Mental health- Legal/Ethical issues Townsend CH. 3 ATI 2

Joe is very restless and is pacing the room. The nurse says to Joe, "If you don't sit down in the chair and be still, I'm going to put you in restraints!" With which of the following legal actions might the nurse be charged because of this nursing action? a. Defamation of character b. Battery c. Breach of confidentiality d. Assault

D

What is an ethical dilemma?

"A situation that requires an individual to make a choice between two equally unfavorable alternatives." A conscious conflict for decision maker. There is often no clear answer. Nursing implications: critical thinking and clinical judgement.

Tonja: Selecting an alternative

** Alternative 3- Referral to another source outside of the hospital and risk reprimand from supervisor. Does the most good for the greatest number. Upholds value of "do unto others as you would have other do unto you." Upholds ethical principles of autonomy, beneficence and nonmaleficence. Success of this decision depends on Tonja's follow through with the referral and compliance.

Mental Health Patient's Have Rights

**Least restrictive measures **Refuse treatment (some exceptions by law) Refuse medications **Receive humane treatment Privacy Receive and make phone calls Receive and send mail Confidentiality (health care information) Make their own decisions

3 criteria to force medication

-client must exhibit behavior that is dangerous to self and others -medication order by the physician must have a reasonable chance of providing help to the client -clients who refuse medication must be judged incompetent to evaluate the benefits of the treatments in question

Psychiatric Hospitalization

1. Involuntary emergency admission (IEA) criteria (can also be called a civil commitment): Danger to self Danger to others Gravely disabled -follows federal and state laws 2. Voluntary psychiatric admission

Bioethics

A term applied to ethics when they refer to concepts within the scope of medicine, nursing, and allied health.

Tort

A wrongful act or an infringement of a right (other than under contract) leading to civil legal liability.

Guidelines relating to "duty to warn" state that a therapist should consider taking action to warn a third party when his or her client does which of the following? (Select all that apply.) a. Threatens violence toward another individual b. Identifies a specific intended victim c. Is having command hallucinations d. Reveals paranoid delusions about another individual

A, B

Informal admission

type of voluntary admission with no formal or written application. Patient is free to stay or leave even against medical advice.

Model for making ethical decisions

•Assessment (gather all the facts) Problem Identification Planning: consider benefits + alternatives, consider ethical principles, consider consulting ethics committee Nursing Intervention Evaluation of the outcome

Informed consent

Decision to accept health care treatment after being INFORMED about: benefits risks alternatives basics of treatment Three elements of informed consent: Knowledge Competency (Nurses need to consider healthcare literacy.) Free will

Nurse Practice Act (NPA)

Defines legal parameters of professional and practical nursing. Each state has a nurse practice act that determines the parameters. Can differ from state to state. Board of nursing is the holder of the nursing scope of practice.

Autonomy

Emphasizes the status of persons as autonomous moral agents whose rights to determine their destinies should always be respected. ex. Rather than giving advice to a client who has dificulty making decisions, a nurse helps the client explore all alternatives and arrive at a choice

Beneficence

Refers to one's duty to benefit or promote the good of others. ex. nurse taking care of child who has trauma to sit with the child at night so they can fall asleep better

Statutory Laws

Statutory: written laws passed by legislature and government of a country and those which have been accepted by the society. Violations can be either criminal or civil. Example: nurse practice act, civil law violation is negligence or malpractice. Criminal law violation falsifying medical records, theft of narcotics, insurance fraud.

Unintentional torts

negligence and malpractice

Exceptions to confidentiality

- Duty to Protect community - Tarasoff Decision/Ruling (1974) - Reporting child and elder abuse

HIPPA: Confidentiality

1996: HIPAA a federal law. Protected Health Information (PHI)Caution: Elevators Social media: !!!!!!! Hallway conversations At the nurse's station if it is not behind a closed door Faxing without a release of information or cover sheet Telephone conversations Documentation in medical records

Which statement would a nurse identify as correct regarding a client's right to refuse treatment? 1. Clients can refuse pharmacological but not psychological treatment. 2. Clients can refuse any treatment at any time. 3. Clients can refuse only electroconvulsive therapy (ECT). 4. Professionals can override treatment refusal by an actively suicidal or homicidal client.

4 -they are a danger to themselves

The nurse decides to respect family wishes and not tell the client of his terminal status because that would bring the most happiness to the most people. Which of the following ethical theories is considered in this decision? a. Utilitarianism b. Kantianism c. Christian ethics d. Ethical egoism

A

Ethics

A branch of philosophy that deals with distinguishing right from wrong.

