Legal and Ethical Considerations

What is an intentional tort?

A voluntary act performed with the intent to bring about a physical consequence Battery: causing harm, actual touching Assault: person is fearful of being harmed (carried out by a threat of bodily harm coupled with an apparent, present ability to cause the harm) False imprisonment: when a person is confined in a limited area

What are some key aspects of documentation of care?

Accurate Descriptive Factual (not opinion) Legible Timely Computerized charting

How often must seclusion/restraint be monitored for adults, adolescents, and children?

Adults (18 y/o) x 4hrs adolescents (9-17 y/o) x 2hrs Children (<9 y/o) x 1 hr

What are the statutes for reporting child and elder abuse?

All 50 states and the District of Columbia have child abuse reporting statutes Under most state laws, failure to report suspected abuse, neglect, or exploitation of a disabled adult may be guilty of crime

The intervention that will be most effective in preventing a nurse from making decisions that will lead to legal difficulties is? A. Asking a peer to review nursing intervention related decisions. B. Balancing the rights of the client and the rights of society. C. Maintaining currency in state laws affecting nursing practice. D. Seeking value clarification about fundamental ethical principles.

C

What is HIPAA?

Federal law protecting privacy of health insurance information

What is parity?

Federal law provides for the equality for the mental ill with other patients, in terms of payment for services from health insurance plans

When did mental health laws undergo substantial change?

Following the Community Mental Health Centers Act of 1963 enacted under President JFK The changes reflect a shift in emphasis from institutional care of people with psychiatric disorders to a more community-based care *More therapeutic approach to are*

If a nurse is charged with client abandonment, it is being suggested that the nurse's behavior has violated the ethical principle of? A. Autonomy B. Veracity C. Fidelity D. Justice.

C

What is a writ of habeas corpus?

"Free the person" A patient who believes that he or she is being held without just cause can file a petition

What are the guidelines for nurses who suspect negligence?

*Duty to intervene* -the psychiatric mental health nurse has a duty to intervene when the safety or well being of the client is at risk *Duty to report* *Unethical or illegal practices*

What are the different types of psychiatric hospital admissions?

*Emergency* -used for people who are so confused they cannot make own decision -extremely ill -24 to 96 hours *Observational/temporary* *Long-term/formal* *Outpatient*

What are the five principles of bioethics?

1. *Beneficence*: doing good; actions benefit/promote wellness of others 2. *Autonomy*: client has right to make own decisions 3. *Justice*: treating others fairly and equally 4. *Fidelity*: loyalty to client; faithfulness to duties 5. *Veracity*: duty to communicate truthfully and not in a misleading way

List the clients' rights

1. Civil rights -communication -freedom from harm -dignity and respect 2. Participation in plan of care 3. Right to treatment 4. Right to refuse treatment 5. Right to informed consent 6. Rights surrounding involuntary commitment 7. Rights regarding seclusion and restraint (least restrictive doctrine) 8. Psychiatric advanced directive 9. Rights to confidentiality (duty to warn, child abuse)

What things must the nurse consider before seclusion and restraint?

1. Verbal intervention 2. Reducing the stimulation 3. Active listening 4. Providing diversion 5. Offering PRN medications

Laws do not override ethical principles: TRUE or FALSE?

FALSE Laws *override* ethical principles

In the course of providing best psychiatric care for a client the nurse must place greatest reliance on? A. Legal principles B. Ethical principles C. Independent judgment D. Institutional standards

A

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 the ethical principles of? A. Autonomy and beneficence B. Advocacy and confidentiality C. Veracity and fidelity D. Justice and humanism

A

Mrs. Smith is admitted for treatment of depression with suicidal ideation triggered by marital discord. She had spoken with staff about her fears that the marriage will end, had indicated that she did not know how she could cope if her marriage ended, and has a history of suicide attempts when the marriage had seemed threatened in the past. Her spouse visits one night and informs Mrs. Smith that he has decided to file for divorce. Staff are aware of the visit and the husband's intentions regarding divorce but take no further action, feeling that the q15-minute suicide checks Mrs. Smith is already on are sufficient. Thirty minutes after the visit ends, staff make rounds and discover Mrs. Smith has hanged herself in her bathroom, using hospital pajamas she had tied together into a rope. Which of the following statements best describes this situation? Select all that apply. A. The nurses have created liability for themselves and their employer by failing in their duty to protect Mrs. Smith. B. The nurses have breached their duty to reassess Mrs. Smith for increased suicide risk after her husband's visit. C. Given Mrs. Smith's history, the nurses should have expected an increased risk of suicide after the husband's announcement. D. The nurses correctly reasoned that suicides cannot always be prevented and did their best to keep Mrs. Smith safe via the q15-minute checks. E. The nurses are subject to a tort of professional negligence for failing to prevent the suicide by increasing the suicide precautions in response to Mrs. Smith's increased risk. F. Had the nurses restricted Mrs. Smith's movements or increased their checks on her, they would have been liable for false imprisonment and invasion of privacy, respectively.

