Chapter 6: Legal and Ethical Considerations

Emergency detention/commitment

"Temporary admission - For people who are confused and cannot make decisions for their own, or those so ill they need emergency admission. Purpose is to observe, dx, and treat those with a mental illness or who are a danger to themselves or others - Held for 48-96hrs to observe, diagnose and treat. - Court hearing before discharge or next admission

Unintentional Torts: Negligence

* The most common unintentional tort * - The failure to use ordinary care in any professional or personal situation when there is a duty to do so. i.e. failure to question a physician's order failure to protect a patient from self-harm, failure to provide patient teaching

Unintentional Torts: Malpractice and its 5 elements

- A special type of professional negligence. - Duty (you have a duty to understand the principles of care and medications used in this specialty) - Breach of duty - if nursing performance falls below the standard of care and exposes the patient to an unreasonable risk of harm - Cause in fact - "actual cause" - "if it were not for what this nurse did/failed to do, would this injury have occurred? - Proximate cause - "legal cause" - determined by whether the event was foreseeable - Damages - actual (loss of something or pain and suffering) and/or incidental/consequential

Involuntary commitment Fun fact - patient still has right to refuse care

- Court ordered admission to a facility without the patient's approval. - Usually starts in ER or police department, evaluated by psych - Criteria for commitment (legal standards considering whether admission is necessary) *Dx of mental illness *Danger to self or others *Gravely disabled (cannot provide basic necessities for self) *In need of treatment and illness prevents voluntary help-seeking This is for SAFETY, NOT PUNISHMENT

Discharge procedures: Released AMA

- Disagreement between mental healthcare providers and the patient as to whether continued hospitalization is necessary - No compelling reason for involuntary continuance of stay - Patients are required to sign a form indicated they are leaving AMA

Patients' Rights Under the Law Right to treatment AND refusal of treatment

- May withhold consent or withdraw consent at any time, verbally or in written form, even if involuntarily committed - May be medicated even if refusing only in emergency situations where all criteria is met, OR after a court hearing

A client reports to the nurse that once he is released he will make sure his wife will never again be able to have him committed to a psychiatric hospital. What action should the nurse take? a. None, because no explicit threat has been made. b. Ask the client if he is threatening his wife. c. Call the client's wife and report the threat. d. Report the incident to the client's therapist.

d. Report the incident to the client's therapist.

Which ethical principle refers to the individual's right to make his or her own decisions? a. Beneficence b. Autonomy c. Veracity d. Fidelity

b. Autonomy

Patients' Rights Under the Law Rights regarding restraint and seclusion

- Orders from physician/psychiatrist necessary **** In an emergency, nurses may place patient in seclusion or restraint, but must obtain a written or verbal order ASAP thereafter **** - Never "as needed" or as a standing order - DOCUMENT in treatment plan, including specific behaviors leading up to, the amount of time the patient was in it. - Patient should be assessed regularly and frequently for physical needs, with each assessment documented - Considered vulnerable while in restraints, so protection from harm required

Patients' Rights Under the Law Right to informed consent

- Patient is informed of risks, benefits, and alternatives - Person must voluntarily accept treatment

Discharge procedures: Unconditional release

- Termination of the legal patient-institution relationship - Discharged with treatment plan, non-legally binding, voluntary

Insurance will not pay for continued private hospitalization of a mentally ill patient. The family considers transferring the patient to a public hospital but expresses concern that the patient will not get any treatment if transferred. Select the nurse's most helpful reply. A. "By law, treatment must be provided. Hospitalization without treatment violates patients' rights." B. "All patients in public hospitals have the right to choose both a primary therapist and a primary nurse." C. "You have a justifiable concern because the right to treatment extends only to provision of food, shelter, and safety." D. "Much will depend on other patients, because the right to treatment for a psychotic patient takes precedence over the right to treatment of a patient who is stable."

A. "By law, treatment must be provided. Hospitalization without treatment violates patients' rights." The right to medical and psychiatric treatment was conferred on all patients hospitalized in public mental hospitals with the enactment of the federal Hospitalization of Mentally Ill Act in 1964.

Tort Law

Any wrongful act, intentional or accidental, that results in injury to another.

A nurse is concerned that an agency's policies are inadequate. Which understanding about the relationship between substandard institutional policies and individual nursing practice should guide nursing practice? A. Agency policies do not exempt an individual nurse of responsibility to practice according to professional standards of nursing care. B. Agency policies are the legal standard by which a professional nurse must act and therefore override other standards of care. C. Faced with substandard policies, a nurse has a responsibility to inform the supervisor and discontinue patient care immediately. D. Interpretation of policies by the judicial system is rendered on an individual basis and therefore cannot be predicted.

