MENTAL HEALTH: CHAPTER 9: LEGAL & ETHICAL ISSUES:

Which of the following would be considered an unintentional tort? A. Malpractice B. Assault C. Battery D. False imprisonment

A. Malpractice - Rationale: Malpractice is an unintentional tort. o Assault, battery, and false imprisonment are intentional torts.

Is the following statement true or false? The greatest good for the greatest number reflects the deontologic ethical theory.

False - Rationale: Deontologic theory bases decisions on whether an action is morally right or wrong, without regard for the consequences. o Utilitarianism bases decisions on "the greatest good for the greatest number."

Is the following statement true or false? Mental health clients who are hospitalized voluntarily give up their right to leave the hospital.

False - Rationale: Mental health clients who are hospitalized voluntarily retain all the civil rights afforded to any person, including the right to leave the hospital. o However, clients hospitalized involuntarily give up this right.

Intentional Torts: Battery:

- Involves harmful or unwarranted contact with a client; actual harm or injury may or may not have occurred. - Examples include touching a client without consent or unnecessarily restraining a client

Duty:

- A legally recognized relationship (i.e., physician to client, nurse to client) existed. - The nurse had a duty to the client, meaning that the nurse was acting in the capacity of a nurse.

Self-Awareness Issues:

- All nurses have beliefs about what is right or wrong and good or bad. - That is, they have values just like all other people. - Being a member of the nursing profession, however, presumes a duty to clients and families under the nurse's care: a duty to protect rights, be an advocate, and act in the clients' best interests even if that duty is in conflict with the nurse's personal values and beliefs. - The nurse is obligated to engage in self-awareness by identifying clearly and examining his or her own values and beliefs, so they do not become confused with or overshadow a client's. - For example, if a client is grieving over her decision to have an abortion, the nurse must be able to provide support to her even though the nurse may be opposed to abortion. - If the nurse cannot do that, then he or she should talk to colleagues to find someone who can meet that client's needs.

Who Makes Restrictions To Civil Rights?

- All restrictions to civil liberties must be made by the court or decision-making person (nurse/treatment team) and be verifiable and documented

Ethical Dilemmas In Mental Health:

- An ethical dilemma is a situation in which ethical principles conflict or when there is no one clear course of action in a given situation. - For example, the client who refuses medication or treatment is allowed to do so on the basis of the principle of autonomy. - If the client presents an imminent threat of danger to him or herself or others, however, the principle of non-maleficence (do no harm) is at risk. - To protect the client or others from harm, the client may be involuntarily committed to a hospital, even though some may argue that this action violates his or her right to autonomy. - In this example, the utilitarian theory of doing the greatest good for the greatest number (involuntary commitment) overrides the individual client's autonomy (right to refuse treatment) - . Ethical dilemmas are often complicated and charged with emotion, making it difficult to arrive at fair or "right" decisions. - The legal aspect of an action is behavior that is allowed or required by law—there is almost always a clear "answer" to a question about the legality of an action. - The ethical aspect of an action involves what is "right," or what a person should do - . The answer is not always clear, and there is often more than one possible course of action. - Ethical points of view are influenced by values, opinions, and beliefs. - Many dilemmas in mental health involve the client's right to self-determination and independence (autonomy) and concern for the "public good" (utilitarianism). Examples include the following: •Once a client is stabilized on psychotropic medication, should the client be forced to remain on medication through the use of enforced depot injections or through outpatient commitment? •Are psychotic clients necessarily incompetent, or do they still have the right to refuse hospitalization and medication? •Can consumers of mental health care truly be empowered if health care professionals "step in" to make decisions for them "for their own good?" •Should physicians break confidentiality to report clients who drive cars at high speeds and recklessly? •Should a client who is loud and intrusive to other clients on a hospital unit be secluded from the others? •A health care worker has an established relationship with a person who later becomes a client in the agency where the health care worker practices. Can the health care worker continue the relationship with the person who is now a client? •To protect the public, can clients with a history of violence toward others be detained after their symptoms are stable? •When a therapeutic relationship has ended, can a health care professional ever have a social or intimate relationship with someone he or she met as a client? •Is it possible to maintain strict professional boundaries (i.e., no previous, current, or future personal relationships with clients) in small communities and rural areas, where all people in the community know one another? - The nurse will confront some of these dilemmas directly, and he or she will have to make decisions about a course of action. - For example, the nurse may observe behavior between another health care worker and a client that seems flirtatious or inappropriate. - Another dilemma might represent the policies or common practice of the agency where the nurse is employed; the nurse may have to decide whether he or she can support those practices or seek a position elsewhere. - An example would be an agency that takes clients with a history of medication noncompliance only if they are scheduled for depot injections or remain on an outpatient commitment status. - Additional dilemmas are in the larger social arena; the nurse's decision is whether to support current practice or to advocate for change on behalf of clients, such as laws permitting people to be detained after treatment is completed when there is a potential of future risk for violence.

