Patient Rights and Legal Issues

Chapter 4

Ethics and Psychiatric Nursing

• Bioethics – “medical ethics”• Ethical principles

– Autonomy– Beneficence– Justice– Veracit– Fidelity

Ethics: Psychiatric Nursing

• Professional Boundaries– Intimate nature of relationship can blur

boundaries• Nurses SHOULD NOT

– Accept gifts or services from clients– Hug clients– Use unprofessional language– Excessively disclose self-information

Ethics: Psychiatric Nursing• Allocation of resources

– Fair and equitable distribution of resources across society• Client Advocacy

– Ensures client voice is heard– Nurse holds the interest of the client above the interest of

others– Nurse educates client about the health care system and

their rights within that system• Moral issues

– When conflicts occur between what the nurse believes about her loyalty to her employer/health care provider and her client/s

Patient Rights

• Bill of Rights– Necessary because of vulnerability to abuse and

mistreatment– Universal Bill of Rights for Mental Health Patients

(Text Box 4.1)

• Americans with Disabilities Act (ADA)– Outlaws discrimination against individuals with

disabilities– Protects people with mental disorders

Issues of Consent• Self-determinism: The right to choose one’s

own health-related behaviors, which, at times, may differ from those recommended by health professionals

• Competence: Degree to which the patient is able to understand and appreciate the information given during the consent process

• Informed consent: The right to determine what shall be done with body and mind

Issues of Consent

• Necessary elements for legal consent– Person must be capable of consenting– Person must have the ability to refuse

consent– Person must have adequate information for

consent or have agreed to waive right to information

– Consent must not be illegal

Client rights

• Right to refuse medication– This right is 15 years old– Forcible medicating only if “danger to self

or others”• MUST DOCUMENT THE

DANGER/MEDICATION GIVEN/AND RESPONSE

Types of Treatment

• Voluntary: Full legal rights• Involuntary commitment: Confined

hospitalization of a persons without the person’s consent (finding of dangerousness, sine qua non) and or competency

Least Restrictive Environment

• Patients have the right to refuse treatment.

• A person cannot be restricted to an institution when he or she can be successfully treated in the community.

• Medication cannot be given unnecessarily.

Issues of Confidentiality• Privacy: Part of person’s life not governed by

society’s laws and government intrusion

• Confidentiality: Ethical duty of nondisclosure (Provider has information about patient and should not disclose it.)

• Breach of confidentiality: Release of patient information without the patient’s consent in the absence of legal compulsion or authorization

Mandates to Inform

• A legal obligation to breach confidentiality

• “Duty to warn” - when there is a judgment that the patient has harmed any person or is about to injure someone (based on Tarasoff v. Regents of University of California)

Documentation

• It is common for all disciplines to record on one progress note.

• Patients have access to their records.

• Nursing documentation is based on nursing standards.

Required Nursing Documentation

• Observations of subjective/objective responses

• Interventions implemented

• Evaluation of outcomes of interventions

Documentation

• Documentation is mandatory for patients who are suicidal, homicidal, aggressive or restrained in any way.

• Always write in pen. Corrected entries are initialed.

• Avoid judgmental statements (i.e., “patient manipulating staff”).

Laws and Psychiatry

• NGRI - Not Guilt by Reason of Insanity

• GBMI - Guilty but Mentally Ill

• Forensic Commitment

Laws and Psychiatry

• Elopement– Official term when clients are “absent” from

an official facility without proper procedure• Discharge

– Unconditional– Conditional

• Stipulations regarding where a client will live, follow-up requirements etc. or behavior that must be avoided i.e. stalking

Laws and Psychiatric Nursing

• Abuse– Child Abuse– Elder Abuse

• Negligence and Malpractice– Unintentional injury when failed to act

according to standards of practice– Injury from professional misconduct

Misconceptions about the Insanity Plea

• Very few insanity pleas are successful (less than 2%).

• Insanity is usually determined by whether the person has substantial appreciation or understanding of the criminality (wrongfulness) of his or her conduct.

• Public safety? Patients are more likely to be the victims than the perpetrators.

Laws and Systems of Protection• Internal Rights Protection System

– Public law 99-319 (1986)– Each mental health system establishes a system

to protect and advocate for the rights of persons being treated.

– Canadian Charter of Rights and Freedoms (1982)

• External Advocacy Systems – Bills of Rights - AHA, APHA, WHO

• Accreditation - JCAHO, HCFA

TRUE OR FALSE:1. THE CLIENT HAS THE RIGHT TO REVIEW THE

RECORDS PERTAINING TO HIS OR HER CARE

2. THE CLIENT’S RIGHT TO REFUSE TREATMENT IS BASED ON COMPETENCY

3. COMPETENCE IS THE EQUIVALENT TO RATIONALITY

4. MOST STATES PROVIDE FOR EMERGENCY SHORT-TERM HOSPITALIZATION OF 7 – 10 DAYS

5. BREACH OF CONFIDENTIALITY IS APPROPRIATE IF THE CLIENT IS ABOUT TO INJURE SOMEONE

6. GUILTY BUT MENTALLY ILL CLIENTS ARE COMMITTED TO THE MENTAL HEALTH SYSTEM

WHICH OF THE FOLLOWING STATEMENTS IS MOSTAPPROPRIATE WHEN DOCUMENTING IN MENTALHEALTH NURSING?

A. Client is manipulating female staffB. Client slept. Good night.C. Client upset and withdrawnD. Client states “I have no reason to live”

A depressed client is scheduled for electroconvulsive Therapy (ECT). Which of the following remarks by the client would cause the nurse to question the signed Informed consent?

A. “The treatment will help me feel less sad all the time.

B. “ I won’t be able to remember anything about the procedure”

C. “ Just one treatment will help cure my depressionfor good”

D. “They don’t know how this therapy works, justthat it does”