Ethical Concepts

Beneficence

  • Definition: The obligation to help the patient by removing harm, preventing harm, and promoting good; acting in the patient’s best interest; core principle in patient advocacy; aligns with compassionate patient care.
  • Key commitments: do no harm; actively seek to improve patient well-being.
  • Examples:
    • Educating a patient with a new prescription about how to take the medication.
    • Encouraging a patient to stop smoking and enroll in a smoking-cessation program.
    • Prescribing or advocating for effective postoperative pain medication.

Nonmaleficence

  • Definition: The obligation to avoid harm and protect the patient from harm.
  • Example: A middle-aged woman with osteoporosis desires bisphosphonates; NP evaluates and identifies past GI bleeding and peptic ulcer disease making her a poor candidate; NP decides not to prescribe.

Utilitarianism

  • Definition: The obligation to act in a way that is useful to or benefits the majority; the outcome of the action matters.
  • Resource-use emphasis: e.g., tax money should be used for the benefit of most people.
  • Relationship to justice: may resemble justice but is not the same concept.
  • Example: WIC program limited to pregnant women, infants, and young children to prevent harm to brain growth if food intake is inadequate.

Justice

  • Definition: Fairness and lack of bias; equitable distribution of societal resources.
  • Example: A patient with alcoholism, who is homeless and uninsured, receives triage and ED treatment in the same manner as insured patients.

Dignity

  • Definition: The quality or state of being worthy of ethical and respectful treatment.
  • Significance: Respect for human dignity is central; beliefs (religious, cultural, personal) influence what is considered dignified care.
  • Examples:
    • Hospital gowns secured correctly so back isn’t exposed when patient stands.
    • Foley catheter urine bags not visible to visitors; move bags to the opposite bed rail to avoid embarrassment.

Fidelity

  • Definition: The obligation to maintain trust in relationships; dedication and loyalty to patients; keeping promises.
  • Example: Building and maintaining a trusting relationship between a patient and their healthcare team; NP aims to be diligent in this trust.

Confidentiality

  • Definition: The obligation to protect patient identity, personal information, test results, and medical records.
  • Legal protection: HIPAA safeguards patient information; psychiatric/mental health records require separate handling.
  • PHI: Protected Health Information includes demographic data and past, present, or future health information.
  • Example/Rule: HIPAA Privacy Rule protects most PHI in any format (oral, paper, electronic).

Autonomy

  • Definition: The obligation to ensure mentally competent adults can make their own health decisions and express treatment preferences.
  • Surrogate decision-making: If the patient is incapacitated, a designated surrogate’s choices are respected; advance directives discussed later.
  • Example: An alert elderly woman with breast cancer chooses lumpectomy after discussion; adult children oppose due to perceived age; NP respects the patient’s decision.

Accountability

  • Definition: Healthcare providers are responsible for their own choices and actions; do not blame others for mistakes.
  • Example: NP misdiagnoses pleurisy as acute bronchitis; patient experiences MI; NP is held accountable in a court of law.

Paternalism

  • Definition: Interfering with or over-ruling another’s autonomy; when providers or family members decide what’s best for a patient, minimizing or ignoring the patient’s preferences.

Veracity

  • Definition: Obligation to present information honestly and truthfully; provide information needed for informed decisions; do not withhold pertinent information.
  • Example: A mammogram result highly indicative of breast cancer; adult children don’t want the mother to know; NP must discuss results with the patient and refer to a breast surgeon.

The American Nurses Association (ANA) Code of Ethics for Nurses

  • Purpose: The ethical standard for the nursing profession; a guide for ethical analysis and decision-making.
  • Characterization: Nonnegotiable ethical standard; nurses must demonstrate ethical competence.
  • Provision 4.4 (example): Nurses may not delegate responsibilities such as assessment and evaluation; they may delegate selected interventions according to state nurse practice acts.
  • Source reference: ANA Code of Ethics with Interpretive Statements (2015).

Legal Terms

  • Ombudsman: Intermediary between patient and organization (e.g., LTCFs, hospitals, courts); investigates and mediates complaints to reach fair conclusions.
  • Guardian Ad Litem: Court-appointed guardian with legal authority to act in the best interest of a ward (child or vulnerable adult); can be assigned for adults who are incompetent.
  • Advance Healthcare Directives
    • Living Will: Document outlining patient preferences for healthcare if seriously ill or dying; includes preferences for aggressive life-support; copy should be in patient’s chart.
    • Healthcare Power of Attorney (healthcare proxy, durable medical power of attorney, or healthcare surrogate): Designates a person to make future healthcare decisions if the patient becomes incapacitated; effective when doctor determines the patient cannot communicate; must be signed in the presence of two adult witnesses (witnesses cannot be the designated surrogate); power reserved for healthcare decisions only.
    • Power of Attorney (durable POA): Broad document designating an agent to make all decisions for the incapacitated patient, including financial affairs; must be signed and notarized.
  • HIPAA (Health Insurance Portability and Accountability Act): Also known as the HIPAA Privacy Rule; Public Law 104-191; protects the use and disclosure of PHI by covered entities.
  • Covered Entities: All healthcare providers, health plans, laboratories, hospitals, SNFs, etc., that electronically transmit health information and must follow HIPAA.
  • Third-Party Administrator (TPA): Organization that processes claims and administrative work for another company (e.g., health insurer, health plan, retirement plan).

