Ethical and Legal Issues in Patient Care – Key Vocabulary

Objectives

• Differentiate between ethics and bioethics

• Identify ethical dilemmas in nursing practice

• Discuss the nurse’s role in advance directives and end-of-life care

• Review principles and models of ethical decision-making

• Identify interventions that protect patients’ rights (legally and ethically)

• Discuss the responsibilities and composition of an ethics committee

• Differentiate negligence from malpractice and list required legal elements

• Explain why nurses are especially at risk for legal action

• Identify key issues in documentation / charting

• Review common risk factors in health-care settings

• Summarize the essential content of each state’s Nurse Practice Act (NPA)

Ethics vs. Bioethics

• Ethics

  • Science of right vs. wrong, good vs. bad

  • Grounded in personal values, morals, culture, religion, philosophy

• Bioethics

  • Sub-category specific to health-care delivery

  • Focus on life, death, and quality-of-life questions arising from technology

• Personal Morals / Values

  • Internal guides that shape day-to-day decisions and professional conduct

Common Contemporary Ethical Dilemmas in Nursing

• Life-support technology for severely premature infants

• Life-support for patients with devastating neurological injury

• Stem-cell research and embryonic tissue use

• Organ transplantation / donor allocation systems

• End-of-life decisions: DNR, withdrawal of treatment, palliative sedation

• Health-care business ethics: access, equity, cost containment

Core Ethical Principles & Their Bedside Rules

• Beneficence – Duty to actively do good and safeguard patient welfare

  • e.g., strict adherence to infection-control protocols for every patient

• Nonmaleficence – Obligation to do no harm

  • Maintain competence; practice within scope to avoid preventable harm

• Justice – Fairness; equal and culturally competent care for all

• Autonomy – Respect for individual liberty / self-determination

  • Informed consent embodies autonomy

• Fidelity – Keeping one’s promises/commitments (organizational & personal)

• Respect for Persons – Foundation for all other duties; never treat people as mere means

• Veracity – Obligation to tell the truth; disclose errors promptly

Patient Self-Determination Act (PSDA)

• Federal law affirming patient right to make prospective decisions

• Competent individuals may refuse care or leave \text{AMA}

• When not competent or unresponsive, wishes communicated through:

  • Advance Directives (AD)

  • Living Will

  • Durable Power of Attorney (DPA) for Health Care

  • Health-Care Proxy

  • POLST (Physician Order for Life-Sustaining Treatment)

• Patients have legal right to inspect and obtain copies of their chart

Classic Ethical Theories (Box 17-1)

• Utilitarianism

  • Action judged by consequences; choose option producing the greatest good for the greatest number

  • Ex: Mandatory treatment of infectious tuberculosis protects public health

• Teleology / Consequentialism

  • Morality = outcome; "\text{All’s\ well\ that\ ends\ well}" approach

• Deontology / Formalism

  • Duty-based; action is moral only if it arises from good will, regardless of outcome (means > ends)

Professional Codes of Ethics

American Nurses Association (ANA) – Code of Ethics (Revised)

• Practice with compassion and respect for every person

• Primary commitment = patient (individual, family, community)

• Advocate, protect, and promote health, safety, rights

• Exercise authority, accountability, responsibility

• Same duty to self as to others (self-care, growth)

• Create/maintain ethical work environment

• Advance the profession (research, policy, scholarly inquiry)

• Collaborate to protect human rights, diplomacy, reduce disparities

• Profession articulates values, integrity & social justice

International Council of Nurses (ICN) – International Code

• Actions guided by social values & global needs

• Primary responsibility to people needing nursing care

• Accountable for own practice & standards development

• Cooperate with colleagues in nursing & other disciplines

Advance Directives & End-of-Life Instruments

• Advance Directive / Living Will – Written instructions about medical care before incapacity

• DNR (Do-Not-Resuscitate)

  • Legally binding MD order; no CPR if cardiac/resp arrest

  • Must reflect patient/proxy wishes & be documented, signed, dated

• AND (Allow Natural Death) – Positive phrasing emphasizing comfort care

• POLST

  • Portable MD order (hot-pink form in NV) valid across settings

  • Central registry (goal); legally binding & actionable by EMS

• Durable Power of Attorney for Health Care

  • Legal designation of surrogate decision-maker

• Health-Care Proxy – Similar term granting decision authority when patient incapacitated

Organ Donation & Procurement

• Declaration can be indicated on driver’s license; final family consent sometimes disputed

• Only 58 federally designated Organ Procurement Organizations (OPOs) may recover organs

• Hospitals must refer all deaths to OPO for evaluation

• Ethical controversies:

  • Internet solicitation for organs

  • Organ purchasing / market systems

  • Allocation priority: healthiest vs sickest candidates?

• Many hospitals employ donation coordinators / committees

Futility of Care

• When further treatment offers no reasonable benefit vs burden

• Tension between beneficence and nonmaleficence

• Ethics committee consultation advisable

• Families may misinterpret DNR; clarify "AND" concept

• POLST offers granular treatment choices (e.g., antibiotics, nutrition)

Organizational Ethics & Corporate Compliance

• Each unit must set an ethical culture; protect patient & staff rights

• Managers practice ethical leadership; ensure staff free to report concerns (whistle-blower protection)

• Patient Care Partnership (AHA) replaced Patient Bill of Rights; educates patients on rights & responsibilities

• Key organizational questions:

  • Obligation to treat uninsured?

  • How to balance justice with resource limitations?

