Ethical & Legal Issues in MH

Ethics

Broad term to connote the study of morals and moral choices

Bioethics

Attempts to apply ethical reasoning to healthcare

Beneficence

Duty to act to benefit or promote the good of others (do good)

Nonmaleficence

Duty to do no harm to patients (do no harm)

Autonomy

Respecting the rights of others to make their own decisions (rights to medical decisions)

Justice

Duty to distribute resources or care equally regardless of personal attributes

Fidelity

Maintaining loyalty and commitment to the patient

Veracity

Ones duty to communicate truthfully

A pt. Hospitalized on an inpatient psychiatric unit is placed in seclusion after repeatedly attempting to assault staff. The nurse uses the least restrictive intervention, monitors the pt closely, and discontinues seclusion as soon as the pt regains behavioral control. Which ethical principle is most directly demonstrated by the nurses actions?

A. Autonomy

B. Justice

C. Nonmaleficence

D. Fidelity

C

5 steps to ethical decision making

1. Assess situation

2. Identify problem/conflict

3. Plan

4. Implement

5. Evaluate

Health insurance portability and accountability act (HIPAA)

US federal law from 1996 that sets national standards to protect sensitive pt health information (PHI)

Exceptions to confidentiality

• info can be shared with pts direct treatment team

• May be shared for billing purposes

• Confidentiality can be broken if pt expresses suicidal or homicidal thoughts

• Providers legally required to report suspected abuse or neglect of children, elders, or other vulnerable individuals

Criteria for involuntary commitment

• Used when a pt poses a danger to self or others (suicidal or homicidal ideation; a cute psychosis)

• Medial providers must clearly document

• Documentation is legally required

2 types of involuntary commitments

• Emergency hold (6401)

• 6404 Certificate of need

Emergency hold (6401)

• usually completed by ED physician

• Pt may be held up to 72 hours usually for the purposes of receiving a psychiatric evaluation

• Certificate that the lot is danger to self or others required

6404 (certificate of need)

• requires two professional evaluations (1st from ED physician, 2nd psychiatrist)

• Medical or judicial approval required within 24 hours

• Patient assigned legal counsel

• Court hearing typically held on psych unit

Legal and civil rights of psych patients

• informed consent

• Right to least restrictive treatment

• Right to privacy

• Right to access legal counsel

• Others items vary by state

Patients have the right to … for treatment at any time

Withhold or withdraw consent

A retraction of consent must be honored and must either be …

Verbal or written

Patients have rights to ________ restrictive environment to meet specific needs, but can be overridden in …

Least; psychiatric emergency to prevent harm

Implied consent

Patient willingly accepts a med offered by the nurse

State psych hospitals generally required __________ informed consent forms

Signed

Competency hearing

Court hearing to determine an individuals capacity to make major life decisions; if declared incompetent, individual may lose ability to (drive, vote, sign wills, sue, etc.)

Insanity

Legal, not clinical term

• refers to a mental illness that prevents a person from fully understanding their action

• Can be raised as a defense in criminal cases

Purpose of seclusion and restraint use

• Protect pts, staff, and others from harm

• Ensures interventions are safe and legal

• Use LEAST RESTRICTIVE MEASURES for the SHORTEST TIME

• Maintain continuity of care throughout

Physical restraints

Manual methods or devices restricting movements

Ex. Wrist, ankle, waist straps, mitts, safety vests

Mechanical restraints

Devices limiting movement, sometimes overlaps with physical restraints

Ex. Bed rails

Chemical restraints

Medications to manage violent/self harming behavior

Ex. Antipsychotics, benzos

Environmental restraint/seclusion

Pt placed in a safe, controlled room to prevent harm

When to use seclusion and restraints

• Used ONLY when pt poses high risk to self or others

• Not a form of punishment

• LAST RESORT

3 requirements for seclusion and restraints

1. Written order

2. Time limited confinement

3. Regular documentation

When can seclusion and restraints be continued

• original order may be extended

• In an emergency

Nursing assessment if pts in restraints

Initial RN assessment must occur within 1 hour of seclusion or restraint

• precursors to behavior

• Methods and techniques that were used

• What type of seclusion or restraint

• Pre existing medical or psych conditions

• History of abuse

• Time in and time out

Pts in seclusion or restraints must be …

• Assessed for physical needs, safety, and comfort every 15-30 minutes

• Removed from restraints when safe and quieter

• Document every 15 to 30 minutes

Post seclusion and restraint best practices

• Review why seclusion or restraint was used

• Identify alternative coping strategies

• Listen to pt perspective

• Use empathy

• Avoid judgement

Tarasoff v Regents of University of California

Established the duty to warn identifiable potential victims

Tarasoff law

• duty to warn to a broader duty to protect

• Nurses must report threats of harm to provider

• Failure to do so may be considered negligence

Tort law

Civil law addressing wrongful acts that cause harm or injury, with the goal of monetary compensation

A nurses duty is defined by ….

Standard of care

Breach of duty occurs when …

Care falls below the standard and creates unreasonable risk of harm