Legal and Ethical Issues

1
Legal and Ethical Issues
2
Learning Outcomes

• Describe the rights of the patient in a
  psychiatric setting.
• Describe the types of admissions of patients on a
  mental health unit.
• Discuss the legal and ethical issues of seclusion
  and restraints.
• Identify the legal terms pertinent to psychiatric
  nursing.
• Explain the meaning of standard of care.

3
Rights of Patients

• Mental health patients retain all civil rights
  afforded to all people except the right to leave
  the hospital in the case of involuntary commitment

4
Bill of RightsChapter 9

• Least restrictive environment- at home, hospital
  if possible.
• Confidentiality- HIPAA, pt gives code for callers
  they allow, release of info signed
• Access to attorney/courts- 24-7, private rm for
  meeting, can go to court if feel held against
  will
• Access to belongings- shampoo, clothes- in bends
• Informed of rights- know why they r there, meds
• Refuse medications/treatment
• Visitors- at visiting hours, certain limited
• Telephone- with some limits
• Writing materials/uncensored mail- in certain
  areas- open in front of case worker or nurse

5
Types of Admissions

• Voluntary admission- patient is agreeable to in
  house treatment
• Involuntary admission- patient admitted without
  their consent through legal processes

6
Involuntary AdmissionsTo retain without the
right is false imprisonment Magistrates order
check chart to understand whats going on for the
admission

• Evaluation/emergency care (ED) form filled out
  by police/others usually for 48 to 72 hours-
  gives time to assess find illness (UTI)/mental
• Order of protective custody (OPC)- legal papers
  filed in court vary from days to weeks
• 2 different drs have assessed court decides to
  lock up 7d to 14d pt must be released after the
  time/OPC is up.
• Extended/indeterminate care- legal system
  involved long term may be 30-90 days
• Magistrates warrant legal sworn statement
  issued about a patient through judge, by a family
  member, signs document that pt is incompetent.

7
Involuntary Hospitalization

• Laws are determined by each state know the laws
  of the state where you practice
• Persons detained in this way lose only the right
  to freedom all other rights are intact
• Persons held without their consent must present
  an imminent danger to themselves or others

8
Release From the Hospital

• Patients hospitalized voluntarily have the right
  to request discharge at any time and must be
  released unless they represent a danger to
  themselves or others if such a danger is
  present, then commitment proceedings must be
  instituted to keep them in the hospital
• Patients who are no longer dangerous must be
  discharged from the hospital

9
Mandatory Outpatient Treatment

• Requires that patients continue to participate in
  treatment on an involuntary basis after their
  release from the hospital into the community
• Examples include taking prescribed medications,
  keeping appointments with healthcare providers
  for follow-up, and attending specific treatment
  programs or groups

10
Conservatorship

• Legal guardianship is separate from civil
  commitment for hospitalization
• A hearing can be held to determine whether the
  person is competent. An incompetent patient
  cannot provide his or her own shelter, food, and
  clothing cannot act in his or her own best
  interests and cannot run his or her own business
  and financial affairs. If a patient is found
  incompetent, a guardian is appointed to speak for
  the patient.

11
Competency

• An incompetent patient can no longer
• Enter into legal contracts with a signature
• Sign checks
• Use a credit card
• Make a will
• Open bank accounts
• Sell property
• Get married
• Give consent for surgery

12
Least Restrictive Environment Legal- file
suite- keeping them they dont want to be kept

• Treatment must be provided in the least
  restrictive environment appropriate to meet the
  patients needs
• Physical restraint or seclusion (assess 1st- take
  high priority) in a locked room can be used only
  when the person is imminently aggressive or
  threatening to harm himself- hit or threatened
  someone then use this methods
• Any pt in seclusion or restraints take high
  priority

13
Least Restrictive Environment (contd)

• Restraint and seclusion, if used, must be in
  place for the shortest time necessary
• Many regulations govern the monitoring of clients
  in seclusion or restraint for their safety

14
Restraints/Seclusion

• Restraint application of force without the
  patients permission (human, mechanical,
  chemical)
• Seclusion involuntary confinement in specially
  constructed, locked room equipped with security
  window or camera

15
Restraints/ Seclusion

• Face to face evaluation in 1 hour, every 8 hours
• Physicians order every 4 hours
• Documented assessment by nurse every 1-2 hours
• Close supervision of patient
• Debriefing session within 24 hours after release
  from restraint or seclusion

16
Confidentiality

• Regulated by the Health Insurance Portability and
  Accountability Act (HIPPA) of 1996
• Both civil (fines) and criminal (prison
  sentences) penalties exist for violation of
  patient privacy
• If the pt states that after discharge they plan
  to take an overdose of meds The nurse must
  advise the team/phys know.

17
Duty to Warn Third Parties Do have the right to
warn the person that is being threatened error
on the side of safety

• Duty to warn a third party is an exception to
  client confidentiality
• Clinicians must warn identifiable third parties
  of threats made by a client

• Is the client dangerous to others?
• Is the danger the result of serious mental
  illness?
• Is the danger serious?
• Are the means to carry out the threat available?
• Is the danger targeted at identifiable victims?
• Is the victim accessible?

18
Nursing Liability

• Nurses are expected to meet standards of care
  developed from
• ANAs Code of Ethics for Nurses with Interpretive
  Statements
• ANAs Scope and Standards of Psychiatric-Mental
  Health Nursing Practice
• State nurse practice acts
• Federal agency regulations
• Agency policies and procedures
• Job descriptions
• Civil and criminal laws

19
Tort A wrongful Act That Results in Injury,
Loss, or Damage Have to watch what say do
assault battery

• Unintentional Torts
• Negligence harm caused by failure to do what is
  reasonable and prudent
• Malpractice breach of duty directly causes
  injury or loss to the client

• Intentional Torts
• Assault causes person to fear being touched in
  an offensive manner)
• Battery harmful or unwanted actual contact)
• False imprisonment unjustifiable detention

20
Prevention of Liability DOCUMENT any unusual
events so that if you have to go to court you
have notes to refresh what occurred
Nurses can minimize the risk of lawsuits through
safe, competent nursing care and descriptive,
accurate documentation
21
Ethical Principles Knowing rules policies on
the floor you are working is key

• Autonomy right to self-determination and
• independence
• Beneficence duty to benefit others or
  promote good
• Nonmaleficence do no harm
• Justice fairness
• Veracity honesty, truthfulness
• Fidelity honor commitments and contracts

22
Ethical Dilemmas in Mental Health

• Ethical dilemma is a situation in which ethical
  principles conflict or there is no one clear
  course of action.
• Many dilemmas in mental health involve the
  clients right to self-determination and
  independence (autonomy) and concern for the
  public good (utilitarianism)
• ANA Code of Ethics for Nurses guides choices
  about ethical actions

23
Ethical Decision-Making

• Ethical decision-making includes
• Gathering information
• Clarifying values
• Identifying options
• Identifying legal considerations and practical
  restraints
• Building consensus for the decision reached
• Reviewing and analyzing the decision

24
Self-Awareness Issues

• Talk to colleagues or seek professional
  supervision
• Spend time thinking about ethical issues and
  determine what your values and beliefs are
  regarding situations before they occur
• Be willing to discuss ethical concerns with
  colleagues or managers