A. Agency policies do not exempt an individual nurse of responsibility to practice according to professional standards of nursing care. Nurses are professionally bound to uphold standards of practice regardless of lesser standards established by a health care agency or a state. Conversely, if the agency standards are higher than standards of practice, the agency standards must be upheld. The courts may seek to establish the standard of care through the use of expert witnesses when the issue is clouded.

A patient in alcohol rehabilitation reveals to the nurse, "I feel terrible guilt for sexually abusing my 6-year-old before I was admitted." Select the nurse's most important action. A. Anonymously report the abuse by phone to the local child protection agency B. Reply, "I'm glad you feel comfortable talking to me about it." C. File a written report with the agency's ethics committee. D. Respect nurse-patient relationship confidentiality.

A. Anonymously report the abuse by phone to the local child protection agency Laws regarding child abuse reporting discovered by a professional during the suspected abuser's alcohol or drug treatment differ by state. Federal law supersedes state law and prohibits disclosure without a court order except in instances in which the report can be made anonymously or without identifying the abuser as a patient in an alcohol or drug treatment facility.

A psychiatric nurse best applies the ethical principle of autonomy by: A. exploring alternative solutions with a patient, who then makes a choice. B. suggesting that two patients who were fighting be restricted to the unit. C. intervening when a self-mutilating patient attempts to harm self. D. staying with a patient demonstrating a high level of anxiety.

A. exploring alternative solutions with a patient, who then makes a choice. Autonomy is the right to self-determination, that is, to make one's own decisions. By exploring alternatives with the patient, the patient is better equipped to make an informed, autonomous decision. The distracters demonstrate beneficence, fidelity, and justice.

Patients' Rights Under the Law When is the patient advised?

Are given to patient on admission, and put in chart that it was done.

An adolescent hospitalized after a violent physical outburst tells the nurse, "I'm going to kill my father, but you can't tell anyone." Select the nurse's best response. A. "You are right. Federal law requires me to keep clinical information private." B. "I am obligated to share that information with the treatment team." C. "Those kinds of thoughts will make your hospitalization longer." D. "You should share this thought with your psychiatrist."

B. "I am obligated to share that information with the treatment team." Breach of nurse-patient confidentiality does not pose a legal dilemma for nurses in these circumstances because a team approach to delivery of psychiatric care presumes communication of patient information to other staff members to develop treatment plans and outcome criteria. The patient should also know that the team has a duty to warn the father of the risk for harm.

Select the example of a tort. A. The plan of care for a patient is not completed within 24 hours of the patient's admission. B. A nurse gives a PRN dose of an antipsychotic drug to an agitated patient because the unit is short-staffed. C. An advanced practice nurse recommends hospitalization for a patient who is dangerous to self and others. D. A patient's admission status changed from involuntary to voluntary after the patient's hallucinations subside.

B. A nurse gives a PRN dose of an antipsychotic drug to an agitated patient because the unit is short-staffed. A tort is a civil wrong against a person that violates his or her rights. Giving unnecessary medication for the convenience of staff controls behavior in a manner similar to secluding a patient; thus, false imprisonment is a possible charge. The other options do not exemplify torts.

Which nursing intervention demonstrates false imprisonment? A. A confused and combative patient says, "I'm getting out of here, and no one can stop me." The nurse restrains this patient without a health care provider's order and then promptly obtains an order. B. A patient has been irritating and attention-seeking much of the day. A nurse escorts the patient down the hall saying, "Stay in your room, or you'll be put in seclusion." C. An involuntarily hospitalized patient with suicidal ideation runs out of the psychiatric unit. The nurse rushes after the patient and convinces the patient to return to the unit. D. An involuntarily hospitalized patient with homicidal ideation attempts to leave the facility. A nurse calls the security team and uses established protocols to prevent the patient from leaving.

B. A patient has been irritating and attention-seeking much of the day. A nurse escorts the patient down the hall saying, "Stay in your room, or you'll be put in seclusion." False imprisonment involves holding a competent person against his or her will. Actual force is not a requirement of false imprisonment. The individual needs only to be placed in fear of imprisonment by someone who has the ability to carry out the threat. If a patient is not competent (confused), then the nurse should act with beneficence. Patients admitted involuntarily should not be allowed to leave without permission of the treatment team.

Which action by a nurse constitutes a breach of a patient's right to privacy? A. Documenting the patient's daily behavior during hospitalization B. Releasing information to the patient's employer without consent C. Discussing the patient's history with other staff during care planning D. Asking family to share information about a patient's pre-hospitalization behavior

B. Releasing information to the patient's employer without consent Release of information without patient authorization violates the patient's right to privacy. The other options are acceptable nursing practices. See relationship to audience response question.