Release From The Hospital:

- Clients admitted to the hospital voluntarily have the right to leave, provided they do not represent a danger to themselves or others. - They can sign a written request for discharge and can be released from the hospital against medical advice. - If a voluntary client who is dangerous to him or herself or to others signs a request for discharge, the psychiatrist may file for a civil commitment to detain the client against his or her will until a hearing can take place to decide the matter. - While in the hospital, the committed client may take medications and improve fairly rapidly, making him or her eligible for discharge when he or she no longer represents a danger. - Some clients stop taking their medications after discharge and once again become threatening, aggressive, or dangerous. - Mental health clinicians increasingly have been held legally liable for the criminal actions of such clients; this situation contributes to the debate about extended civil commitment for dangerous clients.

Least Restrictive Environment:

- Clients have the right to treatment in the least restrictive environment appropriate to meet their needs. -. It means that a client does not have to be hospitalized if he or she can be treated in an outpatient setting or in a group home. - It also means that the client must be free of restraint or seclusion unless it is necessary. - The Joint Commission develops and updates standards for restraint and seclusion as part of their accreditation procedures. - This is usually done every 2 years with accreditation manuals provided to facilities and organizations that are or seek to be accredited. - Otherwise, these standards are available for purchase only.

Rights Of Clients:

- Clients receiving mental health care retain all civil rights afforded to all people except the right to leave the hospital in the case of involuntary commitment - They have the right to refuse treatment, to send and receive sealed mail, and to have or refuse visitors. - Any restrictions (e.g., mail, visitors, clothing) must be made for a verifiable, documented reason. - These decisions can be made by a court or a designated decision-making person or persons, for example, a primary nurse or treatment team, depending on local laws or regulations. Examples include: •A suicidal client may not be permitted to keep a belt, shoelaces, or scissors because he or she may use these items for self-harm. •A client who becomes aggressive after having a particular visitor may have that person restricted from visiting for a period of time. •A client making threatening phone calls to others outside the hospital may be permitted only supervised phone calls until his or her condition improves

Important Note:

- Clients receiving mental health services retain all civil rights except right to leave hospital if they are a danger to themselves/others

Children In Restraints:

- Face-to-face evaluation by licensed independent practitioner every 4 hours - Renewed physician order every 2 hours

Ethical Decision-Making:

- Gathering information - Clarifying values - Identifying options - Identifying legal considerations and practical restraints - Building consensus for decision reached - Reviewing and analyzing decision

HIPPA:

- HIPPA is mandated by federal government and made mandatory for everyone in 2003

Insanity:

- Has legal definition but not medical definition

Mental Health Lawsuits:

- In mental health, most lawsuits are related to suicide, attempt for suicide, clients harming others, sexual assault, medication errors

Seclusion (Outline):

- Involuntary confinement in locked room that has either security window or camera for direct visual monitoring - Purpose is for client to regain physical/emotional control over themselves

Civil Commitment:

- Involuntary hospitalization: your right to leave the hospital is gone but all other civil liberties are retained

Intentional Tort: Assault:

- Involves any action that causes a person to fear being touched in a way that is offensive, insulting, or physically injurious without consent or authority. - Examples include making threats to restrain the client to give him or her an injection for failure to cooperate.

