Ethics, QUIZ 3

AIDS and HIV Testing (CDC Recommendation has changed from what to what?(1, 1-1) CONFIDENTIALITY--Healthcare providers?~ Warning known partners?(1) --->this is an ethical duty, and many times a _____ duty in most states? Most statues do NOT authorize nurses to do what?(1) ANA supports ethical responsibility of what, when?(1-3) -->if the nurse is to be the one to disclose this info to a 3rd party, why?(1-1))

AIDS and HIV Testing •CDC recommendation --Recommendations changed from HIV testing of those with high risk factors to HIV screening of all patients between the ages of 13 and 64 years old •Confidentiality --Healthcare providers must keep HIV information confidential --Usually a few exceptions to the rule (not listed in book) •Warning known partners --Physicians and nurses have a duty to their patients to keep HIV information confidential •This is an ethical duty and many times a legal duty in most states *Most statutes do NOT authorize nurses to pass this information to known partners *ANA supports ethical responsibility of disclosing HIV information to an identified partner who is at risk by the nurse's patient when certain conditions apply •Nurse must be primary care provider •Patient must have received counseling on the benefits of warning partners •Nurse must reasonably believe the patient will not warn the partner *If a nurse is to be the one to disclose information to a 3rd party, they should consult an attorney who is familiar with the state statute

AIDS and HIV Testing Continued (EXCEPTIONS TO INFORMED CONSENT?(4) Mandatory testing may be done when?(1)-->unless?~)

AIDS and HIV Testing Continued •Exceptions to informed consent --In urgent situations for diagnostic confirmation purposes and the patient is unconscious --If a healthcare provider has exposure throughout their duty and the patient refuses testing •--->Example: a needle-stick injury that occurs in the nurse should be allowed to have the patient tested regardless of if they want to or not --If patient is deceased and diagnosis is necessary for cause of death --Prior to organ donation •Mandatory testing may be done when: --During pregnancy—unless there is specific written proof of a refusal

Abusive Situations (Family Violence is defined how?~ When to suspect abuse?(1) Nurses are what in these situations?(1)--->suspected abuse of a child?(1))

Abusive Situations •Family violence is defined as inappropriate and damaging interpersonal harm among individuals with interpersonal relations regardless of their actual biological or legal relationships •When to suspect abuse? --If there is a discrepancy between the physical findings and explanations of how an incident occurred—this is a valid reason to suspect abuse •Nurses are mandated reporters --Suspected abuse of a child needs to be communicated to the appropriate authorities

Agency protocols related to organ and tissue donation (Every agency must have protocols for what?(2)-->must provide this for what?(1) Must provide staff training for what kinds of things?~ Notify who of a potential donor?(1))

Agency protocols related to organ and tissue donation •Every agency must have protocols for: --Identifying potential donors --Notifying family of potential options donating or refusing to donate •----Must provide for acceptance of family's decision to decline --Must include staff training to ensure discretion and sensitivity regarding views, beliefs, the circumstances --Notify an OPO of potential donor

Informed Consent Exceptions (5)

Are there any exceptions? 1. Delay to get consent would result in injury or death 2. Patient is unconscious 3. No one is available or has the legal authority to give consent 4. Any reasonable person would consent under similar circumstances 5. There is no reason to believe the patient would refuse this treatment

Competency and Guardianship (Presumption of competence--What is this?~ DETERMINING COMPETENCY--For patients who temporarily lack decision making capacity?~ If the patient might not want the particular care or family questions the care--What should you do?(2))

Competency and Guardianship •Presumption of competence -All persons over age 18 years are presumed competent unless clear and convincing proof that person lacks decision making capacity. -Determining competency •For patients who temporarily lack decision making capacity it is proper to render usual nursing care •If the patient might not want the particular care or the family questions the care that is given to the patient, it is best to document this objectively in the record and bring it to the attention of the physician

Confidential Communication (What does this mean?(1)*-->examples? What is the legal and ethical framework--Includes things such as?(2) Examples--Act?(1) Various?(1) Standards set by who?(1))

Confidential Communication •What does this mean? -This basically means ANY information obtained via the nurse-patient relationship is considered confidential (be it from the electronic record, pt. assessment, pt. talking, ANYTHING). •What is the legal and ethical framework? -ANA Code of Ethics -U.S. Constitution --Examples: •--->Federal Privacy Act of 1974, Various patients' bills of rights, standards set by The Joint Commission

Consequences of disclosure of confidential information (Exposure to civil suits--Nurses may be held liable for what?(1) Who else may be also held liable?(1) Disciplinary action by who?(1)-->State boards are increasingly dealing with discipling for what?(1) Job Loss--as a result of what?(1) Employers usually?(1)* Fines are based on what?(1)--->can be subject to what?(1 or 1))

