Legal and Ethical Issues

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					Legal and Ethical Issues
              Learning Outcomes

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

Mental health patients retain all civil rights
afforded to all people except the right to leave the
hospital in the case of involuntary commitment
                          Bill of Rights
                               Chapter 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
           Types of Admissions
• Voluntary admission- patient is agreeable to
  in house treatment
• Involuntary admission- patient admitted
  without their consent through legal processes
                    Involuntary Admissions
             To retain without the right is false imprisonment
   Magistrate’s order – check chart to understand what’s going on for the

1) Evaluation/emergency care (ED) –form filled out by police/others;
   usually for 48 to 72 hours- gives time to assess & find illness (UTI)/mental
2) 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.
3) Extended/indeterminate care- legal system involved; long term;
   may be 30-90 days
4) Magistrates warrant – legal sworn statement issued about a
   patient through judge, by a family member, signs document that
   pt is incompetent.
         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
          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
     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

• 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

• 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
         ***Least Restrictive Environment
       Legal- file suite- keeping them & they don’t want to be kept

• Treatment must be provided in the least restrictive
  environment appropriate to meet the patient’s 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
   – Any pt in seclusion or restraints take high priority
 Least Restrictive Environment (cont’d)

• 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
• Restraint: application of force without the
  patient’s permission (human, mechanical,

• Seclusion: involuntary confinement in
  specially constructed, locked room equipped
  with security window or camera
         Restraints/ Seclusion
• Face to face evaluation in 1 hour, every 8
• Physician’s order every 4 hours
• Documented assessment by nurse every 1-2
• Close supervision of patient
• Debriefing session within 24 hours after
  release from restraint or seclusion

• 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.
              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
                                   • Is the client dangerous to
  party is an exception              others?
  to client                        • Is the danger the result of
  confidentiality                    serious mental illness?
• Clinicians must warn             • Is the danger serious?
                                   • Are the means to carry out
  identifiable third                 the threat available?
  parties of threats               • Is the danger targeted at
  made by a client                   identifiable victims?
                                   • Is the victim accessible?
                 Nursing Liability

• Nurses are expected to meet standards of care
  developed from:
   – ANA’s Code of Ethics for Nurses with Interpretive
   – ANA’s 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
Tort: A wrongful Act That Results in Injury,
            Loss, or Damage
       Have to watch what say & do – assault & battery

Unintentional Torts                Intentional Torts
– Negligence: harm caused          – Assault: causes person
  by failure to do what is           to fear being touched in
                                     an offensive manner)
  reasonable and prudent           – Battery: harmful or
– Malpractice: breach of             unwanted actual
  duty directly causes               contact)
  injury or loss to the            – False imprisonment:
  client                             unjustifiable detention
            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
                     Ethical Principles
    Knowing rules & policies on the floor you are working is key

Autonomy: right to self-determination and
Beneficence: duty to benefit others or
  promote good
Nonmaleficence: do no harm
Justice: fairness
Veracity: honesty, truthfulness
Fidelity: honor commitments and contracts
       Ethical Dilemmas in Mental Health

• Ethical dilemma is a situation in which ethical
  principles conflict or there is no one clear course of
• Many dilemmas in mental health involve the client’s
  right to self-determination and independence
  (autonomy) and concern for the “public good”

• ANA Code of Ethics for Nurses guides choices about
  ethical actions
          Ethical Decision-Making

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

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