Tonja Problem Identification

A conflict exists- 1)The client needs information 2)The nurses desire to provide the information 3)Institutions policy prohibiting the provision of that information.

Civil law

A law that governs relationships between individuals and defines their legal rights.

An individual may be considered gravely disabled for which of the following reasons? (Select all that apply.) a. A person, because of mental illness, cannot fulfill basic needs. b. A mentally ill person is in danger of physical harm based on inability to care for himself or herself. c. A mentally ill person lacks the resources to provide the necessities of life. d. A mentally ill person is unable to make use of available resources to meet daily living requirements.

A, B, D

Competency

Ability to express choice Capacity to comprehend the information given about treatment Capacity to grasp what the information means Capacity to reach a logical conclusion

Nonmaleficence

Abstaining from negative acts toward another; includes acting carefully to avoid harm. ex. client taking a med but now they are having bad side effects we would want to switch the medication

Restraints and Seclusion Overview

Aim: least restrictive measures to maintain safety. Never used as a punishment Used as a last resort, try least restrictive measures first Risk: false imprisonment, physical and psychological harm Joint Commission Accreditation of Health Care Organization (JCAHO) guidelines. Health Care Organization Policy: collects data/reports data Clear documentation of assessment and interventions

Tonja Alternatives

Alternative 1: Benefit: Give the client information. Consequence: Risk losing job for violating hospital's policy. Alternative 2: Benefit: Do not give client information (comply with the hospitals policy). Consequence: Compromise own values of holistic nursing. Alternative 3: Benefit: Refer the client to another source outside the hospital. Consequence: risk reprimand from supervisor

Assault

An act that results in a person's fearthat they will be touched without consent (threat). Harm need not have occurred. -making a threat to a client e.g. "if you do not take these meds I will force them down your throat."

Nursing liability in psychiatric setting

Assault and battery Breach confidentiality False imprisonment (restraint and seclusion when it is not part of the clients treatment) Invasion of privacy (phones; mail) Boundary violations (social media) Failure to warn Negligence (not providing reasonable nursing care resulting in an injury). Defamation of character: slander (oral defamation) libel (written)

A nurse decides to put a client who has a psychotic disorder in seclusion overnight because the unit is very short-staffed, and the client frequently fights with other clients. The nurse's actions are an example of which of the following torts? A. Invasion of privacy B. False imprisonment C. Assault D. Battery

B

A nurse gave a client 5 mg of haloperidol (Haldol) for agitation. The client's chart was clearly stamped "Allergic HALDOL." The client suffered anaphylactic shock and died. How would the nurse's actions be labeled? A. Intentional tort B. Negligence C. Battery D. Assault

B

A nurse hears a newly licensed nurse discussing a client's hallucinations in the hallway with another nurse. Which of the following actions should the nurse take first? A. Notify the nurse manager. B. Tell the nurse to stop discussing the behavior. C. Provide an in-service program about confidentiality. D. Complete an incident report.

B

The nurse assists the physician with electroconvulsive therapy on a client who has refused to give consent. With which of the following legal actions might the nurse be charged because of this nursing action? a. Assault b. Battery c. False imprisonment d. Breach of confidentiality

B

The nurse decides to go against family wishes and tell the client of his terminal status because that is what she would want if she were the client. Which of the following ethical theories is considered in this decision? a. Kantianism b. Christian ethics c. Natural law theories d. Ethical egoism

B

A nurse is caring for a client who is in mechanical restraints. Which of the following statements should the nurse include in the documentation? (Select all the apply.) A. "Client ate most of his breakfast." B. "Client was offered 8 oz of water every hour." C. "Client shouted obscenities at assistive personnel." D. "Client received chlorpromazine 15 mg by mouth at 1000." E. "Client acted out after lunch."

B, C, D

Which of the following statements is correct regarding the use of restraints? (Select all that apply.) a. Restraints may never be initiated without a physician's order. b. Orders for restraints must be reissued by a physician every 2 hours for children and adolescents. c. Clients in restraints must be observed and assessed every hour for issues regarding circulation, nutrition, respiration, hydration, and elimination. d. An in-person evaluation must be conducted within 1 hour of initiating restraints.