Consequences of disclosure of confidential information •Exposure to civil suits --Nurse may be held liable to a patient in a tort action for breach of confidentiality --Nurse's employer may also be held liable --Invasion of privacy (tort) may also be another issue •Disciplinary action by state board of nursing --Violation of ethical codes or negligence in performing ordinary duties can be the basis of a disciplinary proceeding against a nurse --State boards are increasingly dealing with discipline of nurses who improperly use social media to disclose confidential patient information •Job loss --A nurse could be discharged from his or her job as a result of proven breach of confidentiality related to the care of patients •Employers usually have ZERO tolerance policy for this behavior •Fines based on violations of HIPAA --Can be subject to fines or possible criminal charges by government

Consequences of error (Malpractice action?(1) Disciplinary action by SBON?(3) For serious errors that result in serious injury or death?(1))

Consequences of error •Malpractice action: civil action, nurse may be liable •Disciplinary action by SBON: suspension, revocation, censure •Criminal action or charges: for serious errors that result in serious injury or death

Definitions of pain (ACUTE PAIN--Occurs when, continuing when?(1-1) If not managed?(1) CHRONIC PAIN--Lasts how?(1)-->usually more than how long?(1) & is often associated with what?(1) MALIGNANT PAIN--Can be described as what?(1) and is often associated with what?(2))

Definitions of pain •Acute pain --Occurs immediately after an injury and continues until healing is completed --If not managed it can lead to a chronic state •Chronic pain --Lasts for a prolonged period of time, usually for more than 6 months and is often associated with depression •Malignant pain --Can be described as intractable and is often associated with cancer or other prolonged and debilitating conditions

Disclosure Permitted (5) (Patient Permission--must do what?(1) Waver should be specific how?~ Other healthcare workers/ agencies--only on what kind of basis? Statutory/legal duty to report--some types of information? Nurse should check with what/ who first?(2) Common law or public interest--Can happen in what kinds of extreme situations?~ Ex?(1) Nurses need to be careful-->for example?~ Duty to Warn--when does this happen? Should document what?~)

Disclosure Permitted •Patient permission --Must sign a waver --Waver states that the patient waives the right to keep the information confidential but should be specific as to what exact information can be released and to whom •Other healthcare workers or agencies --Relevant information can be shared with other caregivers or agencies that have a legitimate right to know the information but only on a "need to know basis" •Statutory or other legal duty to report --Some type of information can be reported to public health agencies or other authoritative bodies --Nurse should check agency policies or with a supervisor before any information is released •Common law or public interest --Can happen in extreme situations where release of confidential patient information is in the public interest or is required for the safety of other patients --Regulations or laws permit disclosure of contagious disease when a contact person's health is in danger •Be aware of specific exceptions permitted for the patient's situation •Example: there is a right to withhold information about STIs •Duty to warn --Nurses may have professional duty to disclose confidential information to protect an identifiable victim --Should document repeated serious threats against another

Donation process, organ allocation

Donation process, organ allocation •Inclusion criteria: -Any age -Trauma -Stroke -Primary brain tumor -Cerebral anoxia -Homicide and suicide victims with medical examiner's permission •Exclusion criteria: -Transmissible diseases •---->IDS, hepatitis, etc. -Sepsis -Cancer •--->Other than skin cancer or primary brain tumor --Organ specific disease •Donor classifications -Cadaveric organ donor •---->Person who died of an injury or illness that did not affect the major organs and who can be maintained on mechanical support -Living related organ donor •---->Living person who donates a kidney or a part of the liver or a lung to an immediate blood relative -Living non-related •----->Non-blood relative or other person •Time of death -TISSUE donors don't require intact circulation, tissue donation sx needs to take place within maximum 24 hours after death. Organs can only be preserved for so long •Heart, lung: 4-6 hours •Liver: 8-12 hours •Pancreas: 12-18 hours •Kidney: 24-36 hours

Emergency psychiatric admissions (INVOLUNTARY ADMISSION--Also called what?(1) Permitted where?(1) Does NOT indicate what?(1) Does NOT negate what?(1) There is a delicate balance between what different things?~ When is patient consent not required?(1))

Emergency psychiatric admissions •Involuntary admission --Also called civil commitment --Permitted in all states --Does NOT indicate incompetence --Does NOT negate patient's rights •There is a delicate balance between patient rights and protecting the patient from themselves or protecting the public from the patient •Patient consent is not required when lifesaving measures are required

Ethical issues—what is death? (Uniform Determination of Death Act: DEFINED as what?(2 or 1) Two guiding moral principles of Dead Donor Rule?(2) Ethical Issues Regarding Retrieval of a Person's Organs--Until death is pronounced? Well-being of who? Perceived _____ of the organ donation itself. MISSOURI'S DEFINITION OF DEATH--(2))