Ethics:

- Is a branch of philosophy that deals with values of human conduct related to the rightness or wrongness of actions and to the goodness and badness of the motives and ends of such actions. - Ethical theories are sets of principles used to decide what is morally right or wrong. - All these principles have meaning in health care. The nurse respects the client's autonomy through patient's rights and informed consent and by encouraging the client to make choices about his or her health care -. The nurse has a duty to take actions that promote the client's health (beneficence) and that do not harm the client (nonmaleficence). - The nurse must treat all clients fairly (justice), be truthful and honest (veracity), and honor all duties and commitments to clients and families (fidelity).

Utilitarianism:

- Is a theory that bases decisions on "the greatest good for the greatest number." - Decisions based on utilitarianism consider which action would produce the greatest benefit for the most people.

Deontology:

- Is a theory that says decisions should be based on whether an action is morally right with no regard for the result or consequences. - Principles used as guides for decision-making in deontology include autonomy, beneficence, non-maleficence, justice, veracity, and fidelity.

Unintentional Torts: Malpractice:

- Is a type of negligence that refers specifically to professionals such as nurses and physicians - Clients or families can file malpractice lawsuits in any case of injury, loss, or death. - For a malpractice suit to be successful, that is, for the nurse, physician, or hospital or agency to be liable, the client or family needs to prove four elements:

Tort:

- Is a wrongful act that results in injury, loss, or damage. Torts may be either unintentional or intentional.

Unintentional Torts: Negligence:

- Is an unintentional tort that involves causing harm by failing to do what a reasonable and prudent person would do in similar circumstances.

Intentional Torts: False Imprisonment:

- Is defined as the unjustifiable detention of a client, such as the inappropriate use of restraint or seclusion. Proving liability for an intentional tort involves three elements 1. The act was willful and voluntary on the part of the defendant (nurse). 2 .The nurse intended to bring about consequences or injury to the person (client). 3 .The act was a substantial factor in causing injury or consequences.

Restraint:

- Is the direct application of physical force to a person without his or her permission to restrict his or her freedom of movement. - The physical force may be human or mechanical or both. - Human restraint occurs when staff members physically control the client and move him or her to a seclusion room. - Mechanical restraints are devices, usually ankle and wrist restraints, fastened to the bed frame to curtail the client's physical aggression, such as hitting, kicking, and hair pulling.

Veracity:

- Is the duty to be honest or truthful

Seclusion:

- Is the involuntary confinement of a person in a specially constructed, locked room equipped with a security window or camera for direct visual monitoring. - For safety, the room often has a bed bolted to the floor and a mattress. - Any sharp or potentially dangerous objects, such as pens, glasses, belts, and matches, are removed from the client as a safety precaution. - Seclusion decreases stimulation, protects others from the client, prevents property destruction, and provides privacy for the client. - The goal is to give the client the opportunity to regain physical and emotional self-control. - Short-term use of restraint or seclusion is permitted only when the client is imminently aggressive and dangerous to him or herself or to others, and all other means of calming the client have been unsuccessful - For adult clients, use of restraint and seclusion requires a face-to-face evaluation by a licensed independent practitioner within 1 hour of restraint or seclusion and every 8 hours thereafter, a physician's order every 4 hours, documented assessment by the nurse every 1 to 2 hours, and close supervision of the client. - For children, the physician's order must be renewed every 2 hours, with a face-to-face evaluation every 4 hours. - The nurse assesses the client for any injury and provides treatment as needed. - Staff must monitor a client in restraints continuously on a one-to-one basis for the duration of the restraint period. - A client in seclusion is monitored one-to-one for the first hour and then may be monitored by audio and video equipment. - The nurse monitors and documents the client's skin condition, blood circulation in hands and feet (for the client in restraints), emotional well-being, and readiness to discontinue seclusion or restraint. - He or she observes the client closely for side effects of medications, which may be given in large doses in emergencies. - The nurse or designated care provider also implements and documents offers of food, fluids, and opportunities to use the bathroom per facility policies and procedures. - As soon as possible, staff members must inform the client of the behavioral criteria that will be used to determine whether to decrease or to end the use of restraint or seclusion. - Criteria may include the client's ability to verbalize feelings and concerns rationally, to make no verbal threats, to have decreased muscle tension, and to demonstrate self-control. - If a client remains in restraints for 1 to 2 hours, two staff members can free one limb at a time for movement and exercise. - Frequent contact by the nurse promotes ongoing assessment of the client's well-being and self-control. - It also provides an opportunity for the nurse to reassure the client that restraint is a restorative, not a punitive, procedure. - Following release from seclusion or restraint, a debriefing session is required within 24 hours. - The nurse should also offer support to the client's family, who may be angry or embarrassed when the client is restrained or secluded. - A careful and thorough explanation about the client's behavior and subsequent use of restraint or seclusion is important. - If the client is an adult, however, such discussion requires a signed release of information. - In the case of minor children, signed consent is not required to inform parents or guardians about the use of restraint or seclusion. - Providing the family with information may help prevent legal or ethical difficulties. - It also keeps the family involved in the client's treatment. - The goal of seclusion is to give the client the opportunity to regain self-control, both emotionally and physically. - Most clients who have been secluded, however, have very different feelings and thoughts about seclusion. - Clients report feeling angry, agitated, bored, frustrated, helpless, and afraid while in seclusion. - They perceive seclusion as a punishment and receive the message that they were "bad." - Many clients are not clear about the reasons for seclusion or the criteria for exiting seclusion, and they believe that seclusion lasted too long. - In general, clients think that other interventions such as interaction with staff, a place to calm down or scream when needed, or the presence of a family member could reduce or eliminate the need for seclusion. - Clients who had not been secluded describe the seclusion of others in more positive terms, such as helpful, caring, fair, and good. - However, these clients also express the wish that "that never happens to me."

Non-Maleficence:

- Is the requirement to do no harm to others either intentionally or unintentionally

Mandatory Outpatient Treatment:

- Legally assisted or mandatory outpatient treatment is the requirement that clients continue to participate in treatment on an involuntary basis after their release from the hospital into the community. - This may involve taking prescribed medication, keeping appointments with health care providers for follow-up, and attending specific treatment programs or groups. - In the United States, 46 states and the District of Columbia have laws for some type of mandated outpatient treatment - . The four states that do not have assisted outpatient treatment are Connecticut, Maryland, Massachusetts, and Tennessee - Benefits of mandated treatment include shorter inpatient hospital stays, though these individuals may be hospitalized more frequently; reduced mortality risk for clients considered dangerous to themselves or others; and protection of clients from criminal victimization by others. - In addition, after an initial financial investment, assisted outpatient treatment is more cost-effective than repeated involuntary hospital stays. - Mandated outpatient treatment is sometimes also called conditional release or outpatient commitment. - Court-ordered outpatient treatment is most common among persons with severe and persistent mental illness who have had frequent and multiple contacts with mental health, social welfare, and criminal justice agencies. - This supports the notion that clients are given several opportunities to voluntarily comply with outpatient treatment recommendations and that court-ordered treatment is considered when those attempts have been repeatedly unsuccessful - The court's concern is that clients with psychiatric disorders have civil rights and should not be unreasonably required to participate in any activities against their will. - Another concern is that once court-ordered treatment was permitted, it would be used with ever-increasing numbers of people. However, such an increase has not occurred. - Communities counter that they deserve protection against dangerous people with histories of not taking their medications and who may become threats.