B, D

Documentation

Based on nursing standards ( e.g. nurse practice act; code of ethics, policy/procedures at facility) Electronic medical record (EMR) or paper chart are legal documents. Document client behaviors: objectively Avoid jargon and avoid judgment. Follow the nursing process Assessment Diagnosis Planning/goals Intervention Evaluation

A client tells a nurse, "Don't tell anyone, but I hid a sharp knife under my mattress in order to protect myself from my roommate, who is always yelling at me and threatening me." Which of the following actions should the nurse take? A. Keep the client's communication confidential. but talk to the client daily, using therapeutic communication to convince him to admit to hiding the knife. B. Keep the client's communication confidential, but watch the client and his roommate closely. C. Tell the client that this must be reported to the health care team because it concerns the health and safety of the client and others. D. Report the incident to the health care team, but do not inform the client of the intention to do so.

C

A competent, voluntary client has stated he wants to leave the hospital. The nurse hides his clothes in an effort to keep him from leaving. With which of the following legal actions might the nurse be charged because of this nursing action? a. Assault b. Battery c. False imprisonment d. Breach of confidentiality

C

A nurse in an emergency mental health facility is caring for a group of clients. Then nurse should identify that which of the following clients requires a temporary emergency admission? A. A client who has schizophrenia with delusions of grandeur B. A client who has manifestations of depression and attempted suicide a year ago C. A client who has borderline personality disorder and assaulted a homeless man with a metal rod D. A client who has bipolar disorder and paces quickly around the room while talking to himself

C

Attempting to calm an angry client by using "talk therapy" is an example of which of the following clients' rights? a. The right to privacy b. The right to refuse medication c. The right to the least-restrictive treatment alternative d. The right to confidentiality

C

The nurse decides to tell the client of his terminal status because she believes it is her duty to do so. Which of the following ethical theories is considered in this decision? a. Natural law theories b. Ethical egoism c. Kantianism d. Utilitarianism

C

Seclusion

Client is confined alone in a designated safe room from which they are unable to leave. Considered a physical restraint.

Common laws

Common: law that has been developed on the basis of preceding rulings by judges. Example: informed consent, patients right to refuse treatment.

True or False: A client who is admitted involuntarily to an acute care mental health facility automatically loses their right to informed consent.

False

Philips IEA

IEA Petition: Danger to self and others due to current symptoms of mental illness. •Clinician calls local police to inform them an IEA petition is being filed and requesting Philip be brought to the ER for further evaluation. •Once at the ER Philip is medically and psychiatrically evaluated.

IEA - State of NH Judicial Branch

IEA petition with specific evidence of harm to self/harm to others. Within 72 hours of IEA admission: a probate court hearing is held to determine if IEA still needed. -for involuntary emergency admission must be seen by a judge and they will be released if judge says so but if not they could have to stay there for up to 10 days

Utilitarianism

Idea that the goal of society should be to bring about the greatest happiness for the greatest number of people

Guardienship

If a Judge (Probate Court) determines a person is incapacitated (incompetent), a guardian is appointed that has authority to make decisions for that individual.

JCAHO

Joint Commission on Accreditation of Healthcare Organizations

Weak documentation

Judgmental language Assessment not objective No patients statements included as evidence No documentation of the patient response to the nursing intervention (i.e. what was the response to lorazepam dose). Credentials not included; no date or time included ex. The patient is out of control; he is going to hit somebody; he is all over the place; he is aggressive; he is angry at Dr. J for committing him to the State Hospital; trying to destroy hospital property. The client received. lorazepam 1mg. PO X 1 @ 2pm.

Health Care Organization (HPO) Policy and Procedure Guides

Know facilities specific policies and procedures. They could differ from states scope of practice. Example: a nurse may be able to perform a procedure under the nurse practice act but the facility doesn't allow that procedure to be performed by nurses.

JCAHO seclusion and restraint guidelines

Never a standing order or a prn order. A provider must provide a face-face assessment within 1 hour. Discontinued as soon as possible. Continuous monitoring Nursing face to face assessment- seclusion every hour, restraints every 30 minutes Offer hydration, food, bathroom, range of motion Documentation every 15 minutes during seclusion/ restraint episode Use of restraints need to be renewed: Every 4 hours for an adult Every 2 hours for ages 9-17yrs. Every 1 hour for ages under 9 yrs. ** Be aware of false imprisonment

Stronger documentation

Objective assessment loud, angry tone of voice kicked the office doorPatient statements: "dr. J put me here because he just doesn't like me" Nursing process followed: assessment Interventions (always reassess after interventions) evaluation Signed and dated Ex. The patient is alert, oriented x 4; dressed in sweatshirt and hospital pants, barefoot; eye contact is intense, affect congruent with irritable, anxious mood; angry loud tone of voice ; thought content focused on hospitalization - " he put me here because he just doesn't like me"; hands clenched tightly; pacing back and forth in hall kicking Dr. J. office door as he passes by. Nurse spent time 1:1 providing support and allowing patient to share feelings re: hospitalization and frustrations with unit rules. Lorazepam 1 mg po given @ 2pm. Patient receptive to nursing interventions and at 3pm reported in a softer tone of voice, " I feel less anxious now" Jane Sobolov, RN September 24, 2020 2pm

Guilty but mentally ill (GBMI)

Person with a mental illness: Knew the wrongfulness of actions. Had the ability to act otherwise.

