Ethics and Legal Aspects in Nursing

Ethical and Legal Considerations in Nursing

• The American Nurses Association (ANA) has a specific practice manual for psychiatric-mental health nurses and it aligns with the ANA's general code of ethics.
• It addresses nurses' responsibility to maintain competency.
• The manual clarifies nurses' expectations and highlights ethical and legal competence in ensuring quality care.

Core Ethical Concepts

• Ethics concerns principles of right and wrong behavior.
• Bioethics applies these principles to the medical field, including nursing.
• Morals are internalized, personal beliefs about right and wrong.
• Moral behavior application involves critical thinking and respect for values like autonomy, freedom, justice, honesty, and confidentiality.
• Values guide informed decisions, considering the impact on others and patients.
• Rights are entitlements established by law, policies, or ethics and are absolute without restrictions.
• Legal rights are formalized by society into law.
• Nurses and hospitals must uphold patient rights, even without strict legal documentation.

Ethical Theories as Frameworks

• Ethical theories offer frameworks to guide decisions on ethical issues via philosophical principles.
• Utilitarianism judges action morality by consequences.
• "Greatest-happiness principle" actions promoting happiness are right, and actions causing unhappiness are wrong.
• Utilitarianism focuses on overall happiness, aiming to maximize good for most people involved.
• Kantianism opposes utilitarianism; it states morality depends on intention, emphasizing duty and moral laws.
• Kantianism prioritizes the principle guiding actions, regardless of results.
• Deontology, also known as Kantianism, emphasizes "duty," where choices are made because they are morally right, irrespective of the outcome.
• Divine command ethics is a moral framework where action rightness or wrongness depends on what God commands, seen in religions such as Judaism, Islam, Christianity, and polytheistic faiths.
• Christian ethics bases ethical decisions on Jesus' teachings, emphasizing love, forgiveness, and honesty.
• Natural law theory, from St. Thomas Aquinas, asserts inherent right and wrong nature, and relies on an innate understanding of good and evil which guides decisions.
• Ethical egoism theorizes that the right action benefits oneself most, even impacting others negatively.
• Ethical egoism prioritizes self-interest and emphasizes listening to and respecting the patient’s need.

Ethical Dilemmas

• An ethical dilemma involves choosing between justifiable options without a clear correct answer.
• Weighing possible outcomes creates conflict for nurses.
• Refusal of treatment example: Though acceptable, refusal might be harmful.
• Guidance from ethical committees is required for careful consideration and differing perspectives.

Core Ethical Principles

• Ethical principles guide healthcare, ensuring moral and ethical practices.
• These examples are frequently used in healthcare to ensure moral and ethical practices:
• Autonomy: Respecting patients' right to personal decisions.
• Beneficence: Acting by patient's best interest, as it is defined.
• Nonmaleficence: Avoiding patient harm.
• Veracity: Honesty and truthfulness with patients.
• Justice: Treating all patients fairly and equally.
• Autonomy is respecting the right to make life decisions, derived from how Kant sees people as responsible for their choices.
• Beneficence is acting in the best interest, while considering the patient's beliefs and feelings.
• Nurses should reach out to ethics committees to build confidence that their decisions have explored various vantage points.
• Nonmaleficence is the principle of "do no harm", and healthcare providers should avoid causing intentional or unintentional harm to their patients.
• Justice means healthcare should be fair and equal, regardless of background, and is referred to as "justice as fairness" or "distributive justice."
• Veracity in healthcare includes honesty and truthfulness.
• Patients have the right to access their diagnosis, treatment plan, and expected results.

Ethical Decision-Making

• Ethical decision models in healthcare are similar the nursing process.
• Steps for ethical decision-making:
• Assessment: gather relevant facts and information.
• Problem Identification: identify the central ethical conflict.
• Planning: Explore options, consider ethical theories, then choose an action.
• Implementation: act on the decision and communicate it.
• Evaluation: assess the results for satisfaction and revise if needed.

Patient Rights and Mental Healthcare

• The American Hospital Association (AHA) has a Patient Bill of Rights outlining basic standards of care, respect, high-quality care, and privacy protection
• Nurses need to stay up to date on evolving regulations.
• Patients can refuse medical treatment unless there's a high risk of death or harm to themselves or others, according to amendments to the US Constitution.
• Psychiatric patients can be involuntarily hospitalized, but only within specific legal criteria.
• Patients have the right to the least restrictive treatment alternative, and treatment should be minimally invasive as reasonably practical.
• The concept of a "continuum of care" ranks treatment options from least to most restrictive, and the court cases like O'Connor v. Donaldson clarify the rights of involuntarily hospitalized patients to refuse treatment.