Ethical issues—what is death? •1981 Uniform Determination of Death Act --Defined death as irreversible cessation of circulatory and respiratory functions or irreversible cessation of all functions of the brain •Two guiding moral principles of Dead Donor Rule 1. Person must first be dead before retrieval of organs 2. Person's life and care "must never be compromised in favor of potential organ recipients" •Ethical issues regarding retrieval of a person's organs 1. Properly caring for dying person until death is pronounced. 2. The well-being of family members who must say goodbye to dying loved one. 3. Perceived good of the organ donation itself. •What is Missouri's definition of death? -For all legal purposes, the occurrence of human death shall be determined in accordance with the usual and customary standards of medical practice, provided that death shall not be determined to have occurred unless the following minimal conditions have been met: •-->(1) When respiration and circulation are not artificially maintained, there is an irreversible cessation of spontaneous respiration and circulation; or •-->(2) When respiration and circulation are artificially maintained, and there is a total and irreversible cessation of all brain function, including the brain stem and that such determination is made by a licensed physician.

Informed consent is given when the following 3 elements are met?(3) (Information--what should they understand?~ Voluntary Consent--must NOT be under any what?(2) Sedated pt? Can be expressed?(2) Can also be implied how?(1)-->examples? Silence?(1) Competence--this involves what?(3))

Informed consent is given when the following 3 elements are met: •Information --Patient should be informed of risks and benefits associated with the treatment, risks and benefits involved in refusing treatment, the probability of a successful outcome, alternatives to the procedure, and the credentials of the person who will perform the procedure •Voluntary consent --Patient must not be under any influence or coercion --Sedated patient CANNOT give voluntary consent --Can be expressed in writing or verbally --Can also be implied by a patient's actions •--->Example: holding up an arm when getting a shot --Silence DOES NOT indicate consent to treatment •Competence ---Competent patients communicate choices, understand relevant information concerning treatment, and appreciate the situation as it applies to them

Legal causes of action (FALSE IMPRISONMENT--What is this? WRONGFUL COMMITMENT--Based on what, as opposed to what?(1-1) Patient must show that the mental health professional did what?~ This overall is similar to what?(1) INFLICTION OF EMOTIONAL DISTRESS--Frequently linked with what?(1) Most claims alleging causation between an act and emotional injury require what?(1) FAILURE TO WARN OF HARM TO 3RD PARTY--Mental health providers fails to do what?(1) 3rd party may do what?(1))

Legal causes of action •False imprisonment --This implies that the mental health professionals deliberately and maliciously held the patient by ignoring the statutory requirements for commitment or by failing to evaluate the patient prior to commitment •Wrongful commitment --Based on negligence as opposed to deliberate intent --Patient must show that the mental health professional erroneously certified the patient for commitment by virtue of a negligent diagnosis --Similar to false imprisonment •Infliction of emotional distress --Frequently linked with claims of negligence --Most claims alleging causation between an act and emotional injury require evidence that the alleged mental stress produced physical injury—but not in all cases •Failure to warn of harm to 3rd party --Mental health provider failures to commit a dangerous patient who makes a threat to harm an identifiable third person --3rd party may recovery damages related to the mental health provider's failure to commit a dangerous patient who threatens a 3rd party

Legislation (NATIONAL ORGAN TRANSPLANT ACT--Provides establishment of what?(2) Authorizes what for organ procurement organizations?(1) Requires all OPOs and US transplant centers to be what, in order to receive what?(1-1) OMNIBUS RECONCILIATION ACT OF 1986--Sets forth what?(2) UNIFORM ANATOMICAL GIFT ACT OF 1968 (UCGA)--Every state?~ Recognizes what?(2) Requires what?(1)-->HOWEVER?(1~))

Legislation *National Organ Transplant Act •Provides establishment of a task force on organ transplantation and an organ procurement and transplantation network •Authorizes financial assistant for organ procurement organizations •Requires all OPOs and US transplant centers to be members of Organ Procurement and Transplant Network to receive Medicare funding *Omnibus Reconciliation Act of 1986 •Sets forth hospital protocols for organ procurement and standards for organ procurement agencies *Uniform Anatomical Gift Act of 1968 (UAGA) •the model legislation r/t organ and tissue donation, every state has enacted some form of this. -----Recognizes limited capacity of minors and mentally disabled to make such decisions -----Requires written documentation of one's intent to donate after death (HOWEVER, physician usually seeks families opinion).

