Transcript Chapter_06_-_Legal_and_Ethical_Guidelines_for_Safe-1

Chapter 6
Legal and Ethical Guidelines
for Safe Practice
Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Overview
2
 A nurse who works in a mental health setting is responsible for:
 Practicing ethnically
 Competently
 Safely
 And in a manner that is consistent with all local, state and federal
laws.
Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
3
Ethical Concepts
 Ethics: The study of philosophical beliefs about what is considered
right or wrong in a society
 Bioethics: Used in relation to ethical dilemmas surrounding health
care
 Ethical dilemma: Conflict between two or more courses of action,
each with favorable and unfavorable consequences
Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
4
Ethical Issues for Clients in
Mental Health Settings
 Ethical issues are philosophical ideas regarding right
and wrong.
 Nurse are frequently confronted with ethical dilemmas
regarding client care (bioethical issues).
 Ethics are philosophical and they involve values and
morals, there is frequently no clear-cut simple
resolution to a dilemma.
 Only ethical principles can be used to decide ethical
issues.
Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
5
Five Principles of Bioethics
(Ethical Issues for Clients)
 Beneficence: The duty to promote good
 Autonomy: Respecting the rights of others to make their own
decisions
 Justice: Distribute resources or care equally
 Fidelity (non-maleficence): Maintaining loyalty and
commitment; doing no wrong to a patient
 Veracity: One’s duty to always communicate truthfully
Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
6
Civil Rights of Persons with Mental
Illness
 Guaranteed the same civil rights as other citizens such as:
 The right to human treatment and care, such as medical and dental care
 The right to vote
 The right to due process of law, including the right to press changes
against another person
 Informed consent and the right to refuse treatment
 Confidentiality
 A written plan of care/treatment that includes discharge follow-up as well
as being able to participate in the development of that plan
 Able to communicate with others outside the facility
 Freedom from harm r/t physical or pharmacologic restraint, seclusion and
any physical or mental abuse or neglect
Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
7
Types of Commitment to a Mental
Facility
 Voluntary Admission - Inpatient care sought by a patient or patient’s
guardian through a written application to the facility.
 Involuntary Admission - Admission to a psychiatric facility without a
patient’s consent.
 Emergency involuntary – this is usually temporary for up to 10 days.
This is usually imposed by primary care providers, mental health
professionals or police officers to aid in preventing harm to self or
others.
 Observational or temporary involuntary commitment – this is where
the client needs to be observed and a diagnosis and a treatment
plan need to be established.
 Long-term or formal involuntary commitment is similar to a temporary
commitment but must be imposed by the state.
Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
8
Case Study
 A 27-year-old male is court committed by his parents to your unit with
a diagnosis of paranoid schizophrenia. He lashes out at staff when
they attempt to give him his medications. He states, “You are trying
to poison me.” His family asks if you can “force” him to take his
medications.
Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
9
Case Study (Cont.)
 How would you respond to this family?
Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
10
Tort Law
 Tort – A civil wrong for which money damages may be
collected by the injured party (plaintiff) from the responsible
party (the defendant)
 Intentional tort – Willful or intentional acts that violate
another person’s rights or property
 Assault
 Battery
 False imprisonment
Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
11
Tort Law (Cont.)
 Unintentional tort – Unintended acts against another
that produce injury or harm
 Negligence
 Malpractice
Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
12
Five Elements to Prove
Negligence
 Duty
 Breach of duty
 Cause in fact
 Proximate cause
 Damages
 Foreseeability or likelihood of harm is also evaluated.
Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
13
Orders and documentation
 Seclusion or restraint
 Orders are never written as PRN or as a standing order.
 Orders are to manage self-destructive or violent behavior
 These orders must be renewed every 24 hours with limits
depending on age of patient.
 Adults 18 years or older – limited to 4 hours;
 Children and Adolescents 9 to 17 years – limited to 2 hours; and
 Children under 9 years have a 1 – hour limit
 After 24 hours, a physician or other licensed person responsible for
the patient’s care must personally assess.
 Restraint or seclusion is discontinued as soon as safer and quieter
behavior begins.
 If the behavior begins, then another new order must be obtained.
Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
14
Nurse’s duty when patient is in
Restraint
 Nurse must do the following when her patient is in restraint:
 document restraint or seclusion in the treatment plan or plan of
care;
 noting the behavior leading to restraint or seclusion, and the time
the patient is placed in and released from restraint.
 the patient in restraint must be assessed at regular and frequent
intervals (e.g., every 15 to 30 minutes)
 for physical needs (e.g., food, hydration, and toileting), safety, and
comfort;
 these observations must also be documented every 15 to 30
minutes.
 while in restraints, the patient must be protected from all sources of
harm.
Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
15
Contradictions to Seclusions & Restraints
 Extremely unstable medical and psychiatric conditions*
 Delirium or dementia leading to inability to tolerate decreased
stimulation*
 Severe suicidal tendencies*
 Severe drug reactions or overdoses or need for close monitoring
of drug dosages*

Desire for punishment of patient or convenience of staff*
 *Unless close supervision and direct observation are provided.
 From Simon, R. I. (2001). Concise guide to psychiatry and law
for clinicians (3rd ed., p. 117). Washington, DC: American
Psychiatric Press. Copyright © 2001 by American Psychiatric
Press.
Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
16
Duty to Warn and protect third
parties
 Negligence, irresponsibility, or impairment
 Duty to intervene and duty to report
Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
17
Failure to protect patients
 A common legal issue in psychiatric mental health nursing is the
failure to protect the safety of patients.
 Examples:
 A suicidal patient is left alone with the means of self-harm, the nurse who
has a duty to protect the patient will be held responsible for any
resultant injuries.
 Leaving a suicidal patient alone in a room on the sixth floor with an
open window is an example of unreasonable judgment on the part of a
nurse.
 Patients should be protected from other patients. One patient sued a
hospital when she was beaten unconscious by another patient who
entered her room looking for a fight. Her lawsuit alleged that there was
inadequate staffing to monitor and supervise the patients under the
hospital’s care.
Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
18
Documentation of Care
 A record’s usefulness is determined by evaluating—when the record
is read later—how accurately and completely it portrays the
patient’s behavioral status at the time it was written.
 Example: if a psychiatric patient describes intent to harm himself or
another person and his or her nurse fails to document the
information—including the need to protect the patient or the
identified victim—the information will be lost when the nurse leaves
work. If the patient’s plan is carried out, the harm caused could be
linked directly to the nurse’s failure to communicate the patient’s
intent. Even though documentation takes time away from patient
care, its importance in communicating and preserving the nurse’s
assessment and memory cannot be overemphasized.
Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
19
Medical Records
 Used by the facility for quality improvement
 Used as evidence
 Electronic documentation
Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Question 1
20
Which individual with mental illness may need involuntary
hospitalization?
A.
A person with alcoholism who has been sober for 6
months but begins drinking again
B.
An individual with schizophrenia who stops taking
prescribed antipsychotic drugs
C.
An individual with bipolar disorder, manic phase, who
has not eaten in 4 days
D.
Someone who repeatedly phones a national TV
broadcasting service with news tips
Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
21
Question
1.
Legal and clients’ rights are suspended when a
client is hospitalized involuntarily.
A. True
B. False
C. Not sure
Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
22
Question
2.
A client plans to have electroconvulsive therapy
(ECT). Which member of the team is responsible for
obtaining the client’s informed consent?
A. Physician
B. Psychologist
C. Case manager
D. Registered nurse
Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
23
Question
3.
A nurse was the case manager for a client with
serious mental illness for 6 years. The client died
by suicide 1 week ago. Today, the client’s
spouse asks, “I always wondered if my spouse
was a victim of sexual abuse in childhood.
What can you tell me about that?” Can the
nurse disclose information to the surviving
spouse?
A. Yes
B. No
C. Not sure
Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
FALSE IMPRISONMENT, NEGLIGENCE, AND
MALPRACTICE: PLUMADORE V. STATE OF NEW YORK
24 (1980)
Delilah Plumadore was admitted to Saranac Lake General
Hospital for a gallbladder condition. During her medical
workup, she confessed that marital problems had resulted in
suicide attempts several years before her admission. After a
series of consultations and tests, the attending surgeon
scheduled gallbladder surgery for later that day. After the
surgeon’s visit, a consulting psychiatrist who examined Mrs.
Plumadore told her to dress and pack her belongings because
she was going to be admitted to a state hospital at
Ogdensburg.
Subsequently, two uniformed state troopers handcuffed Mrs.
Plumadore and strapped her into the back seat of a patrol car
and transported her to the state hospital.
Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
25
On arrival, the admitting psychiatrist realized that the referring psychiatrist
lacked the authority to order this involuntary admission. He therefore
requested that Mrs. Plumadore sign a voluntary admission form, which she
refused to do. Despite Mrs. Plumadore’s protests regarding her admission
to the state hospital, the psychiatrist assigned her to a ward without
physical or psychiatric examination. She did not even have the opportunity
to contact her family or her medical doctor and remained in the hospital for
the weekend.
The court awarded $40,000 to Mrs. Plumadore for malpractice and false
imprisonment on the part of health care professionals and negligence on
the part of the troopers. This settlement was greatly influenced by the fact
that she had an acute medical illness that was left untreated for days due
to being locked in a psychiatric ward.
Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.