Standards Of Care:

- Meaning the care they provide to clients meets set expectations and is what any nurse in a similar situation would do. - Standards of care are developed from professional standards, state nurse practice acts, federal agency regulations, agency policies and procedures, job descriptions, and civil and criminal laws.

Most clients admitted:

- Most clients are admitted on voluntary basis

Involuntary Hospitalization:

- Most clients are admitted to inpatient settings on a voluntary basis, which means they are willing to seek treatment and agree to be hospitalized. - Some clients, however, do not wish to be hospitalized and treated. - Health care professionals respect these wishes unless clients are dangers to themselves or others (i.e., they are threatening or have attempted suicide or represent a danger to others). - Clients hospitalized against their will under these conditions are committed to a facility for psychiatric care until they no longer pose a danger to themselves or to anyone else. - Each state has laws that govern the civil commitment process, but such laws are similar across all 50 states. - Civil commitment or involuntary hospitalization curtails the client's right to freedom (the ability to leave the hospital when he or she wishes). - All other client rights, however, remain intact. - A person can be detained in a psychiatric facility for 48 to 72 hours on an emergency basis until a hearing can be conducted to determine whether or not he or she should be committed to a facility for treatment for a specified period. - Many states have similar laws governing the commitment of clients with substance abuse problems who represent a danger to themselves or others when under the influence.

Most Ethical Dilemmas:

- Most ethical dilemmas result from patients autonomy vs. utilitarianism (concerns for the public good)

Nursing Liability:

- Nurses are responsible for providing safe, competent, legal, and ethical care to clients and families. - Professional guidelines such as the American Nurses Association's (ANA's) Code of Ethics for Nurses with Interpretive Statements and the ANA's Psychiatric-Mental Health Nursing: Scope and Standards of Practice outline the nurse's responsibilities and provide guidance - Nurses are expected to meet standards of care, meaning the care they provide to clients meets set expectations and is what any nurse in a similar situation would do. - Standards of care are developed from professional standards, state nurse practice acts, federal agency regulations, agency policies and procedures, job descriptions, and civil and criminal laws.

Prevention Of Liability:

- Nurses can minimize the risk for lawsuits through safe, competent nursing care and descriptive, accurate documentation.

Duty To Warn Third Parties:

- One exception to the client's right to confidentiality is the duty to warn, based on the California Supreme Court decision in Tarasoff vs. Regents of the University of California - As a result of this decision, mental health clinicians may have a duty to warn identifiable third parties of threats made by clients, even if these threats were discussed during therapy sessions otherwise protected by privilege. - On the basis of the Tarasoff decision, many states have enacted laws regarding warning a third party of threats or danger. - These laws vary from state to state. Some states impose a mandatory duty to warn, others have laws stating the clinician "may" warn. - Still other states base decisions on case law, and some states have no statutory or case law to cover warning a third party. - So if a case were litigated in a state with no laws, the judge or jury could make a decision on a case-by-case basis. When making a decision about warning a third party, the clinician must base his or her decision on the following: •Is the client dangerous to others? •Is the danger the result of serious mental illness? •Is the danger serious? •Are the means to carry out the threat available? •Is the danger targeted at identifiable victims? •Is the victim accessible? - For example, if a man were admitted to a psychiatric facility stating he was going to kill his wife, the duty to warn his wife is clear. However, if a client with paranoia were admitted saying, "I'm going to get them before they get me" but providing no other information, there is no specific third party to warn. Decisions about the duty to warn third parties are usually made by psychiatrists or by qualified mental health therapists in outpatient settings.

