Ethical and Legal Concepts

Laws

-Enforceable in court

-Rules that organize society

-May or may not be in congruence with ethics

Ethics

-Internalized morality involving right vs. wrong

-Important in healthcare: again, may differ from the law

Ethical Issues

Common issues:

-Hospitalizing, restraining, medicating patients against their will

-White lies to protect feelings

-Reporting misconduct of a colleague

-Involvement of guardianship proceedings

Nurses must become aware of their values while adhering to ethical standards

Ethical Principles

-Autonomy

-Beneficence

-Nonmaleficence

-Justice

-Veracity

-Fidelity

Autonomy

-Right to self-determination

-Right to choose (Informed consent)

-Right to make decisions on own care

-Persistent through psychosis/mania

-Questionable through delirium/dementia

-Competence vs Capacity

-Paternalism: concept of making decisions that are good, in an individual’s best interest, when they may not be capable of making decisions

Autonomy: Capacity

-The case of whether or not an individual is capable of making healthcare decisions

-Based on if the patient has the ability to: Communicate, Understand information, Understand situation and its consequences, Rationale for treatment options

-Capacity is Fluid, not static; Can change from time to time

-No specific psychiatric disorder automatically reduces capacity

Autonomy: Competence

-Is a legal term— determined by courts, not medical professionals

-Adults are assumed to be competent, but a hearing may be pursued if: Significant psychiatric disorder, Judgment impaired, Disease that impedes an individual’s ability to reason

-If it is deemed that an individual is not competent to make treatment decisions, courts made determinations are best left to the professionals

Beneficence

-Acting in ways that benefits others; doing good

-Ex: Advocating for pain relief or promoting healthy lifestyle changes

-Application: Focus on improving patient well-being though proactive care

Nonmaleficence

-The obligation to “do not harm”

-Ex: Avoiding interventions that could cause unnecessary harm

-Application: Weight risks and benefits to minimize harm while providing effective care

Veracity

-Being truthful and transparent with patients

-Ex: Fully explaining risks and benefits of treatments

-Application: Ensure patients can make informed decisions based on accurate information

Fidelity

-Loyalty and commitment to professional duties

-Ex: Keeping promises, providing consistent care

-Application: Maintain trust by fulfilling professional obligations and providing reliable care

Justice

-Fair and equal treatment of individuals

-Access to resources

-Equity: Fairness ensuring everyone has what they need to succeed, Recognizing that individuals don’t start from the same place

-Equality: Treats everyone the same, Doesn’t necessarily lead to fairness when people have different starting points or challenges

Patient’s Bill of Rights

-There are many rights that patients are legally provided through the BoR

-Refusal to treatment

-Informed consent

-Safe, Respectful care

-Confidentiality

Right to Refuse treatment

-Patients generally have the right to refuse medication/treatment, even if: Experiencing psychosis, Hospitalized involuntarily: Involuntary hospitalization does not automatically allow forced medication

-Medication over objection: Governed by state law and facility policy, Usually requires a formal review process, need 2 providers to sign off for this

-Forcible medications changes from treatment to public protection(safety): Prevent violence to third parties, To prevent suicide, To preserve security

-Forced medications should be provided in the least restrictive method: Offer oral first, if refused and safety risk remains, provide injection; Identify your needs and orders before starting shift

Right to Informed Consent

-Informed consent: A documented agreement from the provider and patient identifying that treatment information was provided and agreed

-Risks and benefits of the treatment

-Other treatment options

-Assume that: Patient can understand and decide, The decision was made freely

-Even if involuntary, must still be informed

Respectful care

-Environment must be humane

-Staff must be qualified and sufficient to provide adequate treatment

-The plan of care must be individualized

Right to the Least Restrictive Environment: Seclusion and Restraint Legal Intervention Behaviors

-The particular behavior is physically harmful to the client or a 3rd party

-The disruptive behavior presents a danger to the facility

-Alternative or less restrictive measures are insufficient in protecting the client and others from harm

-When a decrease in sensory overstimulation (seclusion only) is needed

-When a client requests seclusion

Right to the Least Restrictive Environment: Seclusion and Restraint Documentation

-The nurse can engage seclusion and restrain but must follow up:

-Must be face-to-face exam by MD within 1 hour of the application

-Next 4 hours can have phone order

-Next 4 hours need to have face-to-face exam

-Should reflect that lesser restrictive methods were tried

-The behavior leading to restraint/seclusion

Right to the Least Restrictive Environment: Seclusion and Restraint Legal Safety Guidelines