HIPAA: What Is It and Who Must Follow It

  • Overview: Enacted August 1996; protects use/disclosure of individuals’ health information (PHI) by covered entities.
  • Covered Entities: Healthcare providers, health plans, and other entities that electronically transmit health information.
  • PHI: Protected Health Information; includes demographics (name, address, DOB, SSN) plus health status and care provision.

HIPAA Requirements (Not All-Inclusive)

  • Policies and Consent:
    • Health providers must provide each patient with a copy of the office’s HIPAA policy; patient must sign.
    • HIPAA policy form must be reviewed and signed annually by the patient.
  • Mental Health Records:
    • Mental health providers may refuse requests to view psychiatric/mental health records.
    • When patients request to review records, providers have up to 30 days to comply.
    • Patients may correct errors in their medical records.
  • Privacy Protections: Providers must keep identifying information and health information private except under listed conditions.
  • Practical Tips:
    • Understand roles of ombudsman, guardian ad litem, and others acting on behalf of the patient.
    • A TPA processes claims for another company.
  • When Patient Consent Is Not Required (examples):
    • To contact the paying health plan/insurance company.
    • To contact a third party or business associate (e.g., accounting, legal) hired to assist in payment of services.
    • To perform certain healthcare operations (medical services review, plan audits).
    • To contact a collection agency for unpaid bills.
    • To report abuse/neglect or domestic violence.
    • To consult with other healthcare providers.

HIPAA Case Scenarios

  • Staff member not involved in patient’s care cannot have information released to them.
  • Communicating lab results or procedures: HIPAA does not prohibit leaving messages for patients on answering machines, but privacy must be reasonably safeguarded; avoid leaving messages containing lab results, medication names, or test types; include clinic name, your name, and a call-back phone number.

HIPAA, Psychotherapy, and Mental Health Records

  • Psychotherapy records are treated separately under HIPAA and must be kept distinct from other medical records.
  • A separate consent is required to release psychotherapy records.
  • Exceptions: Mandatory reporting of abuse and duty to warn when patient threatens serious and imminent harm to others.
  • If patient is given opportunity and does not object, HIPAA allows sharing mental health information with family or others involved in care or payment.
  • Source reference: U.S. Department of Health and Human Services (2017).

Minors

  • Minor health records (under 18) can be released to parents or legal guardians without the minor’s consent.
  • If authorization is needed, parent/guardian must sign (except for emancipated minors).
  • Emancipated minors may sign their own legal documents.

Malpractice Insurance

  • Types:
    • Claims-Based Policy: Covers claims only if the incident occurred while the NP paid the premium and is enrolled with the same insurer at the time the claim is filed. If the NP changes insurers, the claim may not be covered. Tail coverage can mitigate this risk.
    • Occurrence-Based Policy: Not affected by job changes or retirement; if a claim is filed later for an incident that occurred while insured under the policy, it is covered.
  • Tail Coverage: Insurance that covers claims filed after retirement or job change for incidents that occurred while insured.
  • Practical example: A retired NP with a claims-based policy may not be covered for a claim filed years later unless they purchased tail coverage.

Malpractice Lawsuits

  • Plaintiff: The person or representative filing suit alleging injury or damage due to another party’s actions.
  • Defendant: The party responding to the lawsuit (e.g., NP, hospital).
  • Elements of a Case: The plaintiff must prove all of the following:
    • Duty owed (legal duty exists).
    • Duty was breached (not meeting the standard of care).
    • Breach caused injury (proximate cause).
    • Damages occurred.

Phases of a Medical Malpractice Trial

  • Steps:
    • Lawsuit filed in the appropriate court.
    • Discovery phase (requesting medical records, depositions, expert opinions).
    • Plaintiff bears the burden of proof.
    • Court trial or settlement/arbitration.
    • Judgment issued.
    • Case dismissed or damages awarded (physical or emotional/mental harm).

Expert Witnesses

  • Ideal expert should practice in the same specialty and geographic area as the defendant NP.
  • Example: An NP in Los Angeles testifying for a case involving an NP in Miami may not be the best choice due to geographic practice differences.