• Hospitals maintain Corporate Compliance departments to monitor adherence to legal/ethical standards (treatment decisions, informed consent, nondiscrimination, accurate billing)

Research & Institutional Review Boards (IRBs)

• Nursing research = generation of new knowledge → must protect human subjects

• IRB responsibilities:

  • Ensure risks < potential benefit

  • Equitable subject selection

  • Obtain & document informed consent

• Nurse researchers / staff must be familiar with federal, state, and facility regulations

Legal Framework for Nursing Practice

Licensing & NCLEX

• Passing NCLEX-RN (or PN) → initial licensure

• License issued by state board of nursing; authorizes practice to minimum entry competence

Nurse Practice Acts (NPA)

• Statutes that:

  • Defines scope of nursing practice by law

  • Sets educational, examination, and licensing requirements

  • Regulates nursing profession in each state

  • Creates state boards of nursing

  • Authorizes BON to discipline violators (probation, suspension, revocation)

• NPAs vary by state – nurses must know provisions in every state where licensed or practicing (e.g., telehealth across state lines)

National Council of State Boards of Nursing (NCSBN)

• Clearinghouse for interstate disciplinary actions; promotes uniform regulation (e.g., licensure compact)

  • Ensures that individual state actions are enforced in all states

  • Created the NCLEX

Nevada State Board of Nursing (Example)

• Mission: Protect public health, safety, welfare via nursing regulation (est. 1923)

• Seven members appointed by Governor

• Licenses, certifies, disciplines > 33{,}000 nurses/CNAs/APRNs

• Enforces Nevada NPA, investigates complaints:

  • Practice outside scope

  • Impaired practice / substance abuse

  • Negligence or abuse

  • Fraud (practicing without license)

Corporate Liability Duties

• Hire, supervise and retain qualified staff

• Provide, inspect, repair, and maintain safe equipment

• Maintain a safe physical environment (e.g., lighting, fall-prevention hardware)

Malpractice

• Defined as "misconduct or lack of skill while carrying out professional duties"

• Five legal elements (all must be proven):

  1. Duty – Automatic once nurse-patient relationship exists

  2. Breach of Duty – Act/omission outside standard of care

  3. Foreseeability / Causation – Breach directly caused injury

  4. Injury / Harm – Physical, emotional, financial damage

  5. Damages – Monetary compensation for patient loss

• Typical nursing malpractice claims: medication errors, falls, improper restraints, failure to monitor, failure to follow policy, equipment misuse

• Recommended: Purchase individual malpractice insurance even if employer has blanket policy

Negligence

• Failure to act as a reasonably prudent person would in similar circumstances (can be layperson or professional)

• May be commission (wrong action) or omission (no action)

Tort Law

• Civil wrongs that result in injury or violation of rights

• Unintentional: negligence, malpractice

• Intentional: assault, battery, false imprisonment, invasion of privacy, defamation

Intentional Torts in Nursing Examples

• Assault – Threat of harmful/offensive contact (e.g., "If you don’t take this injection I’ll strap you down")

• Battery – Actual unconsented contact (e.g., administering injection against capable patient’s refusal)

• False Imprisonment – Unlawful restraint or detaining competent patient (e.g., blocking door for AMA patient)

Documentation Standards (FLAT)

• Factual – objective, no opinions or blame

• Legible – readable handwriting / approved abbreviations

• Accurate – correct data, times, spelling, signatures

• Timely – chart at or near time of occurrence; late entries labelled

• Incomplete or altered records undermine legal defense

Incident Reports

• Tool for internal risk-management (NOT part of medical record)

• Provide factual account of unusual/adverse events

• Used to aggregate data & implement system improvements

HIPAA & Confidentiality

• Health Insurance Portability and Accountability Act (1996)

• Patients control how protected health information (PHI) is used/disclosed

• Organizations must safeguard electronic, paper, verbal PHI; breaches subject to civil & criminal penalties

Informed Consent – 3 Legal Elements

1. Information / Knowledge – Risks, benefits, alternatives explained

2. Competence – Patient (or proxy) can understand & decide

3. Voluntariness – Free of coercion; may withdraw anytime

• Nurse role: witness signature, advocate for understanding, notify provider of concerns

Patient Restraints (CMS / TJC Standards)

• MD/NP order required – specifies type, reason, time limit (no PRN)

• Ongoing assessment & documentation per policy (e.g., circulation, toileting, skin care)

• Use least-restrictive alternative first; obtain informed consent (patient or proxy)

Good Samaritan Laws

• Encourage professionals to render emergency aid outside work

• Provide immunity from civil liability for ordinary negligence (gross negligence still liable)

• Care must be within scope & no compensation given

What Nurses Must Know & Do

• Keep current address with every BON where licensed

• Know and follow their specific NPA & facility policies

• Maintain competence; practice within scope

• Advocate for patient rights & safety

• Document accurately (FLAT) to reduce liability

• Carry personal malpractice insurance as added protection

Key Takeaways / Summary

• Ethics = principles of right/wrong; Bioethics = ethics in health care

• Ethical principles (beneficence, nonmaleficence, justice, autonomy, fidelity, veracity, respect) guide decision-making

• ANA & ICN codes provide professional ethical standards

• Legal foundation: Nurse Practice Acts, BON regulations, tort law, malpractice standards

• Advance directives, DNR, POLST, and organ donation respect patient autonomy & guide end-of-life care

• Nurses must protect confidentiality (HIPAA), secure informed consent, and adhere to documentation standards

• Ethics committees, corporate compliance, and IRBs support ethical practice at organisational level

• Knowing state-specific regulations and maintaining competence are critical to minimise legal risk and uphold patient safety