NURS 112: Exhaustive Notes on Ethical and Legal Issues in Nursing

Learning Competencies and Ethical Foundations

• The course aims to describe the steps in ethical decision-making models and specify strategies helpful to nurses.
• Students must identify ethical dilemmas common to medical-surgical nursing and discuss the nurse’s role in obtaining informed consent.
• A primary competency involves describing the role of the nurse in counseling patients who wish to sign advance directives.
• The material explores advance directives as a means of preventing ethical dilemmas and examines personal concepts regarding end-of-life (EOL) issues.
• The guide covers the comparison of rights versus involuntary hospitalization and the application of ethical decision-making guides to specific dilemmas.
• Emphasis is placed on analyzing the impact of cultural diversity in ethical decision-making.

Ethical Theories

• Utilitarianism: An ethical theory focused on the greatest good for the greatest number of people.
• Deontology: Focuses on the rightness or wrongness of actions themselves, rather than the consequences (duty-based ethics).
• Consensus in Bioethics: Seeking general agreement among different ethical viewpoints.
• Ethic of Care: Emphasizes the importance of relationships and the context of ethical dilemmas.
• Natural Law: A philosophy that certain rights are inherent by virtue of human nature.
• Religious: Ethical frameworks derived from religious texts and traditions.

Professional Codes of Ethics

• American Nurses Association (ANA) Code of Ethics:
  • Comprised of $9$ provisions organized into three focus areas:
    1. Values & Commitments of the Nurse.
    2. Boundaries of Duty & Loyalty.
    3. Duties Beyond Patient Encounters.
  • Specific Provisions/Principles:
    • Practice with compassion and respect for every person.
    • The primary commitment is to the patient.
    • Every client is unique, has worth, and deserves treatment with dignity.
    • Promotion, advocacy for, and protection of the rights, health, and safety of the patient.
    • Authority, accountability, and responsibility for nursing practice.
    • Owning the same duties to self as to others.
    • Establishing, maintaining, and improving the ethical environment of the work setting.
    • Advancing the profession through research and scholarly inquiry.
    • Collaborating to protect human rights, promote health diplomacy, and reduce health disparities.
    • Articulating nursing values and integrating social justice into health policy.
• International Council of Nurses (ICN) Code of Ethics:
  • A supranational code addressing four core elements:
    1. Clients and others seeking healthcare.
    2. Practice of nursing.
    3. Professional responsibilities of the nurse.
    4. Global health.

Values of the Nursing Profession

• Altruism: Concern for the welfare and well-being of others.
• Human Dignity: Respect for the inherent worth and uniqueness of individuals.
• Integrity: Acting in accordance with an appropriate code of ethics and accepted standards of practice.
• Autonomy: Promoting the patient's right to self-determination and independent decision-making.
• Social Justice: Upholding moral, legal, and humanistic principles related to fairness.

Ethical Dilemmas and Principles

• Defining Ethical Dilemmas: Occur when moral appeals can be made for two opposing courses of action. Taking no action is itself an action taken.
• Common Areas of Conflict:
  • Life and death decisions.
  • Quality of Life (QoL).
  • The right to decide.
  • Informed consent.
  • Alternative treatment issues.
  • Social and technological changes.
• Ethical Principles for the Client:
  • Beneficence: Taking positive actions to help others (doing good).
  • Autonomy: Ensuring the client has the right to make their own decisions.
  • Justice: Fairness in care delivery and use of resources.
  • Fidelity: Keeping promises and being faithful to commitments.
  • Nonmaleficence: The obligation to do no harm.
  • Veracity: The duty to tell the truth.
• Ethical Responsibilities for the Nurse:
  • Advocacy, Responsibility, Accountability, and Confidentiality.

Process for Ethical Decision-Making

• Step $1$: Is there an ethical dilemma?
• Step $2$: Clearly identify the ethical dilemma.
• Step $3$: Identify possible solutions.
• Step $4$: Apply ethical principles to the solutions.
• Step $5$: Include all relevant individuals and factors.
• Step $6$: Decide on a solution.
• Step $7$: Review the decision.
• Step $8$: Put the decision into action.

Case Study: "The Confidential Diagnosis"

• Scenario: Emma, a first-year nursing student, is observing care for Mr. Johnson, a $45$-year-old admitted for pneumonia complications. Emma sees his HIV diagnosis in the chart. Mr. Johnson requested that his status not be shared with family. His wife asks Emma, "Do you know what's really going on with my husband? The doctors aren't telling me everything."
• The Dilemma: Respecting patient confidentiality against the urge to disclose information to protect the spouse who may be at risk.
• Questions & Discussion:
  • Emma's best initial response: "I can't share that information, but I can ask the nurse to speak with you."
  • Principle involved: Autonomy is the most direct principle involved in deciding to keep the HIV status private, as it respects the patient's right to control his health information.

