Ethical and Legal Issues in Psychiatric Nursing

2 hours

Unless state law is more restrictive, orders for restraints must be renewed every: -every ____ for children ages 9-17.

· When a client is mentally incompetent, and treatment is necessary to avoid death or harm · Refusing treatment endangers life or health of another · During an emergency and client is in no condition to exercise judgement · When the client is a child · Therapeutic Privilege: physician determines disclosure would hinder necessary treatment, cause severe psychological harm, be so upsetting the client could not make a rational decision

When may a client's refusal for treatment be challenged???

Ethics

___- A branch of philosophy that deals with systematic approaches to distinguishing right from wrong behavior

C. Tell the client that this must be reported to the healthcare team because it concerns the health and safety of the client and others

A client tells a nurse, "Don't tell anyone, but I hid a short knife under my matress in order to protect myself from my roommate who is always 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 them to admit to hiding the knife B. Keep the client's communication confidential, but watch the client and their roommate closely C. Tell the client that this must be reported to the healthcare 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. False imprisonment

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

B. False imprisonment

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. Tell the nurse to stop discussing the behavior

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

C. A client who has borderline personality disorder and assaulted a homeless man with a metal rod

A nurse in an emergence mental health facility is caring for a group of clients. The 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 themselves

B. Client was offered 8oz of water every hour C. Client shouted obscenities at assistive personnel D. Client received chlorpromazine 15mg

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

Ethical Theory

An ____ is a moral principle or a set or moral principles that can be used in assessing what is morally right or morally wrong; these provide frameworks for ethical decision-making

A. A person, because of mental illness, cannot fulfil basic needs B. A mentally ill person is in danger of physical harm based on inability to care for himself or herself D. A mentally ill person is unable to make use of available resources to meet daily living requirements

An individual may be considered gravely disabled for which of the following reasons? SATA A. A person, because of mental illness, cannot fulfil 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

C. The right to least-restrictive treatment alternative

Attempting to calm an angry client be using "talk therapy" is an example of which of the following Client's rights? A. The right to privacy B. The right to refuse medication C. The right to least-restrictive treatment alternative D. The right to confidentiality

· Effective communication with patients and other caregivers. · Accurate and complete documentation in the medical record. · Complying with standards of care · Knowing the client · Practicing within the nurse's level of competence and scope of practice.

Avoiding Liability:

15-30min

Document every ___: precipitative events and behavior prior to restraint, alternative actions taken to avoid seclusion/restraint, time treatment began, the client's current behavior, what foods/fluids were offered, needs provided for, vital signs, medication administration, and time released from restraints.

A. Threatens violence toward another individual B. Identifies a specific intended victim

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

D. Assault

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 with because of this action? A. Defamation of character B. Battery C. Breach of confidentiality D. Assault

-Right to Humane Treatment -Right to receive and refuse treatment -Right to least-restrictive treatment alternative -Right to vote -Right to granting, forfeiture, and denial of driver's license -Right to due process of law, including the right to press legal charges against another person -Informed Consent and the right to refuse treatment -Confidentiality -A writing plan of care/treatment AND Involvement in plan of care and review of the plan of care -Communication with people outside the facility (family, attorneys, other doctors) -Interpretive services -Care provided with respect, dignity, no discrimination -Freedom of harm from physical or pharmacological restraint, mental abuse, or neglect -Psychiatric Advanced Directive (PAD) that includes the client's treatment preferences in the event that an involuntary admission is needed.

Legal Rights of Clients:

· Assessment: Gather subjective & objective data about a situation. Consider the personal values of all involved in the ethical dilemma. · Problem Identification: Identify the conflict between two or more actions. · Planning: Explore pros and cons of each alternative. Consider principles of ethical theories. Select alternative · Implementation: Act on the decision made and communicate the decision to others. · Evaluation: Evaluate Outcomes

Model for Making Ethical Decisions:

· The nurse may choose to implement (if facility policy allows) but should call provider ASAP for verbal order. The written order is typically obtained within 15 to 30 minutes. · Assessment during and after/including VS/pain · Basic needs must be met · Documentation should be thorough. Include precipitating events/alternative and least restrictive measures attempted/ time begin and end/all colleagues involved/ medications offered/taken · Client's behavior afterward

Nurses Role During Restraint or Seclusion:

24 consecutive hours

Orders for restraints may be renewed according to these time limits for a maximum of ____.

continuously monitored by trained staff, either in person or through audio or video equipment positioned near the patient

Patients who are simultaneously restrained and secluded must be ____

as soon as possible regardless of when the order is scheduled to expire

Seclusion or restraint is discontinued as soon as _____

respiratory and circulatory status, skin integrity, and vital signs.