Medication administration (SIX RIGHTS?(6))

Medication administration •VERY IMPORTANT •SIX RIGHTS OF MEDICATION ADMINISTRATION --Patient --Drug --Dose --Time --Method --DOCUMENTATION

Minors and treatment for STDs (Minors with seeking treatment?(1) Treatment information of the minor?(1) Some statues may require what, in what circumstances?(1-1) STATE notification--Some states may require what?(1)-->this is NOT the same as what?(1) Sexual assault--what is required?(1)-->unless?(1))

Minors and treatment for STDs •Minors may seek treatment for STDs without parental consent •Treatment information goes to the minor due to confidentiality •Some statutes may require parental notification that a minor has been hospitalized for STD related treatment if the minor will be hospitalized for greater than a set amount of time •State notification ---Some states may require that the state public health or family advocate services be notified that a minor under a certain age is seeking reproductive services—this is NOT the same as parental notification •Sexual assault ---Parental notification is required unless the parent is the suspected abuser

Nurse's duty to patients in pain (Pain should be considered what, and evaluated when?(1-1) Assess impact pain has on what?(1) Make specific efforts to control pain---attitude when asked for assistance? If initial efforts fail?(1))

Nurse's duty to patients in pain •Consider pain the 5th vital sign and evaluate at EVERY patient assessment •Assess impact pain has on patient's life •Make specific efforts to control pain (non-judgmental attitude when pt. asking for assistance with management) •Request referral to an expert if initial efforts fail

Nurse's role in Discharge AMA (list then READ)

Nurse's role •Determine reason for leaving •Coordinate communication among providers •Offer services and treatment •Explain risks and benefits of care and refusal of care •Attempt to have patient sign waiver of treatment •Offer support, transportation, discharge instructions, supplies and meds •Notify physician and manager/house supervisor •Always make sure to document all efforts to provide the patient with information necessary to make decision to accept or refuse care—should be objective and include date, time, and who spoke with the patient, what the patient was told, comments made by the patient, and the final disposition

Organ and Tissue Donation (Can organs or tissues be bought or sold in the US?(1) Organ / tissue donation in the US is strictly what?(1)--->this protects who, from what?(1-1) Demand vs. Supply?(1) Computer generates list of donors who are ranked according to what?(1) Factors affecting rank?(3-2) First person on list MUST be what?(3))

Organ and Tissue Donation •Can organs or tissues be bought or sold in the U.S.? ---NO! In the US organ and tissue donation is strictly humanitarian gifts and may NOT be bought or sold! This protects vulnerable people from, for example, being a "donor" to escape financial crisis •Demand > Supply—what are issues here? --When a deceased donor is identified, a transplant coordinator from an OPO accesses computer network •---->Computer generates list of donors who are ranked according to organ-allocation policies •---->Factors affecting rank: --------Tissue match, blood type, length of time on waiting list, immune status, and the distance between the potential recipient and the donor ---------First person on list must be available, healthy, and willing to be transplanted immediately

Organ procurement and transplant network (OPTN) (Maintains what?(1) Who must be members of OPTN?(2) Centers for Medicare and Medicaid services defines what within which the OPOs focus?(1))

Organ procurement and transplant network (OPTN) •Maintains the united network for organ sharing •All U.S. transplant centers and OPOs must be members of OPTN •Centers for Medicare and Medicaid services defines the geographic procurement territory within which the OPOs focus

Pain Control (ANA Position Statement--Nurses role?(2) Agency for Healthcare Research and Quality (AHRQ)-->Guidelines for what?(2) American Pain Society Position Statement?(2))

Pain Control •ANA position statement --Pain management is part of the nurse's role in end-of-life decisions to administer effective doses of medications that are prescribed for symptoms control and to advocate for the patient when prescribed medications insufficiently manage pain •AHRQ guidelines --Agency for Healthcare Research and Quality (1992 and 1994)= guidelines for acute pain and cancer pain management --Actual guidelines not in book •American Pain Society position statement --Position statements on treatment at end of life and pain assessment as 5th vital sign

Pain control •Assessment (Objective?(4) Subjective?(4))

Pain control •Assessment -Objective •Nonverbal behavior •Vital signs •Diagnostic information •Cognitive and emotional and additional factors -Subjective •Location •Intensity •Quality •Temporal pattern

Patient's Rights and Responsibilities (Right to INFORMATION--With this?~ Right to CHOOSE--With this?~ Access to what?(1) Being a FULL PARTNER in health care decisions--If unable to fully participate?(1) Care without DISCRIMINATION--With this?~ Right to PRIVACY AND CONFIDENTIALITY--With this?~ Right to SPEEDY COMPLAINT RESOLUTION--With this?~ Taking on NEW RESPONSIBILITIES.)