A nurse prepares to administer a scheduled injection of haloperidol decanoate (Haldol depot) to an outpatient with schizophrenia. As the nurse swabs the site, the patient shouts, "Stop! I don't want to take that medicine anymore. I hate the side effects." Select the nurse's best action. A. Assemble other staff for a show of force and proceed with the injection, using restraint if necessary. B. Stop the medication administration procedure and say to the patient, "Tell me more about the side effects you've been having." C. Proceed with the injection but explain to the patient that there are medications that will help reduce the unpleasant side effects. D. Say to the patient, "Since I've already drawn the medication in the syringe, I'm required to give it, but let's talk to the doctor about delaying next month's dose."

B. Stop the medication administration procedure and say to the patient, "Tell me more about the side effects you've been having." Patients with mental illness retain their civil rights unless there is clear, cogent, and convincing evidence of dangerousness. The patient in this situation presents no evidence of dangerousness. The nurse, as an advocate and educator, should seek more information about the patient's decision and not force the medication.

A patient diagnosed with schizophrenia believes a local minister stirred evil spirits. The patient threatens to bomb a local church. The psychiatrist notifies the minister. Select the answer with the correct rationale. The psychiatrist: A. released information without proper authorization. B. demonstrated the duty to warn and protect. C. violated the patient's confidentiality. D. avoided charges of malpractice.

B. demonstrated the duty to warn and protect. It is the health care professional's duty to warn or notify an intended victim after a threat of harm has been made. Informing a potential victim of a threat is a legal responsibility of the health care professional. It is not a violation of confidentiality.

A nurse finds a psychiatric advance directive in the medical record of a patient experiencing psychosis. The directive was executed during a period when the patient was stable and competent. The nurse should: A. review the directive with the patient to ensure it is current. B. ensure that the directive is respected in treatment planning. C. consider the directive only if there is a cardiac or respiratory arrest. D. encourage the patient to revise the directive in light of the current health problem.

B. ensure that the directive is respected in treatment planning. The nurse has an obligation to honor the right to self-determination. An advanced psychiatric directive supports that goal. Since the patient is currently psychotic, the terms of the directive now apply.

Two hospitalized patients fight whenever they are together. During a team meeting, a nurse asserts that safety is of paramount importance, so treatment plans should call for both patients to be secluded to keep them from injuring each other. This assertion: A. reinforces the autonomy of the two patients. B. violates the civil rights of both patients. C. represents the intentional tort of battery. D. correctly places emphasis on safety.

B. violates the civil rights of both patients. Patients have a right to treatment in the least restrictive setting. Safety is important, but less restrictive measures should be tried first. Unnecessary seclusion may result in a charge of false imprisonment. Seclusion violates the patient's autonomy. The principle by which the nurse is motivated is beneficence, not justice. The tort represented is false imprisonment.

Intentional Torts: Invasion of privacy

Breaking a person's confidences or taking photographs without explicit permission

A voluntarily hospitalized patient tells the nurse, "Get me the forms for discharge. I want to leave now." Select the nurse's best response. A. "I will get the forms for you right now and bring them to your room." B. "Since you signed your consent for treatment, you may leave if you desire." C. "I will get them for you, but let's talk about your decision to leave treatment." D. "I cannot give you those forms without your health care provider's permission."

C. "I will get them for you, but let's talk about your decision to leave treatment." A voluntarily admitted patient has the right to demand and obtain release in most states. However, as a patient advocate, the nurse is responsible for weighing factors related to the patient's wishes and best interests. By asking for information, the nurse may be able to help the patient reconsider the decision. Facilitating discharge without consent is not in the patient's best interests before exploring the reason for the request.

The nurse reads the medical record and learns that a client has asked for treatment, agreed to receive treatment, and to abide by hospital rules. The nurse may correctly assume that the client has met the criteria for which type of admission? a. Outpatient b. Emergency c. Voluntarily d. Involuntarily

C. Voluntarily

A new antidepressant is prescribed for an elderly patient with major depression, but the dose is more than the usual geriatric dose. The nurse should: A. consult a reliable drug reference. B. teach the patient about possible side effects and adverse effects. C. withhold the medication and confer with the health care provider. D. encourage the patient to increase oral fluids to reduce drug concentration.

C. withhold the medication and confer with the health care provider. The dose of antidepressants for elderly patients is often less than the usual adult dose. The nurse should withhold the medication and consult the health care provider who wrote the order. The nurse's duty is to practice according to professional standards as well as intervene and protect the patient.