A B C E

What is a tort?

A civil wrong for which monetary damage may be collected by the injured party (plantiff) from the wrongdoer (the defendant)

What is an ethical dilemma?

A situation that requires a choice between two or more morally conflicting alternatives

Describe involuntary commitment

Also known as assisted inpatient psychiatric treatment A court ordered admission to a facility without the patient's consent

What ethical principle is supported when a nurse witnesses the informed consent for electroconvulsive therapy from a depressed client? A. Beneficence B. Autonomy Correct C. Justice D. Fidelity

B

After 15 days, a patient is released from an inpatient treatment unit where he had been committed by a judge for a period of 90 days. Upon discharge, in return for placement in a mental health group home, the patient is required to attend weekly appointments with his case manager and counselor, take all ordered medications, and meet twice monthly with his psychiatrist. He is told that the judge has ordered that the patient be readmitted to the inpatient facility if he fails to follow these requirements. This scenario includes examples of which of the following type(s) of admissions and/or releases? Select all that apply. A. Involuntary admission B. Long-term involuntary admission C. Unconditional release D. Conditional release E. Involuntary outpatient admission

B D E

An advanced practice nurse wishes to initiate treatment with an antipsychotic medication which, although very likely to benefit the patient, in a small percentage of patients may cause a dangerous side effect. The nurse explains the purpose, expected benefits, and possible risks of the medication. The patient readily signs a form accepting the medication, stating, "These pills will poison the demons inside of me." Although he has been informed of the risk of side effects, he is unable to state what these are and simply reports that he "won't have side effects because I am iron and cannot be killed." Which of the following responses would be most appropriate under these circumstances? A. Begin administration of the medications based on his signed permission, because he has legally consented to treatment. B. Petition the court to appoint a guardian to substitute for the patient's being unable to comprehend the proposed treatment. C. Administer the medications even though consent is unclear, because the patient is clearly psychotic and in need of the medications. D. Withhold the medication until the patient is able to identify the benefits and risks of both consenting and refusing consent to the medications.

C The patient appears to be sufficiently psychotic so as to be unable to comprehend the proposed treatment and thus is unable to make an informed decision and provide informed consent

_____ and ______ mandate the laws regulating the care and treatment of consumers with mental illnesses

FEDERAL and STATE

A patient with depression presents with her family in the emergency room. The family feels the patient should be admitted because "she might hurt herself." An assessment indicates moderate depression with no risk factors for suicide other than the depressed mood itself, and the patient denies any intent or thoughts about self-harm. The family agrees that the patient has not done or said anything to suggest that she might be a danger to herself. Which of the following responses is consistent with the concept of "least restrictive alternative" doctrine? A. Admit the patient as a temporary inpatient admission. B. Persuade the patient to agree to a voluntary inpatient admission. C. Admit the patient involuntarily to an inpatient mental health treatment unit. D. Arrange for an emergency outpatient counseling appointment the next day.

D

What assumption can be made about the client who has been admitted on an involuntary basis? A. The client can be discharged from the unit on demand. B. For the first 48 hours, the client can be given medication over objection. C. The client has agreed to fully participate in treatment and care planning. D. The client is a danger to self or others or unable to meet basic needs.

D

A patient incidentally shares with you that he has difficulty controlling his anger when around children because their play irritates him, leading to resentment and fantasies about attacking them. He has a history of impulsiveness and assault, escalates easily on the unit, and has a poor tolerance for frustration. This weekend he has an overnight pass, which he will spend with his sister and her family. As you meet with the patient and his sister just prior to the pass, the sister mentions that she has missed her brother because he usually helps her watch the children, and she has to work this weekend and needs him to babysit. The patient becomes visibly apprehensive upon hearing this. Which of the following responses would best reflect appropriate nursing practice relative to the conflict this situation presents between safety and the patient's right to confidentiality? A. Cancel the pass without explanation to the sister, and reschedule it for a time when babysitting would not be required of the patient. B. Suggest that the sister make other arrangements for child care, but withhold the information the patient shared regarding his concerns about harming children. C. Speak with the patient about the safety risk involved in babysitting, seeking his permission to share this information and advising against the pass if he declines to share the information. D. Meet with the patient's sister, sharing with her the patient's previous disclosure about his anger towards children and the resultant risk that his babysitting would present.