Patient's Rights and Responsibilities •Include: *Right to information •Have right to receive accurate, easily understood information to assist them in making informed decisions *Right to choose •Have the right to a choice of healthcare provider *Access to emergency services *Being a full partner in healthcare decisions --Patients have a right to fully participate in decisions related to their healthcare --Consumers unable to fully participate have a right to be represented *Care without discrimination •Fair and equal treatment •Patients have the right to considerate, respectful care from all members of the healthcare industry •Patients can not be discriminated against *Right to privacy and confidentiality •Patients have right to communicate with healthcare providers in confidence •They have a right to review and copy their own medical records and request amendments to their records *Right to a speedy complaint resolution •Patients have the right to a fair and efficient process for resolving differences with their health plans, healthcare providers, and the institutions that serve them *Taking on new responsibilities •Patients must take greater responsibility for maintaining good health

Predictors of patients leaving AMA (list then READ)

Predictors of patients leaving AMA •Young •Men •History of substance abuse •Emergency room patients •Personality disorder •Exhibit anger •No primary physician •Long wait times for clinic or ER appointments •Religious beliefs •Personal/financial obligations including lack of insurance

Preventing liability (Know and follow what?(1-2) Work with what?(1) Assess patient in what kind of environment?~ Use checklist of what?(1) DOCUMENT--What kind of things should be documented?(2-2) Confidential peer review and case studies on civilly committed patient.)

Preventing liability •Know & follow state laws & agency policies & procedures •Work with interdisciplinary team •Assess patient in safe non-threatening environment •Use a checklist of involuntary admission criteria •Document document document -----Subjective and objective findings ----Detailed support and basis for decision to commit, and comprehensive plan of treatment •Confidential peer review & case studies on civilly committed patient

Refusal of treatment (Background: Cruzan v. Director, Missouri Department of Health= U.S. Supreme Court case-->as a result of this case?(1) Mandated that what healthcare organizations, had to do what?(2-1) PATIENT'S BILL OF RIGHTS--Individual states? Nurses?~ INFORMED CONSENT--This overall is what, NOT what?(1-1) Patient must be what for this?(1) ASSESSING PATIENT'S COMPETENCE--Usually? Assessment should be made to understand the patients ability to do what?(3)--->sometimes what is necessary?(1))

Refusal of treatment •Background --Cruzan v. Director, Missouri Department of Health (1990) = U.S. Supreme Court case ---•As a result of this case, the Patient Self-Determination Act was passed -------->Mandated that every hospital, nursing home, healthcare agency, and health maintenance organization that receives Medicare and Medicaid funds must provide adult patients with a statement of rights under state statutory laws *Patients' Bill of Rights •Individual states created their own patients' bill of rights •Should be reviewed by each nurse *Informed consent •A process—not just obtaining a signature •Patient must be competent *Assessing patient's competence •It is usually clear if the patient is competent or not •Assessment should be made to understand the patient's ability to understand the situation, understand the risks associated with the procedure, and communicate a decision based on that understanding •Sometimes a psychiatric consult is necessary

Reproductive Services

Reproductive Services •Health care providers have an obligation to inform the patient of all health care choices •Abortion -Termination of pregnancy is not an absolute right •Each state sets limits for adults and minors •Adults --A woman's right to privacy includes her decision to continue with or terminate a pregnancy up to the point of fetal viability. When the point of fetal viability has been reached (usually around 2nd trimester), the state has some interest in preserving life and can put some limits on abortion --Husbands may not compel a wife to complete or terminate a pregnancy --Physicians are told to test fetal viability when the pregnancy is around the 20th week --In some cases the physician can make a good faith conclusion that medical complications of the pregnancy necessitate a therapeutic abortion •Minors --Each state has statutes governing abortions on minors --Some states may require parental consent whereas others may not --An unemancipated minor's right to reproductive choice is not equal with that of an adult, even in the early stages of pregnancy. No state provision may categorically deny a minor the right to an abortion, and parents may not have absolute veto power over the minor's decision—although parents may not have absolute veto power, the minor has no absolute right to exercise that choice without authorization from a parent, guardian, or judge --Bypass provision ----->•Determined by the court if a minor is mature enough to consent to an abortion without parental consent or notification --All minors must be counseled on options such as adoption and keeping the baby. Birth control must also be discussed

Restraints (Current medical trend with this?~ Using these can cause what kind of issues?(1) FEDERAL REGULATIONS--Who regulate the minimum requirements for restraint and seclusion use?(1) Certain states compared?~ The indication for restraint use is only for what?(3) All restraints should be labeled with what?(3) Safe Medical Devices Act---obligates who, to do what?(1-1))