Values

Personal beliefs about what is important

Justice

Principle based on the notion of a hypothetical social contract between free, equal, and rational persons. The concept of justice reflects a duty to treat all individuals equally and fairly. ex. 2 patients smoking in the room, the nurse would want to treat both patients fairly

Veracity

Principle that refers to one's duty to always be truthful. ex. a client states "you and that other nurse were talking about me weren't you?" the nurse would be honest and say " we were discussing ways to help you relate to more clients in a positive way'

Philip

Situation: Stopped taking mood stabilizer, hasn't slept for days, quickly moving between moods- going from euphoria to anger, believes he is the president of the united states, showed up for therapy appointment accusing therapist of breaking into his house last night and eating the food out of his fridge- shouting at therapist and quickly storms out of mental health center office- erratically drives away. Current DX: Bipolar Disorder - manic phase.

Always report...

Suspected child abuse or neglect. Suspected abuse/neglect of vulnerable adult.

Health Care and the Americans with disability Act

The Americans with Disabilities Act (ADA) is a federal civil rights law that prohibits discrimination against people with disabilities. Health care organizations that provide services to the public are covered by the ADA. Federal Law 1990.

Not guilty by reason for insanity (NGRI)

When crime happened: No understanding of their actions No control over actions

Tonja case study

Tonja is a 17 year old girl who is currently on the psychiatric unit with a diagnosis of conduct disorder. Tonja reports that she has been sexually active since she was 14. She had an abortion when she was 15 and a second one 6 weeks ago. She states that her mother told her she has "had her last abortion" and that she has to start taking birth control pills. She asks the nurse, Kimberly, to give her some information about the pills and to tell her how to go about getting some. Kimberly believes Tonja desperately needs the information about birth control pills, as well as other types of contraceptives, but the psychiatric unit is part of a catholic hospital, and hospital policy prohibits distributing this type of information.

Incompetency

Unable to understand and appreciate information given. Decided by the probate court system.

Battery

Unconsented touching of another person. Treatment administered against wishes. Outside of an emergency situation. Harm need not have occurred. e.g. restraints used without first trying other less invasive methods and a patient gets hurt.

Intentional torts

assault, battery, false imprisonment

Medicating without consent

•Clients have the right to refuse medications except: 1.The client exhibits behaviors that are dangerous to self or others. Considered emergency treatment. 2.The treatment team determines the person needs medications as primary treatment to function. 1.The client who is refusing medications must be judged incompetent to evaluate the benefits or the treatment in question. 2.The court system is pursued to approve forced treatment. In NH called a HEM-306. 3.The medications ordered by the physician must have a reasonable chance of providing help to the client.

Philip ER

•ER physician determines Philip meets criteria for involuntary emergency admission due to dangerousness. •Referral to Designated Receiving Facility (NHH) is made. Philip waits for next available bed at NHH for involuntary treatment.

Nurses avoiding liability

•Effective communication •Establishing therapeutic rapport •Respond to client and family needs •Develop a good interpersonal relationship with patient and family •Providing education to patient and family •Knowing the client •Provide education/support: client and family •Accurate and complete documentation in the medical record. •Complying with standards of care and policies •Practicing within the nurse's level of competence and scope of practice. •Appropriate delegation (5 rights) •Use the nursing process.

Restraints

•Mechanical restraint: any manual method used to restrict a person's freedom of movement. •Medications (chemical restraints) •Leather straps •Clothing which limits someone's movement and which the person cannot remove. •Velcro straps, leather straps and belts. •Seatbelt locks on geriatric chairs •Putting a person's wheelchair brakes so they can't move if they want to. •Manual hold. •Side rails (when the person is unable to operate the rails) • When are restraints used in a psychiatric unit? •Used when behavior is out of control and a safety risk exists -anything that doesn't allow them to freely move their body is a restraint

Philip's IEA hearing

•Occurs within 3 business days after admission to NHH. •Court hearing is ensuring there is reasonable probable cause to confine the person for involuntary treatment. •The petitioner of the IEA must be present. •If probable cause is found person can be held up to 10 days for treatment.