Staff who are involved in restraining and secluding patients are trained to monitor the physical and psychological well-being of the patient including but not limited to ____

The Duty To Warn (Tarasoff Law)

The ____ deals with situations where there is an assessment of a threat of violence by a client to another individual. The law states that under certain circumstances, a therapist might be required to warn the individual, notify police, or take whatever steps are necessary to protect the intended victim of harm. · Courts house outlined the following guidelines for therapists to follow in determining their obligation to take protective measures (_____): 1. Assessment of a threat of violence by a client to another individual 2. Identification of the intended victim 3. Ability to intervene in a feasible, meaningful way to protect the intended victim · If a client confides in the nurse about the potential for harm to an intended victim, it is the nurse's duty to report this information to the psychiatrist and to other team members. Nurse may be considered negligent for failing to warn an individual if a client has intentions to harm them. · Document in detail!

§ Presence of mental illness § Poses a danger to self/others § Demonstrates severe disability or inability to meet basic needs § Requires treatment but unable to seek it voluntarily related to the impact of the mental illness

The criteria for involuntary admission are:

B. Battery

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 with because of this nursing action? A. Assault B. Battery C. False imprisonment D. Breach of confidentiality

B. Christian Ethics

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

A. Utilitarianism

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 conserved in this decision? A. Utilitarianism B. Kantianism C. Christian Ethics D. Ethical Egoism

C. Kantianism

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

4 hours

Unless state law is more restrictive, orders for restraints must be renewed every: -every ____ for adults 18yr or older

1 hour

Unless state law is more restrictive, orders for restraints must be renewed every: -every ____ for children younger than 9 years

B. Orders for restraints must be reissued by a physician every 2 hours for children and adolescents. D. An in-person evaluation must be conducted within 1 hour of initiating restraints.

Which of the following statements is correct regarding the use of restraints? SATA A. Restraints may never be initiated without a physician's orders 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.

Christian Ethics

___ are focused on the way of life and teachings of Jesus Christ. The imperative demand is that all decisions about right and wrong should be centered in love for God and in treating others with the same respect and dignity with which we would expect to be treated.

Ethical Egoism

___ espouses that what is right and good is what is best for the individual making the decision. The action may not be best for anyone else involved, but consideration is only for the individual making the decision.

Assault

___ is an act that results in a person's genuine fear and apprehension that he or she will be touched without consent (making a threat). This can result when a client is treated without consent and against their wishes. -EX: approaching a client with a syringe in a threatening way

Kantianism

___ is opposite from utilitarianism; "it is not the consequences or end results that make an action right or wrong, rather it is the principle or motivation on which the action is based that is the morally decisive factor." Decisions based on this theory are made out of respect for moral law ("I make this choice because it is morally right")

Utilitarianism

___ is the "greatest happiness principle"; it holds that actions are right to the degree that they tend to promote happiness and are wrong as they tend to produce the reverse of happiness. Ethical decisions based on this theory look at the end results of the decision

Battery

___ is the unconsented touching of another person, usually touching in a harmful manner. This can result when a client is treated without consent and against their wishes. -EX: a nurse threatening manner with a syringe in hand is considered assault

Bioethics

___- The term applied to these principles when they refer to concepts within the scope of medicine, nursing, and allied health

Moral Behavior

___- is conduct that results from serious critical thinking about how individuals ought to treat others. It reflects the way a person interprets basic respect for other persons, such as the respect for autonomy, freedom, justice, honesty, and confidentiality.

The Mentally Ill Person In Need of Treatment

___: this admission is involuntary and for clients with severe mental illness who are unable to make informed decisions concerning treatment, likely to cause harm to self/others, and is unable to fulfil basic personal needs necessary for health and safety.

Libel

___: when defamation of character occurs and the information shared is in writing, it is called ___.

Slander

___: when defamation of character occurs and the information shared is oral, it is called ___.

Defamation of Character

___: when shared information is detrimental to the client's reputation, the person sharing the information is held liable for defamation of character. The information shared involves communication that is malicious and false. -Libel Slander

Invasion of Privacy

____ is a charge that may result when a client is searched without probable cause.

Statutory Law

____ is a law that has been enacted by a legislative body, city counsel, state legislature, US Congress, etc. An example is the nurse practice acts.

Seclusion

____ is a type of physical restraint in which the client is confined alone in a room from which they cannot leave. It is usually furnished minimally with items to promote client comfort and safety.

Tort

____ is a violation of a civil law in which an individual has been wronged. In a ___ action, one party asserts that wrongful conduct on the part of the other has caused harm and seeks compensation. A ___ may be intentional or unintentional. It is referred to as a civil wrong doing, in which monetary damages can potentially be awarded to the plaintiff (injured) and collected from the defendant (responsible party)

Natural Law Theory

____ is based on the writings of St. Thomas Aquinas; it advances the idea that decisions about right/wrong are self-evident and determined by human nature.