Restraints •Current medical trend is for a restraint free environment --They are dangerous --They have liability issues •Federal regulations --The Centers for Medicare and Medicaid Services regulates the minimum requirements for restraint and seclusion use --States may have more strict requirements --The indication for restraint use is only for the immediate safety of the patient, staff, and others --All restraints should be labeled for size, weight limits, and device orientation --Safe Medical Devices Act obligates facilities that use restraints to report to the FDA all restrain-related deaths or injuries within 10 working days

Restraints continued (PATIENT BILL OF RIGHTS--Under this, restraints/ seclusions cannot be used for what?~ Should ONLY be used when?~ WHAT is required, by who?(1-2) Under the Patient Bill of Rights, initial orders should be reviews how often for adults?(1) How often for children 9-12?(1) How often for children under 9?(1) --->initial order must be renewed when, how?(1-1) CMS and Joint Commission requires that patients in restraints or seclusion have what?(1) DOCUMENTATION--Should include?(7))

Restraints continued •Patient Bill of Rights --Under the patient bill of rights restraints and seclusion cannot be used for punishment, retaliation, coercion, discipline, or staff convenience. Restraints and seclusion can be used only in situations of emergency, physical safety of the patient, staff, and others when less restrictive interventions are not effective •Order is required --Restraints and seclusion require order from the physician or independent practitioner --Under the patient bill of rights initial restraints and seclusion orders for violent or self destructive patients should be reviewed at 4 hours for adults, at 2 hours for children 9-12, and at 1 hours for children under age 9. The initial order must be renewed at 24 hours following an exam by the physician or independent provider •Face to face evaluation of physician or primary provider --CMS and Joint Commission requires that patients in restraints or seclusion have a face to face evaluation by a trained physician, primary provider, or RN for physical and psychological effects of the restraint or seclusion and when deciding to continue or discontinue restraints or seclusion •Documentation --Documentation should include description of patient behavior, intervention used, patient condition that warrants use of restraints or seclusion, document the 1 hour assessment, patient's response, staff train in personnel file, and document monitoring

Restraints continued (STAFF TRAINING--Who has specific training requirements for staff members?(1) -->including?(2) Must be included in what for staff members?(1) Staff who use restraints/ seclusion must be what?(3) DEATH REPORT--Under what circumstances?(3) Report to CMS within how long?(1) INFORMED CONSENT--CMS recognizes--Patients?(1) Family?(1) It is recommended that family be notified when?(1) LIABILITY--Prevent liability? BUT?(1))

Restraints continued •Staff training --CMS has specific training requirements for staff members --Include: demonstration of competency in applying restraints and implementing seclusion before performing each on a patient --Must be part of initial orientation --Staff who use restraints and seclusion must be trained, periodically updated, and documentation in employee file •Death report --Report to CMS within the next business day and document in the patient record when a death occurs in a restraint or seclusion regardless of cause, death occurs within 24 hours after removal of restraints or seclusion regardless of cause, and death known to the institution that occurs within 1 week of restraint or seclusion removal with it is reasonable to assume that the restraint or seclusion contributed to the death •Informed consent --CMS recognizes that patients do not have the right to refuse restraints or seclusion and family do not have the right to demand that a patient be restrained. It is recommended that family be notified when intervention is necessary •Liability --Restraints or seclusion can prevent liability but regulations and laws must be followed (must adhere)

Sources of Patients' Rights •Patient self determination act (What is this? Requires all providers who receive what, to do what?(1-1) Medical providers are also required to do what, when?(1-1))

Sources of Patients' Rights •Patient self determination act -Provided the legal means by which patients could, by law, obtain more control over their health care, treatment, and decisions pertaining to both -Requires all providers who receive Medicaid funds to provide individuals with written information regarding their rights to make decisions about their medical care -Medical providers are also required to inform patients about their rights to establish advance directives at the time of admission

The nurse's role in treatment of pain (list then READ)

The nurse's role in treatment of pain •Assessment using appropriate, validated tool •Documentation including specifics •Consider, implement, document nonpharmacological pain relief •Completes AIR cycles •Documents AIR cycles and pain scale used •Determine if and when analgesic given (if prn order) •Select appropriate analgesic, know action, potency, absorption, interactions with other meds, and pharmacokinetics •Evaluates effectiveness of medication (including trends) •Observe for side effects of adverse reactions •Informs provider when change in medication is needed

Informed Consent: What about... (INCOMPETENT PATIENTS--This should be determined by who?(1) In the absence of predetermined decision maker?(1~2) SPECIAL INFORMED CONSENT--Examples of this?(2) RELIGION---Competent adults?~ MINORS--General Rule is that what?(1)--->however statutory exceptions?(1) Emancipated minors? Odd rule in some states?(2) SEXUAL ASSAULT--What is required?(1)-->unless? REPRODUCTIVE EXCEPTION--To encourage tx without fear of parental punishment, some states?~ DRUGS AND ALCOHOL---To encourage tx without fear of parental punishment, some states?~)