Insanity Defense:

- One legal issue that sparks controversy is the insanity defense, with insanity having a legal meaning but no medical definition. - The argument that a person accused of a crime is not guilty because that person cannot control his or her actions or cannot understand the wrongfulness of the act is known as the M'Naghten Rule. - When the person meets the criteria, he or she may be found not guilty by reason of insanity. - The public perception of the insanity defense is that it is used frequently and that it is usually successful; that is, the person accused of the crime "gets off" and is free immediately. - In actuality, this defense can only be used when the person meets the criteria for an insanity defense. - So it is used infrequently and is not usually successful. However, when the insanity defense is successful, it is widely publicized, leading to the perception that it is commonplace. - A few states allow a verdict of guilty but insane when the client has an insanity defense. - Four states—Idaho, Kansas, Montana, and Utah—have abolished the insanity defense, although all but Kansas will allow a verdict of guilty but insane. - Ideally, this means that the person is held responsible for the criminal behavior but can receive treatment for mental illness. - Critics of this verdict, including the APA, argue that people do not always receive needed psychiatric treatment and that this verdict absolves the legal system of its responsibility.

M'Naghten Rule:

- Person accused of crime is not guilty b/c that person cannot control his actions or understand wrongfulness of actions - Used infrequently and NOT very successful

Conservator = Legal Guardian:

- Provides informed consent/writes checks and may handle finances/enters contracts for person who is severely disabled, found to be incompetent, can't provide food/clothing/shelter even when resources exist or cannot act in their own best interest

Intentional Torts:

- Psychiatric nurses may also be liable for intentional torts or voluntary acts that result in harm to the client. Examples include assault, battery, and false imprisonment.

Autonomy:

- Refers to a person's right to self-determination and independence

Justice:

- Refers to fairness, treating all people fairly and equally without regard for social or economic status, race, sex, marital status, religion, ethnicity, or cultural beliefs.

Beneficence:

- Refers to one's duty to benefit or to promote the good of others.

Fidelity:

- Refers to the obligation to honor commitments and contracts.

Release From Restraints:

- Release from restraint/seclusion requires debriefing session within 24 hours

When Do We Use Restraints/Seclusion?

- Restraints/seclusions are to be used ONLY when all other methods have been proven to be unsuccessful and for shortest time possible

Civil Rights:

- Right to be involved in plan of care, be treated in least restrictive environment, refuse participation in research, have unrestricted visitors/mail/phone calls, and right to refuse treatment

Standard Of Care:

- Set expectation and what any other nurse would do in a similar situation

Conservatorship & Guardianship:

- The appointment of a conservator or legal guardian is a separate process from civil commitment. - People who are gravely disabled; are found to be incompetent; cannot provide food, clothing, and shelter for themselves even when resources exist; and cannot act in their own best interests may require appointment of a conservator or legal guardian. - In these cases, the court appoints a person to act as a legal guardian who assumes many responsibilities for the person, such as giving informed consent, writing checks, and entering contracts. - The client with a guardian loses the right to enter into legal contracts or agreements that require a signature (e.g., marriage or mortgage). - This affects many daily activities that are usually taken for granted. Because guardians speak for clients, the nurse must obtain consent or permission from the guardian. - In some states, the term conservator refers to a person assigned by the court to manage all financial affairs of the client. - This can include receiving the client's disability check, paying bills, making purchases, and providing the client with spending money. - Some states include the management of the client's financial affairs under legal guardianship. - Some states distinguish between conservator of the person (synonymous with legal guardian) and conservator of financial affairs only—also known as power of attorney for financial matters.

Causation:

- The breach of duty was the direct cause of the loss, damage, or injury. In other words, the loss, damage, or injury would not have occurred if the nurse had acted in a reasonable, prudent manner. - Not all injury or harm to a client can be prevented, nor do all client injuries result from malpractice. - The issues are whether or not the client's actions were predictable or foreseeable (and therefore preventable) and whether the nurse carried out appropriate assessment, interventions, and evaluation that met the standards of care. - In the mental health setting, lawsuits are most often related to suicide and suicide attempts. - Other areas of concern include clients harming others (staff, family, or other clients), sexual assault, and medication errors.

