, impairment, or criminal activity

–Bodies to whom the nurse must report vary from state to state

Negligence, Irresponsibility, Impairment, Incompetence, impairment, or criminal activity

Whom the nurse must report vary from state to state – usually directly with peer, then supervisor (depends on how dangerous the situation is)

what is Documentation of Care / Medical Record used for

•Used for quality improvement

•Used as evidence

•Growing use of electronic documentation

A record’s usefulness is determined by evaluating—when the record is read later—how accurately and completely it portrays the patient’s behavioral status at the time it was written. Psych documentation and use of appropriate words is extremely important for legal purposes. Appropriate documentation can save your case.

what is forensic nursing

•Application of nursing principles in a court of law to assist a decision

•Nurse often educates the Court on the science of nursing

May provide opinions using appropriate nursing standards.

Issues at stake may include:

Patient competency

Individual’s fitness to stand trial

Involuntary commitment

Responsibility for a crime

Other tasks

Support of victims or perpetrators of crime and violence

Collection of evidence

Provision of health care in prison settings

A nurse was the case manager for a client with serious mental illness for 6 years. On the last visit, the client disclosed that they are going to shoot their significant other. What law covers the nurse to protect a third party?

A. Duty to warn

B. HIPPA

C. Legal privilege of confidentiality

D. Right to privacy

A.Correct – obligation to warn third parties when they may be in danger from a patient

B.Incorrect – right to have medical records kept confidential

C.Incorrect – disclosure of privileged information

D.Incorrect – legal duty to maintain confidentiality