What about... •Incompetent patients --Incapacity to consent may come from a temporary condition or it can be longer term such as a mental illness --Incompetency must be determined by a physician --In the absence of a predetermined decision maker, the state statutes will determine a surrogate for end-of-life decisions or the next of kin in an emergency •Special informed consent -->Example: •HIV statutes requiring provider to give information to patient when obtaining consent (such as counseling and confidentiality) ---Many states now have HIV statues that require a healthcare provider to give specific information to the patient when obtaining informed consent, such as counseling and confidentiality ---Experimental treatments •Religion --Competent adults may refuse treatment (even lifesaving) for religious reasons without medical or legal interference •Minors --General rule= parents must given consent, however many states allow statutory exceptions such as medical testing or treatment of STDs, HIV, mental health, substance abuse, pregnancy ----- also there are "emancipated minors" (live separately from parent; consent on their own) --Odd rule—in some states a minor with a child may consent for her child's treatment but not for her own •Sexual assault --Parental notification is required unless the parent is the suspected abuser •Reproductive exception --To encourage treatment without fear of parental punishment, some states have enacted statutes that permit providers to treat minors for STDs, educate minors about contraception, and dispense contraception to minors •Drugs and alcohol --To encourage minors to seek treatment, there are state statutes that allow minors to consent for treatment without parental consent

Who obtains consent? (Who is responsible for obtaining consent?(2)) (Can obtaining consent be delegated?(1))

Who obtains consent? •The physician or advanced health care practitioner who performs the medical or surgical procedure is responsible for obtaining informed consent Can obtaining consent be delegated? •NO

Why is pain control so important? (Compared to other reasons for treatment?(1) Essential component of nursing care regardless of setting.)

Why is pain control so important? •Number one reason patient's seek treatment •Essential component of nursing care regardless of setting

Why so important? (Negligence in this area?(1) Pain should never be classified how? Do not assume a patient is what, and then do what?(1-1)--->this is considered what?(1))

Why so important? •Nurses spend an estimated 40-60% of time performing medication administration (Westrick, 2014). •PATIENT SAFETY •Negligence in this area is one of greatest areas liability for nurses and employers •Pain should never be classified as "generalized", "severe", "good", "better", or "fair" •Do not assume a patient is addicted and withhold medication—this is "inhumane"

Sources of Patients' Rights •ANA (What is this?(1)* Sets forth the nurses what, based on what?(2-1) The nurse has the responsibility to protect what?(1) Nurse also has the obligation to ensure the patient is not doing what?(1))

•ANA *"Code for Nurses with Interpretative Statements" •sets forth the nurses' moral and professional obligation to patients based on a value belief system •nurse has a responsibility to protect the patient's ability to manage his or her own health care and treatment •Nurse also has an obligation to ensure that the patient is not acting in a manner that would hinder treatment or exacerbate a medical condition

Sources of Patients' Rights •American Hospital Associated (Replaced the patient's bill of rights with what, titled what?(1-1) Shows that patients have the rights to?~)

•American Hospital Associated -Replaced the patient's bill of rights with a brochure titled "The patient care partnership: understanding expectations, rights, and responsibilities" •Shows that patients have rights to: ---High quality hospital care ---A clean and safe environment ---Involvement in their own care ---Protection of privacy ---Help when leaving the hospital ---Help with billing claims

Sources of Patients' Rights •Centers for Medicare and Medicaid Services (Compared to the others?(1)* Has ______________ tools of ___________ payments for participating institutions and civil monetary penalties? To receive payments via Medicare or Medicaid a facility must do what?(2-1)-->Specifically?(5))

•Centers for Medicare and Medicaid Services *Have the strongest patients' rights protections *Has enforcement tools of suspending payments for participating institutions and civil monetary penalties *To receive payments via Medicare or Medicaid, a facility must protect and promote patients' rights under these standards according to CMS: •Notice of rights •Exercise of rights •Privacy and safety •Confidentiality of medical records •Restraint or seclusion (including staff training requirements and death notification requirements) - restraints and seclusion can only be used for immediate physical safety of patient, staff, or other individuals

Patient's rights (Competency is defined as the ability to understand what?(2) Hospitals are NOT what, AKA?(1~1))

•Competency is defined as the ability to understand the nature and effects of one's acts --Competent adults have the right to make decisions regarding their medical care and any invasions into the privacy of their body --Hospitals are not prisons, patients have the right to leave

Donation process, organ allocation cont. (CONSENT--Filling out what?(1)-->signing in presence of who? Almost ALL states also use what?(1) If donor card lost or not available-->important for who to be aware, why?(1-1) MO requires what in order to proceed, by who?(1-2) A few states recognize "presumed consent"--what is this? What is a MAJOR source of lost donations?(1))