-Seclusion and Restraint

-Restraint must be rotated every 2 hours

-Food and fluids should be offered at least every 2 hours

-The patient should be released from restraint immediately after it is reasonably safe for them to do so

-If they are sleeping it is unacceptable to maintain seclusion/restraint

Psychiatric Commitment

-The hospital’s role is to provide safety and treatment

-Requires certain legal processes to occur

-PA and most states, have legal definitions to provide commitment in a psychiatric hospital

-States all have different codes but most have similar criteria identifying safety risks

Psychiatric Commitment: Voluntary

-To go into the psychiatric locked unit legal agreement to be in the hospital locked floor is required called a “Voluntary Agreement” (201 in PA)

-Safety concerns are still required, This pt has identified themselves that they are unsafe

-If the patient later requests discharge: Pt can be held on the unit for up to 120 hours until evaluated for safety

-The pt will be discharged if the provider determines that the pt is safe

Psychiatric Commitment: Involuntary Criteria for 302

-120 hour hold

-The person is unable without the care, supervision and assistance of others to satisfy their need for nourishment, personal or medical care, shelter or self-protection or safety and that death or serious physical debilitation would occur within 30 days unless treatment was provided

-The person has attempted suicide, or the person has made threats to commit suicide and committed acts in furtherance of the threats

-The person has mutilated himself/herself or the person has made threats to mutilate and committed acts in furtherance of the threats

-Danger to others shall be shown by establishing that within the previous 30 dyas the person has inflicted or attempted to inflict serious bodily harm on another or has threatened serious bodily harm and gas committed acts in furtherance of the threat to commit harm to another

Involuntary Commitment Process: Obtaining the Warrant

-Subjective belief that the individual has met the criteria for a commitment

-Located crisis center in counter and meet with case worker who will support call to county delegate

-County delegate: 24-hour service of an appointed individual’s staff that can give the power of warrant for arrest

-Review narrative with county delegate

-Approval or denial of the warrant/petition

Involuntary Commitment Process: Hospitalization

-Petitioner must agree to keep the client’s belongs secure

-Fax or deliver the warrant to the police who will pick up the client and take to the nearest facility for evaluation

-ER provider agrees with warrant (or doesn’t) and the pt is admitted

Involuntary Commitment Process: Post-Hospitalization

-Within 5 days, the pt will have a hearing to determine the validity of the need for treatment based on the 302 criteria

Psychiatric Commitment: Involuntary Denial

-If the county delegate, at any time denies the petition the evidence use cannot be used for further petitions

-If the pt isn’t found, the 302 is canceled

-If the judge for the inpatient hearing find no safety issue with the petition the patient is allowed to leave (no 48 hours)

Details with the 302

•Details

-Anyone can 302 anyone

-Practitioners and providers can call delegate directly; others must use emergency centers

•Issues

-If an individual is not found for admission the petition is ruined

-If the petitioner does not present for the hearing

-If the information provided in the narrative does not meet criteria for the delegate

-Well known patients

-Authoritarian vs Autonomy

-Approved 302->303 prevents the patient from owning firearms in the future

Legal Concerns: Tort Law

-Torts are civil wrongs for which money damages are collected by the injured party (plaintiff) from the wrongdoer (defendant)

-Civil liability for nursing practice falls in the area of tort law

3 types of torts: Intentional, Quasi-intentional, Unintentional

Intentional Tort Law

-Assault: An act resulting in a person’s apprehension of an immediate harmful or offensive touching (battery)

-Battery: Harmful or offensive touching

-False imprisonment: An act with intent to confine a person to a specific area, The use of seclusion or restraint that is not defensible as being necessary or in the patient’s best interest

Quasi-intentional Tort Law

-Defamation is made up of 2 torts:

-Slander or oral communication

-Libel or written communication

-Breach of confidentiality

Unintentional Tort Law

Professional negligence: Involves harm resulting from the failure of a person to conduct himself or herself in a reasonable and prudent manner

4 items needed to prove negligence are:

•Duty—measured by standard of care

•Breach of duty—conduct that exposes the client to an unreasonable risk of harm

•Proximate cause—Intervening actions or persons that were, in fact, the causes of harm to the client

•Damages—pain and suffering

Duty to Warn Third Parties

-Tarasoff case of 1976

-A duty to warn third parties exists when a therapist determines that the patient presents a serious physical danger to another person

-Nonetheless, in this instance – likely involuntarily commitment should be pursued