False imprisonment

____ is the deliberate unauthorized confinement of a person within fixed limits by the use of verbal or physical means. It is confining a client to a specific area physically, verbally, or using a chemical restraint when it is not part of the clients treatment

Criminal Law

____ law provides protection from conduct deemed injurious to the public welfare. It provides for punishment of those found to have engaged in such conduct. An example of a violation of criminal law is the theft by a hospital employee of supplies or drugs.

Contracts

____: In a ____ action, one part asserts that the other part, in failing to fulfill an obligation, has breached the ___, and either compensation or performance of the obligation is sought as a remedy.

Long-term Involuntary Commitment

____: This type of admission is similar to temporary commitment but it must be imposed by courts. Typically 60 to 180 days.

The Gravely Disabled Client

____: a ____client has a condition /mental illness that is in danger of harm as a result of inability to provide for basic needs like food, clothing, or shelter. When an individual is determined to be gravely disabled, a guardian is appointed to the individual to ensure management of care.

Autonomy

____: ethical principle based on the client's right to make decisions/must accept consequences of decisions. People are autonomous moral agents whose right to determine their destinies should be respected. § EX: rather than giving advice to a client who has difficulty making decisions, a nurse helps the client explore all options to arrive at a choice

Fidelity

____: loyalty/faithfulness to client and one's duty § EX: a client asks a nurse to be present when they talk to their guardian for the first time in a year. The nurse remains with the client during this interaction.

Involuntary admission

____: this admission occurs when the client enters the mental health facility against their will for an indefinite amount of time. It is based on the need for treatment, risk of harm to self/others, and ability to provide -Client can request a legal review of admission at any time -It is conducted in adherence to state and federal laws that usually cite the following criteria for admission: 1. The client is an imminent risk to self or others. 2. The client is a danger to others 3. Client is unable to meet basic personal needs -Clients are still considered competent and have the right to refuse treatment. -Admission is limited to 60 days and must have psychiatric and legal review of commitment.

Justice

____: this ethical principle is fair and equal treatment for everyone regardless of race, gender, marital status, medical diagnosis, social standing, economic level, or religious beliefs. § EX: during a treatment team meeting, a nurse leads a discussion regarding whether or not two clients who broke the same facility rule were treated equally

Nonmaleficence

____: this ethical principle is the requirement that health-care providers do not harm to their clients, either intentionally or unintentionally. Ethical Dilemmas arise when a conflict exists between an individual's rights and what is thought to be best represent the welfare of the individual (a psychiatric client refuses antipsychotics, and the nurse must then decide how to maintain client safety which psychotic symptoms continue).

Veracity

____: this ethical principle refers to one's duty to always be truthful; honesty/truthfulness. It requires the health-care provider to tell the truth and not intentionally decieve or mislead clients § EX: a client states "you and that other staff member were talking about me weren't you?" the nurse truthfully replied, "We were discussing was to help you relate to the other clients in a more positive way."

Beneficence

____: this ethical principle refers to one's duty to benefit or promote the good of others (doing good/charity). Health care workers who act in their client's best interests are beneficent. § EX: a nurse helps a newly admitted client who has a psychotic disorder to feel safe in the environment of the facility § Client Advocacy is an essential role for a psychiatric nurse and means acting in another's behalf as a supporter or defender. Helping clients fulfill needs that, without assistance and because of their illness, may go unfulfilled. Strategies include educating clients and their families about legal rights, ensuring clients have info to make informed decisions, helping clients consider alternatives, and supporting the client's decisions.

Civic Law

_____ law protects the private and property rights of individuals and businesses. -Tort -Contracts

Common Laws

_____ laws are derived from decisions made in previous cases. These apply to a body of principles that evolve from court decisions resolving various controversies. An example might be how different states deal with a nurse's refusal to provide care for a specific client.

Ethical Dilemma

_____- The nurse is forced to choose between two equally unfavorable alternatives. Evidence exists to support the moral "rightness" and wrongness" related to a certain action. -E____ arise when there is no clear reason to choose one action over another. Often, reasons supporting both arguments are logical and appropriate. -EXAMPLE: A patient has the right to refuse their heart medication. The nurse knows the patient also suffers from depression and suicidal ideations. Could the patient be intending self-harm by refusing the medication? What is the best course of action?

Values

_____- are personal beliefs about what is important and desirable. Values clarification is a process of self-exploration through which individuals behave in certain ways. Values clarification is important in nursing to increase understanding about why certain choices and decisions are made over others and how values affect nursing outcomes.