•Consent --Filling out Uniform Donor Card, signing in presence of two witnesses. Almost ALL states also use Dept. Motor Vehicles donation registration and consent to donate - can place on driver's license; or there is an online form for donor registration. http://donatelife.net/understanding-donation/ --If donor card lost or not available - is important for family to be aware - because they are the ones asked at time of death. --MO Requires informed consent (either by donor or next of kin) to proceed with organ or tissue donation. A few states recognize "presumed consent" (i.e. Florida with corneal donation) - as long as has been no indication that donation is against patient's wishes. --Healthcare professionals are reluctant to allow donation without family members' consent (for fear of conflict? Lawsuit? Bad publicity?). Blocked donations by family members are a MAJOR source of lost donations!

Confidential Communication HIPAA (What does this stand for, when was it developed?(1-1) What did this state?(1)* Spans ______ areas.)

•HIPAA --Health Insurance Portability and Accountability Act of 1996 --Means information is ONLY shared with those who have a "need to know" role in the healthcare of an individual --Spans ALL areas •--Example: --->Nurse using two identifiers before giving pt. information over the phone. To a secretary NOT needing to know diagnosis over the phone.

Competency and Guardianship •Normal situations in which guardians are used (Minors--natural guardian, until when?(1-1) Elders--if what occurs?~ Psychiatric Patients--Not all patients?~ It comes down to what?(2) End of Life Decisions--If there is no what present?(1) Typical orders of next of kin consult?(6) Ethical Considerations of Guardianship--Intrudes on what, diminishes what?(1-1) The goal of guardianship?(2))

•Normal situations in which guardians are used *Minors •Parents are natural guardians until 18 years old *Elders •If lack of decision making capacity *Psychiatric patients •Not all patients admitted to inpatient psych or long term psych care lack decision-making capacity •It comes down to if the patient can understand refusal or consent and the consequences thereafter *End of life decisions •If no DPOA is in place via advance care planning •Typical orders of next of kin consult? 1. Spouse 2. Adult children 3. Parents 4. Grandparents 5. Adult brothers and sisters 6. Adult nieces and nephews •Ethical considerations of guardianship --Intrudes on a person's autonomy and diminishes his or her privacy --The goal of guardianship is to protect the individual and to protect his or her assets

Refusal of treatment (Nurse has a legal duty to ensure a patients decision to refuse?(1) Duty ending with documentation of refusal?(1)--->In fact?(1-->1) Ultimate goal in this situation?(1))

•Nurses role in caring for a patient refusing treatment --Nurse has legal duty to ensure patient's decision to refuse is an informed one. Our duty is not over when we document "patient refuses." --In fact, if we don't include patient teaching with the "patient refuses" documentation, we may still be held liable in a court of law! --Ultimate goal = INFORMED refusal

Confidential Communication •PHI (What does this stand for?(1) HIPAA states what?(1) A person who is using the covered entity--has the right?(2))

•PHI --Protected Health Information --HIPAA occurs that PHI is not released to any third party without permission --A person who is using the covered entity has a right to know how their PHI is being used by the healthcare organization and who has access to it

Discharge Against Medical Advice (What is this?~)

•Patients who leave an environment where medical care is available and either refuse initial treatment or continuing treatment area cause for concern from a medical, legal, and ethical viewpoint

Sources of Patients' Rights •President's Advisory Commission on Consumer Protection and Quality in the Health Care (Proposed what?(1) What did this group do?(1-2))

•President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry -Proposed a national bill of patient's rights -They promoted and assured healthcare quality and to protect consumers and workers in the healthcare system

Informed Consent (Recognized as what?(1) Negligence for lack of Informed Consent is basis for what?(1) This is NOT just doing what, instead doing what?(1-1))

•Recognized as professional standard of conduct •Negligence for lack of is basis for liability •Communication process, not solely obtaining signature

Sources of Patients' Rights •The Joint Commission (Accreditation by them includes what?(1) Success is determined by what?(1))

•The Joint Commission *Accreditation by them includes establishing procedures that ensure patient rights *Certain elements for performance under patients' rights must be measured for success by the accredited institution •Success is determined by a quantifiable measure

What is the nurse's role in informed consent? (Usually involves either what or what?(2) As always it is the nurses duty to do what in these types of situations?(1)--->for example?~)

•Usually involves witnessing consent which involves observing patient consent by signing the consent form, or informing provider of LACK of consent prior to procedure •As always advocating for patient --Example: They might sign consent, but then later nurse discovers pt. truly does not understand what is going to happen, it would be nurse's duty to call provider and request they revisit pt.