Ethical Legal Issues
Chapter Three: Patient Rights and Legal Issues
Self-Determinism Promotes Growth and Well-being
Definition: Self-determinism refers to the internal motivation to make choices based on personal values.
Key Values:
Personal Autonomy: The fundamental right to make personal medical decisions.
Nurse's Responsibility: Nurses must ensure that patients are informed while making medical decisions.
Reality vs. Perception in Mental Health:
Common media portrayal: Patients are seen as being forced to follow rules in psychiatric facilities.
Reality: Patients maintain autonomy even in psychiatric settings, although certain measures may be enacted for safety.
Avoidance of Dependence on Others
Promoting Independence: Patients should participate in their own care as much as possible. Nurses should encourage self-management since they won't always be present post-discharge.
Self-Determinism as a Right
Basic Right: Patients possess the inherent right to choose their health-related behaviors, even when these choices diverge from healthcare recommendations.
Example: Smoking among schizophrenia patients can alleviate anxiety but carries health risks. Restricting such behaviors can have negative implications on their well-being.
Patient Rights to Refuse Treatment
Patients may refuse treatment and seek second opinions, with limitations in cases of involuntary holds (e.g., a 72-hour hold).
Protection of Patient Rights
Patient Self-Determination Act
Advanced Care Documents: Patients typically discuss their advanced care wishes upon admission, detailing preferences for medical treatment if they become incapacitated.
Timing and Sensitivity: Inappropriate to discuss advanced directives immediately post-crisis (e.g., after a suicide attempt); advice may be deferred to a calmer moment.
Types of Advanced Directives:
Living Will: Details medical preferences if incapacitated (e.g., no CPR).
Durable Power of Attorney: Designates another person to make medical decisions on behalf of the patient.
Psychiatric Advance Directive: Similar to durable power of attorney, applicable when the patient is deemed cognitively impaired.
Legal Framework Protecting Patient Rights
Important Acts:
Bill of Rights for Mental Health Patients
Americans with Disabilities Act (ADA)
Patient Protection and Affordable Care Act
Mental Health Parity and Addiction Equity Act
Internal Rights Protection Systems
External Advocacy Systems
Accreditation: Necessary for the operation of medical facilities; affects reimbursement and ensures compliance with care standards.
Treatment Implied Rights
Competency in Decision-Making
Definition: Competency refers to whether a patient can make rational decisions regarding their care and legal situations.
Assessment Areas:
Ability to communicate choices.
Understanding relevant information.
Appreciation of the situation and consequences.
Utilization of logical processes to weigh treatment risks and benefits.
Informed Consent
Informed: Patients must be given total understanding of treatment risks and benefits before consenting.
Mandated by Law: This becomes complex in mental health, as competency can often fluctuate.
Least Restrictive Environment
Rights: Patients have the right to the least restrictive environment that maintains their safety and autonomy.
Understanding Restrictiveness:
Restrictiveness affects mobility and personal freedom (e.g., seclusion, restraints).
Levels of Restrictiveness:
Chair restraints or four-point restraints represent high restrictiveness, often involving chemical restraints as well.
Voluntary vs. Involuntary Treatment
Voluntary Admission: Patients retain all civil rights and can leave unless determined a threat to self/others.
Involuntary Treatment: Court-mandated, typically resulting from assessment of immediate danger wherein patient cannot leave without the approval of authorities.
Seclusion and Restraints
Definition and Purpose
Seclusion: Involuntary confinement where a patient is prevented from leaving for safety or behavioral management.
Environment: Must be safe (e.g., avoiding windows, outlets, and harmful devices). Continual observation is mandatory to ensure safety and monitor comfort.
Restraints
Definition: Any manual, physical, or mechanical method used to immobilize or reduce a patient’s ability to move freely.
Types of Restraints:
Wrist Restraints: Commonly used to prevent movement.
Chair Restraint: Limits mobility and usage of limbs.
Chemical Restraints: Medication used to restrict movement or control behavior, debated on restrictiveness versus physical restraints.
Care Standards and Legal Implications
Negligent Care and Legal Liability
Malpractice: Significant legal risk involving inappropriate patient care.
Assault and Battery:
Assault: Threatening harm (e.g., threatening to restrain a patient).
Battery: Unpermitted contact leading to harm (e.g., treatment without consent).
False Imprisonment: Inappropriately restraining a patient without proper legal grounds or assessments.
Negligence: Defined as failure to provide reasonable care leading to patient injury; requires five elements to prove (duty, breach, cause-in-fact, proximate cause, and damages).
The Impact of Mental Illness on Criminal Justice
Higher Risk of Arrest: Individuals with severe mental illnesses are disproportionately represented in the criminal justice system; nearly 40% of incarcerated individuals have mental health histories.
Forensic Settings: Individuals may transition through various community and institutional care environments (e.g., state hospitals, transitional units, day treatment).
Nine Eleven Program: Highlights treatment pathways for those deemed not guilty by reason of insanity (NGRI), which leads to involuntary commitments for treatment.
Insanity Defense and Mental Health Law
Misconceptions and Legal Standards
Insanity Defense: Often misunderstood; must involve complex evaluations and legal processes.
Evolving Laws: John Hinckley’s acquittal led to significant changes in insanity defense applications across various states, leading to stricter regulations and oversight.
Gun Laws Relation: The Brady Handgun Violence Prevention Act restricts firearm purchases to ensure that individuals with severe mental illnesses cannot obtain weapons.
Documentation and Ethical Framework in Psychiatric Nursing
Importance of Documentation
Legal and Ethical Obligations: Documentation must reflect appropriate care and follows legal standards; potential for scrutiny in legal implications.
Patient Access: Patients may access their own medical records, necessitating clear, non-judgmental documentation.
Ethical Principles in Psychiatric Nursing
Respect for Autonomy: Supporting the patient's right to make the best decisions for themselves.
Beneficence: The duty to act in the patient's best interest and enhance their welfare.
Nonmaleficence: Duty to avoid inflicting harm on others.
Justice: Fair treatment and distribution of resources regardless of personal circumstances.
Veracity: Commitment to honesty and transparency with patients.
Fidelity: Upholding obligations and responsibilities toward patients.
Paternalism: The need to avoid imposing decisions on patients, considering their individual circumstances and rights.
Standards of Practice
Nursing Process: The assessment of patients, diagnosis, planning, implementation, and evaluation are crucial, emphasizing continuous and evolving care.
Interprofessional Collaboration: Engagement with the healthcare team is critical for comprehensive patient care and effective planning.
Documentation Practices
Accuracy and Clarity: Documentation should be detailed, meaningful, and adhere to professional standards.
Legal Status: Records are legally binding and subject to review during litigation; therefore, adherence to standards is paramount.
Next Steps
Ethical Standards and Frameworks: Further explore the ethical principles guiding psychiatric nursing as detailed in the next chapter.