Patients' Rights Under the Law Capacity and Competency

Capacity - A person's ability to make an informed decision. Is fluid (individuals may posses capacity in one moment, and not in another) Competency - a legal term related to the degree of mental soundness a person has to make decisions or carry out specific acts (Patients are considered competent until they have been declared incompetent)

In a team meeting a nurse says, "I'm concerned about whether we are behaving ethically by using restraint to prevent one patient from self-mutilation, while the care plan for another self-mutilating patient requires one-on-one supervision." Which ethical principle most clearly applies to this situation? A. Beneficence B. Autonomy C. Fidelity D. Justice

D. Justice The nurse is concerned about justice, that is, fair distribution of care, which includes treatment with the least restrictive methods for both patients. Beneficence means promoting the good of others. Autonomy is the right to make one's own decisions. Fidelity is the observance of loyalty and commitment to the patient.

A newly admitted acutely psychotic patient is a private patient of the medical director and a private-pay patient. To whom does the psychiatric nurse assigned to the patient owe the duty of care? A. Medical director B. Hospital C. Profession D. Patient

D. Patient Although the nurse is accountable to the health care provider, the agency, the patient, and the profession, the duty of care is owed to the patient.

What is the legal significance of a nurse's action when a patient verbally refuses medication and the nurse gives the medication over the patient's objection? The nurse: A. has been negligent. B. committed malpractice. C. fulfilled the standard of care. D. can be charged with battery.

D. can be charged with battery. Battery is an intentional tort in which one individual violates the rights of another through touching without consent. Forcing a patient to take medication after the medication was refused constitutes battery. The charge of battery can be brought against the nurse. The medication may not necessarily harm the patient; harm is a component of malpractice.

A family member of a patient with delusions of persecution asks the nurse, "Are there any circumstances under which the treatment team is justified in violating a patient's right to confidentiality?" The nurse should reply that confidentiality may be breached: A. under no circumstances. B. at the discretion of the psychiatrist. C. when questions are asked by law enforcement. D. if the patient threatens the life of another person.

D. if the patient threatens the life of another person. The duty to warn a person whose life has been threatened by a psychiatric patient overrides the patient's right to confidentiality. The right to confidentiality is not suspended at the discretion of the therapist or for legal investigations.

Which patient meets criteria for involuntary hospitalization for psychiatric treatment? The patient who: A. is noncompliant with the treatment regimen. B. fraudulently files for bankruptcy. C. sold and distributed illegal drugs. D. threatens to harm self and others.

D. threatens to harm self and others. Involuntary hospitalization protects patients who are dangerous to themselves or others and cannot care for their own basic needs. Involuntary commitment also protects other individuals in society. The behaviors described in the other options are not sufficient to require involuntary hospitalization.

Which individual with mental illness may need emergency or involuntary admission? The individual who: A. resumes using heroin while still taking naltrexone (ReVia). B. reports hearing angels playing harps during thunderstorms. C. does not keep an outpatient appointment with the mental health nurse. D. throws a heavy plate at a waiter at the direction of command hallucinations.

D. throws a heavy plate at a waiter at the direction of command hallucinations. Throwing a heavy plate is likely to harm the waiter and is evidence of dangerousness to others. This behavior meets the criteria for emergency or involuntary hospitalization for mental illness. The behaviors in the other options evidence mental illness but not dangerousness. See related audience response question.

Patients' Rights Under the Law Rights regarding confidentiality

HIPAA Dead Man's Law - HIPAA rules still followed, rights still apply after death

Intentional Torts: Battery

The actual harmful or offensive touching of another person

Intentional Torts: Assault

The intentional threat designed to make another pesron fearful that you will cause them harm

Discharge Procedures: Assisted outpatient treatment

Typically, a candidate for this type of treatment will have a history of repeated hospitalizations or arrests caused by treatment nonadherence - Similar to conditional release, but... - Main difference is in legal implications. THIS IS COURT-ORDERED outpatient treatment

Discharge Procedures: Conditional Release

Usually requires outpatient treatment for a specified period of time with follow-through evaluation

Intentional Torts: False Imprisonment

When a person is confined in a limited area or within an institution. May be made if a person is placed in restraints or seclusion - Medications that result in chemical restrain may fit into this category

When considering the duty to warn and protect third parties, which client statement should the nurse report to the treatment team members? a. "That judge is going to really regret putting me in here." b. "All politicians need to be shot." c. "When I'm elected president, I'll make them all pay for doubting me." d. "The man out there who is laughing at me is going to die."

a. "That judge is going to really regret putting me in here."