Involuntary Outpatient Commitment

_____: this is a court ordered admission used to compel a person with mental illness to submit to treatment on an outpatient basis. There are many eligibility criteria such as: -History of repeated decompensation requiring hospitalization - Likelihood that without treatment the individual will deteriorate to requiring inpatient commitment -Presence of severe/persistent mental illness and limited awareness of the illness or need for treatment

Voluntary admission

______: The client seeks admission on own free will and can stay as long as treatment is deemed necessary. They choose to be admitted in order to obtain treatment. The client is competent, has the right to refuse medication. Is free to sign out at any time if not a risk to self or others following a mental status examination

1 hour

o An in-person evaluation must be conducted within ___ of initiating restraint or seclusion by a physician. Trained registered nurses may also conduct the assessment, but must consult with the physician.

Right

· A ____ is a "valid legally recognized claim or entitlement, encompassing both freedom from government interferences or discriminatory treatment and an entitlement to a benefit or service." -A right is absolute when there is no restriction whatsoever on the individual's entitlement. -A legal right is one on which the society has agreed and formalized into law. -The NLN and AHA have established guidelines of patient's rights. Although these are not considered legal documents, nurses and hospitals are responsible for upholding these rights.

timeout

· Client may request a "___" if the environment is too stimulating. It is different from prescribed seclusion because a timeout is by the request of the client.

Autonomy Beneficence Nonmaleficence Justice Fidelity Veracity

· Ethical Principles are fundamental guidelines that influence decision-making. They are helpful and are used be health-care workers to assist with ethical decision-making What are the ethical principles?

suspected child abuse

· Every state requires that health-care professionals report ___ to legal authorities. -Many jurisdictions also have statutes requiring that suspected elder abuse/neglect be reported. · Nurses can be reluctant to report in fear of being held liable for false accusations, but these reports generally grant immunity to anyone making them in good faith. · In some states, it is a criminal act not to report suspected abuse/neglect.

legal guardian

· If an individual has been legally determined mentally incompetent, consent is obtained from the ____.

Restraint

· In psychiatry, the term _____ usually refers to a set of leather straps used to restrain the extremities of an individual whose behaviors is out of control and who poses an immediate risk to the physical safety and psychological well-being of themselves and others. -May be required in certain situations. -Know state/federal/facility policies

-Verbal intervention -Diversion or redirection -Providing a calm, quiet environment -Offering a PRN medication

· Other methods of decreasing agitation, like talking down (verbal intervention) or chemical restraints (tranquilizing medications), are tried first before physical restraints. Methods of less restrictive measures include:

punishment

· Restraints are always a last resort! NEVER TO BE USED AS _____ OR FOR CONVENIENCE OF STAFF. Restrains should also not be used to are extremely physically or mentally unstable OR for clients who cannot tolerate the decreased stimulation of a seclusion room.

The client must exhibit behaviors that is dangerous to self or others; the medication ordered by the physician must have a reasonable chance of providing help to the client; and clients who refuse medication must be judged incompetent to evaluate the benefits of the treatment in question

· Right to receive and to refuse treatment: Patients have the right to refuse treatment unless immediate intervention is required to prevent death or serious harm to the patient or another person. -"The treatment team must determine that three criteria be met to force medication without client consent. ______."

Duty to warn/child or elder abuse

· The Health Insurance Portability and Accountability Act (HIPAA) protects client's right to privacy. It pertains to data called protected health information (PHI). o Know your federal and state laws! · Under HIPAA, individuals have the rights to access their medical records, to have corrections made to their medical records, and to decide with whom their medical information is shared. · Only share information with those directly involved with the client's care! · Client must provide consent to share info with those not involved in client's care. · Exceptions: _____/_____

1. Knowledge/Education: the client has received adequate information on which to base their decision 2. Competency: the individual's cognition is not impaired to an extent that would interfere with decision making; or they have a legal representative 3. Free Will:the individual has given consent voluntarily without coercion from others

· The nurse can sign the consent form as a WITNESS to the client's signature. The nurse acts as a client advocate in ensuring that the following three major elements of informed consent have been addressed:

informed consent

· The rationale for the doctrine of ____ is the preservation and protection of individual autonomy in determining what will and will not happen to a person's body. -_____ is permission granted by a client for a physician to perform a therapeutic procedure.

Emergency admission

· ___: This type of admission is sought when an individual manifests behaviors that is clearly and imminently dangerous to self/others. The client is admitted for emergent mental health care due to inability to make decisions regarding care. It is typically sought by police, friends, relatives, court, or health care professionals. Time limited and court hearing is scheduled within 72 hours. Typically does not exceed 15 days. o EXAMPLE: A child is brought in from a state agency or from the ER