Impact of Ethical Stress on Nurses

• Moral Distress: Results from exposure to unethical practices, lack of autonomous decision-making, or hesitancy to address unethical practices.
• Burnout: General exhaustion and lack of motivation due to prolonged workplace stress.
• Compassion Fatigue: A state of physical and emotional exhaustion that reduces the ability to sympathize or feel compassion for others.

Patient Bill of Rights and Confidentiality

• Clients retain rights as individuals and citizens even while receiving healthcare.
• Rights include Confidentiality, Information Security, Informed Consent, Advance Directives, and the Refusal of Care.
• HIPAA (Health Insurance Portability and Accountability Act):
  • Governs sharing of written and verbal information.
  • Information should only be shared with those responsible for implementing care.
  • Prohibits discussing care in public places or on social media.
• Dead Man’s Statute: Relates to confidentiality after death.
• Exceptions to HIPAA:
  • Duty to Warn: When a patient poses a threat to a specific individual.
  • Mandatory Reporting: Situations such as abuse.
  • Communicable Disease: Reporting required for specific diseases as listed by CDC.gov.

Informed Consent Responsibilities

• Provider Responsibility:
  • Explain proposed treatment/procedure and who will perform it.
  • Clarify purpose, expected outcomes, benefits, and risks.
  • Discuss alternatives and their associated benefits/risks.
  • Inform the patient of their right to refuse.
• Client/Patient Responsibility:
  • Must be voluntary and competent.
  • Must be of legal age or an emancipated minor ($18$ in most jurisdictions; mature adolescents may sign an assent).
  • If unable to consent, an authorized person (DPOA, legal guardian, parent) must provide it.
  • Must understand what will happen based on provided information.
• Nurse Responsibility:
  • Know the legal age and state laws.
  • Witness the signature.
  • Ensure the provider gave necessary information and the client understood it.
  • Notify the provider if the client has questions or lacks understanding.
  • Document questions, notifications, reinforcement of education, and use of medical interpreters (for hearing or language impairments).

Advance Directives

• Purpose: To communicate wishes regarding end-of-life and medical treatment.
• NH General Court Statute (RSA 137-J:1):
  • Recognizes the right to control medical decisions based on autonomy and sanctity.
  • Recognizes directives that delegate authority to an agent if the person lacks capacity (temporarily or permanently).
  • Permits instruction to withhold or withdraw life-sustaining treatment if near death or permanently unconscious.
  • Includes the right to refuse cardiopulmonary resuscitation (CPR).
• Types of Legal Documents:
  • Living Will: Communicates treatment wishes; should be shared with loved ones and doctors.
  • Psychiatric Advanced Directives (PAD): Helpful for mental health treatment wishes.
  • DPOAHC (Durable Power of Attorney for Healthcare): Appoints an agent/proxy. Limitations: Cannot be the healthcare provider, residential care provider, or their employees.
  • POLST/MOLST: Physician/Medical Orders for Life-Sustaining Treatment.
  • Portable DNR (P-DNR).
• Nurse's Role with ADs:
  • Ask all patients upon admission if they have them.
  • Document status and provide written information.
  • Ensure directives reflect current wishes and inform the healthcare team.
  • Act as an advocate.

Determination of Capacity and Competency

• Competency: A global assessment and legal determination made by a judge in court.
• Capacity: A functional assessment and clinical determination about a specific decision, made by a clinician.
• Four Key Components of Capacity Assessment:
  1. Communication.
  2. Understanding.
  3. Appreciation.
  4. Rationalization/Reasoning.
• Cognitive Assessment Areas: Orientation, speech, thought process, memory, insight/judgment, attention, and concentration.

Mental Health Settings and Involuntary Admission

• Client Rights:
  • Right to informed care and right to refuse.
  • Freedom from harm due to restraints, seclusion, abuse, or neglect.
  • Use of the least restrictive intervention.
  • Mental Health Parity and Addiction Equality Act ($2008$).
• Types of Admission:
  • Informed/Voluntary.
  • Temporary emergency.
  • Involuntary / Long-term Involuntary.
• Involuntary Emergency Admission (IEA) in New Hampshire:
  • Initiated via petition when a personal safety emergency occurs.
  • Hold begins upon initiation but the formal process takes effect when the patient is at a Designated Receiving Facility (DRF).
  • Hearing must occur within $72$ hours of admission to the DRF to determine probable cause.
  • If probable cause is found, the client may be held for a period not exceeding $10$ days from the date of admission.

Psychiatric Ethics and Control of Behavior

• Autonomy is the priority; if autonomy is not possible, the principle of beneficence is used.
• Ethical Challenges: Issues with behavior-controlling interventions like involuntary admission, seclusion, physical restraints, and chemical restraints.
• Case Study: J.S.:
  • $28$-year-old male found yelling and threatening others. Disoriented, paranoid, hearing voices to harm self.
  • Provisional Diagnosis: Acute psychosis with risk of harm to self/others.
  • Constraints: Placed on involuntary psychiatric hold; guardian is mother; seclusion used for safety.
  • Principles applied: Autonomy, Beneficence, Nonmaleficence, Veracity, and Fidelity.