Which hospitalized patient should the nurse identify as being a candidate for the appropriate use of a release from hospitalization known as against medical advice (AMA)? a. A 37-year-old patient scheduled for discharge in 24 hours wishes to be discharged immediately b. A 75-year-old patient with dementia who demands to be allowed to go back to his own home c. A 21-year-old actively suicidal patient who wants to be discharged to home and do outpatient counseling d. A 32-year-old female patient who wishes to stay in the hospital but whose husband demands that she be discharged into his care

a. A 37-year-old patient scheduled for discharge in 24 hours wishes to be discharged immediately

The use of seclusion or restraint to control the behavior of a client who is at risk of harming self or others gives rise to conflict between which ethical principles? a. Autonomy and beneficence b. Advocacy and confidentiality c. Veracity and fidelity d. Justice and humanism

a. Autonomy and beneficence

When considering the civil rights of persons diagnosed with mental illness and hospitalized for treatment, which statement is true? a. They are assured the same as those for any other citizen. b. Their rights are altered to prevent use of poor judgment. c. Their rights are always ensured by appointment of a guardian. d. Their rights are limited to provision of humane treatment.

a. They are assured the same as those for any other citizen.

The nurse is caring for an admitted client with a history of becoming aggressive when angry and has caused physical injury to another client and two staff members. When this client begins to demonstrate signs of anger while in the day room what intervention should the nurse implement to address the safety of the milieu? a. Alert security to come to the unit for a show of strength b. Request that the client accompany the nurse to the client's room c. Inform the client that restraints will be used if the behavior continues d. Prepare to administer a prn chemical restraint to the client

b. Request that the client accompany the nurse to the client's room

When considering client rights, which client can be legally medicated against his or her wishes? a. The client has accepted the medication in the past. b. The client may cause imminent harm to himself or others. c. The client's primary provider orders the medication. d. The client's mental illness may relate to cognitive impairment.

b. The client may cause imminent harm to himself or others.

What nursing action supports a client's right to autonomy? a. Spending time with an extremely anxious client b. Witnessing the informed consent for electroconvulsive therapy from a client c. Spending equal amount of one-on-one time with each client on the unit d. Attending an inservice on a newly approved medication

b. Witnessing the informed consent for electroconvulsive therapy from a client

A client who presents no danger to himself or to others is forced to take medication against his will. This situation represents a. assault. b. battery. c. defamation. d. invasion of privacy.

b. battery.

Which scenarios describe a HIPAA violation associated with a nurse's behavior? a. An ED (Emergency Department) nurse gives the intensive care unit nurse a client report from a telephone at the nurse's station. b. A nurse on the medical-surgical floor calls a patient's primary care provider to obtain a list of current medications. c. A nurse on the cardiac unit gives report to the nurse on the step-down unit while transporting a client in the staff elevator. d. A nurse on the psychiatric unit gives discharge information to the counseling office regarding a client's outpatient treatment.

c. A nurse on the cardiac unit gives report to the nurse on the step-down unit while transporting a client in the staff elevator.

If a client is placed in seclusion and held there for 24 hours without a written order or examination by a physician, the client has experienced which illegal act? a. Battery b. Defamation of character c. False imprisonment d. Assault

c. False imprisonment

If a nurse is charged with leaving a suicidal client unattended, it is being suggested that the nurse's behavior has violated which ethical principle? a. Autonomy b. Veracity c. Fidelity d. Justice

c. Fidelity

After the death of a client, what rule of confidentiality should be followed by nurses who provided care for the individual? a. Confidentiality is now reserved to the immediate family. b. Only HIV status continues to be protected and privileged. c. Nothing may be disclosed that would have been kept confidential before death. d. The nurse must confer with the next of kin before divulging confidential, sensitive information.

c. Nothing may be disclosed that would have been kept confidential before death.

Which right of the client has been violated if he is medicated without being asked for his permission? a. Right to dignity and respect b. Right to treatment c. Right to informed consent d. Right to refuse treatment

c. Right to informed consent

What assumption can be made about the client who has been admitted on an involuntary basis?Select all that apply. a. The client can be discharged from the unit on demand of next of kin. b. For the first 48 hours, the client can be given medication over objection. c. The client has failed to agree to fully participate in treatment and care planning. d. The client is a danger to self or others or unable to meet basic needs. e. The commitment was court ordered.

c. The client has failed to agree to fully participate in treatment and care planning. d. The client is a danger to self or others or unable to meet basic needs. e. The commitment was court ordered.

Patients' Rights Under the Law Implied consent

i.e. approach patient with medication, and patient indicates a willingness to receive the medication