Injury Or Damage:

- The client suffered some type of loss, damage, or injury

Breach Of Duty:

- The nurse (or physician) failed to conform to standards of care, thereby breaching or failing the existing duty. - The nurse did not act as a reasonable, prudent nurse would have acted in similar circumstances.

Confidentiality:

- The protection and privacy of personal health information is regulated by the federal government through the Health Insurance Portability and Accountability Act (HIPAA) of 1996. - The law guarantees the privacy and protection of health information and outlines penalties for violations. - Mandatory compliance with the final HIPAA Privacy Rule took effect on April 14, 2003, for all health care providers, including individuals and organizations that provide or pay for care. Both civil (fines) and criminal (prison sentences) penalties exist for violation of patient privacy. - Protected health information is any individually identifiable health information in oral, written, or electronic form. - Mental health and substance abuse records have additional special protection under the privacy rules. - Some believe that these strict confidentiality policies may pose a barrier to collaboration among providers and families - In community settings, compliance with the privacy rule has decreased communication and collaboration among providers and communication with family caregivers, which may have a negative impact on patient care as well as the rights of families. - Education programs for clients and families about the privacy regulation as well as establishment of open lines of communication between clients and families before a crisis occurs may help decrease these difficulties, Also, dealing with the distress of relatives directly can be beneficial and help families feel included, rather than excluded.

Least Restrictive Environment (OUTLINE):

- Unless necessary, patients treated without use of seclusion/restraints or in outpatient facility

Duty To Warn (outline):

- Warn 3rd party that client made threats against - Exclusion to confidentiality

When Confronted With Ethical Dilemma:

- When confronted with ethical dilemma, talk to others like colleagues or seek professional supervision

When Someone Is In Restraints:

- When someone is in restraints they're supposed to be monitored (1:1) for entire duration in restraint

When Someone Is In Seclusion:

- When someone is in seclusion they must be monitored (1:1) for first hour then monitored by either audio/video surveillance

Adults In Restraints:

- Within 1 hour of restraint/seclusion, requires face-to-face evaluation by licensed independent practitioner every 8 hours - Renewed physician order every 4 hours - Documented assessment by nurse every 1-2 hours

Legally Mandated:

= assisted outpatient treatment = conditional release = outpatient commitment: clients continue treatment on involuntary basis after released from hospital and into the community

Ethical Issues (POWERPOINT):

Remember: - The nurse respects the client's autonomy through patient's rights and informed consent and by encouraging the client to make choices about his or her health care. - The nurse has a duty to take actions that promote the client's health (beneficence) and that do not harm the client (nonmaleficence). - The nurse must treat all clients fairly (justice), be truthful and honest (veracity), and honor all duties and commitments to clients and families (fidelity).

Nurse Liability (POWERPOINT):

Responsible for: - Providing safe care - Competent - Legal - Ethical care to clients and families. •Standards of care - Outline the nurse's responsibilities and provide guidance - The care provided to clients meets set expectations and is what any nurse in a similar situation would do Ethical decision-making includes: - Gathering information, - Clarifying values, - Identifying options, - Identifying legal considerations and practical restraints, - Building consensus for the decision reached, - Reviewing and analyzing the decision to determine what was learned.

Restraints (POWERPOINT):

There are 3 types of restraints: 1. Chemical 2. Human/physical 3. Mechanical •Restrict freedom of movement •Applied when the patient poses as threat to self, others, or both •Provider order is necessary

Is the following statement true or false? A nurse is required to maintain client confidentiality unless the client threatens a specifically identified individual or group.

True - Rationale: In cases where a client threatens an identifiable third party, the nurse has a duty to warn that third party.