D In this case, there is a risk to the sister's children and as a result, the patient's right to privacy is forfeited in the interest of protecting the children. Therefore, the patient's sister must be told of the risk so that she can take whatever actions she reasonably deems necessary to protect her children.

Describe confidentiality after death

It is important that you do not divulge information after a person's death that you could not legally share before the death The "Dead Man's Statute" protects confidential information about individuals when they are not alive to speak for themselves

What are some other rights regarding seclusion and restraint?

Reducing the pt.'s, movement is also a restraint Chemical restraint are the use of a substance that is not being used for the patients condition Seclusion is confining a pt., alone in an area or room and preventing them from leaving Seclusion and time-outs: What's the difference? -timeout is voluntary An emergency situation may warrant obtaining an order after the fact ASAP Never PRN Each occurrence begins a new order

What is an unintentional tort?

Negligence: -most common -failure to use ordinary care in any professional or personal situation when having a duty to do so Malpractice: -special type of professional negligence

What are actions of prudent nurses determined by?

Nurse practice acts Hospital and organizational policies Patient bill of rights Code of Ethics for Nurses with Interpretive Statements of the American Nurses Association (ANA) Standards of Care from the Scope and Standards of Psychiatric-Mental Heath Nursing Practice

What are some exceptions to confidentiality?

Nurses are obligated to report a patient's threats of harm against specified victims or classes of victims to other members of the treatment team The duty to warn is an obligation to warn third parties when they may be involved in danger from a patient

Describe the risk of violence as a psychiatric mental health nurse

Nurses must protect themselves in institutional or community settings Employers are not typically held responsible for employee injuries caused by violent client behavior Nurses have placed themselves knowingly in the range of danger by agreeing to care for unpredictable clients Good judgment means *not placing oneself in a potentially violent situation*

Describe voluntary admission

Occurs when the patients apply in writing for admission to the facility Like checking self into the hospital Have the right to request and obtain release

What is the failure to protect?

Psy-Mental Health RNs have duty to protect the safety of patients. i.e., leaving a suicidal patient alone Miscommunication/medication errors are common - always check ID of patients Abuse dealing with the connection between the provider and patient (sexual misconduct) Nurse must take precaution to prevent harm when a patient is restrained Protect patient from other patients Protect patient from family member or friends (physical/sexual abuse)

Ethical dilemmas can influence laws: TRUE or FALSE?

TRUE

Describe the legal process behind involuntary commitment

The criteria for committment are the legal standards under which the court decides whether admission is necessary... 1. Mentally ill 2. Posing a danger to self or others 3. Gravely disabled 4. In need of treatment, and mental illness prevents helping-seeking on voluntary basis

What is the least restrictive alternative doctrine?

The least drastic measures must be taken

What are the rights regarding seclusion and restraint?

The least restrictive measures of restraint for the shortest duration is always the general rule The least restrictive measures do not necessarily have to be tried, they only have to be considered ineffective in the staff's professional judgement

What is negligence?

The most common unintentional tort An act of omission *Duty performed negligently* *Damages were incurred by the client* *Duty* -a nurse has a duty to understand medications, procedures, etc. *Breach of duty* -do not meet standard of care that other nurses would be expected to supply under similar circumstances *Cause in fact* -"if it were not for what this nurse did (or failed to do), would this injury have occurred?" *Proximate cause* -determined by whether there were any intervening actions or persons that were, in fact, the causes of harm to the patient *Damages* -these include actual damages, as well as pain and suffering

What does release from hospitalization depend on?

The patient's admission status

What is ethics?

The study of philosophical beliefs about what is considered right or wrong in a society

What is bioethics?

The study of specific ethical questions that arise in healthcare

Describe unconditional release

The termination of the patient-institution relationship

What is confidentiality of professional communication?

The theory behind this is to ensure that patients will speak frankly (truthfully) and be willing to disclose personal information because they know that care providers will not repeat or distribute confidential conversations

Describe conditional release

Usually requires outpatient treatment for a specified period to determine if the patient follows the medication regimen, can meet basic needs, and is able to reintegrate into the community