Chapter 6

Legal & Ethical Condsiderations

Morals

Beliefs about what is right or wrong

Ethics

Branch of knowledge and philosophical beliefs about what is right or wrong in a society. It describes what out to be rather than what is

Bioethics

The study of specific ethical questions that arise in healthcare. Important ethical principles in healthcare include:

• Autonomy: respecting the rights of others to make their own decisions, including refusing treatments

• Beneficience: the duty to act to benefit the health and well-being of others

• Nonmaleficence: doing no harm to the patient

• Justice: the duty to distribute resources or care equally, regardless of a person's attributes

• Veracity: the duty to communicate truthfully

Ethical Dilemma

Results when there is a conflict between two or more courses of action, each carrying favorable and unfavorable consequences

• response to these dilemmas is based partly on morals and values

Code of Ethics for Nruses

1. The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems.

2. The nurse’s primary commitment is to the patient, whether an individual, family, group, or community.

3. The nurse promotes, advocates for, and strives to protect the rights, health, and safety of the patient.

4. The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to promote health and provide optimal care.

5. The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth.

6. The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality care.

7. The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy.

8. The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities.

9. The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy.

Pharamacogentic Testing

• Used to identify which antidepressants to use on specific patients based on a DNA profile

• Goal is to eliminate the trial-and-error approach to prescribing antidepressants and improve recovery time

• Concluded that their is insufficent data to support the widespread use of genetic testing, although they may be helpufl in predicing side effects

  • FDA also does not support the use of genetic testing due to inadequate research and clinical evidence

Parity

Federal legislation providing equality for the people wiht mental illness with other patients in terms of payments for services from health insurance plans

• helped improve access to treatments

Hospitalizations

• Some individuals experience such severe sympotms that they require hospitalization for evaluation and close monitoring

• Admission Procedures are all based on several fundamental guidelines:

  • niether voluntary or invountary commitment determines a patient’s ability to make informed descisions about personal healthcare

  • care providers establish that a well-defined psychiatric problem exists based on current illness classifcation in the DSM-5

  • The illness and symptoms should result in an immediate crisis situation and other less-restrictive alternatives are inadequate or unavailable

  • Reasonable expectation that the hospitalization & treatment will improve the presenting problems

Voluntary Admissions

• Occurs when patients apply in writing for admission to the facility

• Person should understand the need for treatment and be willing to be admitted

• If under 16, the parent, guardian, custodian or next of kin may have authority to apply on the person’s behalf, 16+ may seek admission independently

• Have the right to request and obtain release but reevaulation may be necessary and can result in involuntary commitment if criteria is met

Involuntary Committment

• Assisted inpatient psychiatric treatment

• Court-ordered admission to a facility w/o pt’s approval

• State laws vary, but they address both the criteria and process for committment

  • Standards include: person diagnosed with a mental illness, posing danger to self or other, gravely disabled, or in need of treatment and the mental-illness prevents them from voluntarily seeking help

• Often a person close to or related to the individual with a mental illness starts the process with a PCP, a facility, or police

• Two+ physicians must certify need for committment

• Patients have right to take their case before a judge who can order a release

• In most states psychiatric committment cannot last past 72 hours without a formal hearing

• Patients who believe they are being held without just cause can filed a petition for a writ of habeas corpus — challenges unlawful detention by the government

• Patients can also challenge based on the least restrictive alternative doctrine which mandates care providers take the least drastic measure necessary

Emergency Committment

• Temporary admission, emergency hospitalization

• Used for people who are so confused they cannot make decisions on their own or for people who are so ill they need emergency admission

• In some states, anyone can initiate these proceedings throught the court systems

• Other states require a phsyician, APRN, social worker or police offer to initiate

• Purpose is to observe, diagnose, and treat patient

• Length of time they can be held ranges from 24-96 hours depending on the state — court hearing after

Discharge Procedures

• Release from the hospital depends on the patient’s admission status

• Unconditional Release: most common type, termination of the legal patient-institution relationship, may be ordered by attedning pscyhiatrist or otehr advanct practice mental health professional or court ordered, can be patient requested as well

• Release Against Medical Advice (AMA): patients are required to sign a form indicating they are leaving AMA, part of a pt’s permanent record, ethical dilemma between pt autonomy and what the clinician views as the best course of action

• Conditional Release: requires outpatient treatment for a specific period of time for further evaluation outside of the hospital, medical regimen monitored, ability to meet basic needs evaluated

• Assisted Outpatient Treatment: court-ordered outpatient treatment

Patients’ Rights Under the Law

• Right to Treatment: right to be free from excessive/unnecessary meds, right to privacy & dignity, right to least restrictive environment, right to attorney, clergy, and private care providers, right to not be subjected to lobotomies, ECT, and other treatments w/o informed consent

• Right to Refuse Treatments: patients always have the ability to withdraw consent at any time to something they previously consented to or right to refuse immediately. The right to refuse psychopharmacological drugs has been debated in the courts

  • In an emergency situation when a person may cause serious harm to themselves or others institutions can medicate a person without a court hearing

• Right to Informed Consent: patient has been rpovided with basic information regarding risks, benefits, and alternatives to treatment and must be voluntarily accepting the treatments

  • Implied Consent: not stated out loud or written in a document; many psychiatric institutions require signed informed consent documents for all treatments including every medication

  • Capacity: person’s ability to make an informed decision

  • Competency: degree of mental soundness a person has to make a decision or to carry out specific acts

• Rights Regarding Psychiatric Advance Directive: pts who have experienced an epidose of severe mental illness have the opportunity to express treatement preferences in psyciatric advance directive

• Rights Regarding Restraing & Seclusion: In an emergency a nurse may place a pt in either but obtains an order right after, never a standing order, carefully document what happens during the process

• Rights Regarding Confidentiality: prohibits the disclosure of privileged information without the patient’s consent

Health Insurance Portgability & Accountability Act (HIPPA)

Legally protects the psychiatric patient’s right to receive treatment and to have medical records kept confidential.

Duty to Warn & Duty to Protect

• Duty to Warn: obligation to warn third parties when they may be in danger from a patient

• Duty to Protect: protect a person from your pt — required to call and warn the intended victim, their family and the police

Tort

Any wrongful act, intentional or accidental, that results in an injury to another. Tort law is one of the major areas of law and results in more civil litigation than the other areas.

Intentional Torts

Willful or intentional acts that violate another person’s rights or property

• Assault: intentional threat designed to make another person fearful that you will cause that person harm

• Battery: Actual harmful or offensive touching of another person

• False Imprisonment: person is confined in a limited area or within an institution.

• Invasion of Privacy: breaking a person’s confidences or taking photographs without explicit permission

Unintentional Torts

Unintended acts against another person that produce injury or harm

• Negligence: most common unintentional tort; 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

  • Duty: assume a duty of care when you represent yourself as begin capable of caring for pts — knowledgeable and skillful

  • Breach of Duty: if you do not meet the standard of care expected. Doing something that results in harm (act of commission) or failing to do something that results in harm (act of omission)

  • Cause in Fact: an actual cause, if it weren’t for what the nurse did or failed to do would the event happened

  • Proximate cause: legal cause, whether the event was forseeable

  • Damages: actual damages, pain & suffering by the event

Standards for Nursing Care

• State Boards of Nursing

• Professional Associations

• Institutional Policies & Procedures

• Custom as a Standard of Care

Documentation of Care

• Medical records serve as evidence, quality improvement

• there are many guidelines for electronic documentation of healthcare infromation