Torts: Unintentional: (POWERPOINT):

Unintentional: •Negligence: lack of action resulted in harm to the patient Malpractice: - The following has to be proven - Duty-relationship - Breach of duty-did not act reasonably - Injury or damage-loss of damage occurred - Causation-the result was due to the nurse not acting reasonably •Most common suits are suicide or attempt

1. The client who is involuntarily committed to an inpatient psychiatric unit loses which right? a.Right to freedom b.Right to refuse treatment c.Right to sign legal documents d.The client loses no rights

a.Right to freedom

2. A client has a prescription for haloperidol, 5 mg orally two times a day, as ordered by the physician. The client is suspicious and refuses to take the medication. The nurse says, "If you don't take this pill, I'll get an order to give you an injection." The nurse's statement is an example of a.assault. b.battery. c.malpractice. d.unintentional tort.

a.assault.

3. A hospitalized client is delusional, yelling, "The world is coming to an end. We must all run to safety!" When other clients complain that this client is loud and annoying, the nurse decides to put the client in seclusion. The client has made no threatening gestures or statements to anyone. The nurse's action is an example of a.assault. b.false imprisonment. c.malpractice. d.negligence.

b.false imprisonment.

4. Which would indicate a duty to warn a third party? a.A client with delusions states, "I'm going to get them before they get me." b.A hostile client says, "I hate all police." c.A client says he plans to blow up the federal government. d.A client states, "If I can't have my girlfriend back, then no one can have her."

d.A client states, "If I can't have my girlfriend back, then no one can have her."

5. The nurse gives the client quetiapine (Seroquel) in error when olanzapine (Zyprexa) was ordered. The client has no ill effects from the quetiapine. In addition to making a medication error, the nurse has committed which? a.Malpractice b.Negligence c.Unintentional tort d.None of the above

d.None of the above

Involuntary Hospitalization/Treatment:

•Admitted against will •Patient is deemed unsafe to self and/or others •The patient is held for 48-72 hours - Receive a hearing to decide if they will be admitted for treatment •Mandated outpatient - AKA: conditional release - Must adhere to the ordered agreement

Seclusion (POWERPOINT):

•Goal is to give the patient time to regain self control •Patient cannot maintain safe behaviors •Placed in a safe environment separate from others •Provider order is required - Obtained as soon as possible •Patient is monitored closely - One-to-one for the first hour - Documentation every 1-2 hours - Provider within 8 hours •Pt is always debriefed after seclusion - Within 24 hours

Rights Of The Patient:

•Patients admitted to in-patient maintain the same rights as another other patient. Exceptions: •Client is a danger to themselves •Has been admitted involuntarily •Patients belongings are searched for unsafe items. •Patients are discharged when conditions are stabilized.

Steps To Avoid Liability:

•Practice within the scope of state laws and nurse practice act. •Collaborate with colleagues to determine the best course of action. •Use established practice standards to guide decisions and actions. •Always put the client's rights and welfare first. •Develop effective interpersonal relationships with clients and families. •Accurately and thoroughly document all assessment data, treatments, interventions, and evaluations of the client's response to care.

Duty To Warn:

•Tarasoff vs Regent of the University of California •Obligation to warn those who are in or may be in danger The following should be assessed: - Is the client dangerous to others? - Is the danger the result of serious mental illness? - Is the danger serious? - Are the means to carry out the threat available? - Is the danger targeted at identifiable victims? - Is the victim accessible? •Must be a direct threat to a third party not vague threats

Highlights of Patient's Bill of Rights:

•To be informed about benefits, qualifications of all providers, available treatment options, and appeals and grievance procedures •Least restrictive environment to meet needs •Confidentiality •Choice of providers •Treatment determined by professionals, not third-party payers •Parity •Nondiscrimination •All benefits within scope of benefit plan •Treatment that affords greatest protection and benefit •Fair and valid treatment review processes •Treating professionals and payers held accountable for any injury caused by gross incompetence, negligence, or clinically unjustified decisions

Torts: Intentional: (POWERPOINT):

•Torts : a wrongful act that results in injury, loss, or damage Intentional: - Willful and voluntary - Intent to harm or cause a consequence - The act cause injury, loss, or damage •Assault: Verbal attack/threat •Battery: Physical touch without permission •False imprisonment