Legal Considerations

• The Patient Self-Determination Act (PSDA) provides patients control over medical care, requiring healthcare facilities to inform patients in writing of their healthcare decisions.
• Each state has a "Nurse Practice Act" defining what nurses can and cannot do;
• The Nurse Practice Act covers definitions, education/licensure, scope of practice, license suspension/revocation, and the state board of nursing
• Those receiving care for mental health problems are entitled to:
• Appropriate treatment
• A treatment plan
• Participation in planning
• The right to referral
• The two main types of law are statutory and common.
• Statutory Law is created by a legislative body.
• Common Law is based on court decisions interpreting previous cases.

Civil Law and Criminal Law

• Civil Law protects individual and business rights, allowing lawsuits in civil court.
• There are two main types of civil law cases:
• Torts are wrongful acts causing harm, such as medical malpractice, and compensation is sought.
• Contracts deal with breached agreements for compensatory lawsuits.
• Criminal Law addresses acts harmful to public welfare (theft, assault, murder)
• Those cases are prosecuted can result in imprisonment.
• Understanding law types is crucial because a nurse may face negligence lawsuits, criminal charges for practicing without a license, or violating employer contracts.
• Civil law involves torts (like malpractice) and contracts.
• Torts include negligence or battery (touching someone without consent).
• Contracts involve breaches where compensation is sought.

Confidentiality

• The U.S. Constitution protects individual privacy through the Fourth, Fifth, and Fourteenth Amendments.
• Most states have laws protecting the confidentiality of patient records and communications.
• Nurses must protect patient information access
• Patients must decide who can access their information.
• Key points for before and after HIPPA:
• Before HIPPA (1996): There was no federal law specifically protecting patient privacy and confidentiality.
• НІРАА (1996): President Clinton signed HIPAA into law and created federal rules to protect patient data.
• Definition of Protected Health Information (PHI): HIPAA defined "protected health information" (PHI) as anything that could identify a person and relates to their health condition or healthcare payments.
• Patient Rights under HIPAA: Give those who are accessing their medical records access, let them request corrections, and choose who can access their information. Law requires healthcare providers to inform patients about their privacy policies upon entering the system.
• HIPAA Expansion (2013): Patients now have more control over sharing with insurance companies.
• There are exceptions to patient consent in emergencies, but nurses must document specifics.
• "Privileged communication" laws exist, protecting certain professional such as psychiatrists and attorneys, whereas psychologists, nurses, and clergy might also be protected.
• While patient records are confidential, there are civil and criminal exceptions during legal proceedings and that may use them as evidence.
• Maintaining confidentiality in psychiatry is harder, as there is increased stigma surrounding past mental health treatments, but documentation helps prevent issues and legal defense

Duty to Warn

• Tarasoff v. Regents set "duty to warn" legal precedent for mental health.
• Case Summary: Student Mr. P. stalked and threatened student Ms. Tarasoff after the therapist alerted police and released Mr. P, after which he murdered her.
• Ms. Tarasoff’s parents and others sued therapist/university due to failure to warn, as the court ruled, when a patients presents threats/violence, even if it violates confidentiality.
• This established a legal precedent for mental health professionals to prioritize the safety of potential victims even if it means breaking confidentiality called the "duty to warn" to make sure patients and people are aware.
• Nurses must do the following:
• Assess risk of violence
• Identify the intended victim
• Intervene
• The Tarasoff case applies to nurses and healthcare professionals, it states that even if some states don't have "duty to warn" laws, all nurses must be aware of and understand the potential legal duty to be aware, as they may be the first point of contact for patients, so that they can report if possible.

Child Abuse

• The Federal Child Abuse Prevention and Treatment Act (CAPTA) mandates professionals to report suspected child abuse and neglect.
• While healthcare professionals may be concerned about making false allegations, these laws typically provide immunity for good-faith reports based on reasonable suspicion.
• Nurses must investigate all claims and concerns, and work collaboratively within the healthcare team.

Informed Consent

• Informed consent, in healthcare, ensures that patients are fully informed and agree to medical treatment.
• Breakdown:
• Right to Decide: A Patient always has the right to decide if they want to follow through with a medical treatment or procedure.
• Rationale for Informed Consent: to respect an individual's autonomy to choose decisions regarding their own body.
• What Informed Consent Involves: What Informed Consent Involves Requires Clear, written information about the procedure.
• It involves the Benefits, Risks, and alternatives.
• An example is electroconvulsive therapy (ECT).
• Sometimes, the treatment is provided without an informed consent, and specific exceptions.
• The nurse and physician play important roles in knowing the patient's understanding of the decision and the treatment.

Restraints and Seclusion

• Restraint and seclusion use in psychiatric settings requires ethical and legal considerations, emphasizing patient safety and autonomy.
• The Patient Self-Determination Act (1991) protects individuals' right to freedom, as coercion in treatment risks harm/autonomy which ethics committees may help to resolve.
• Due to possible harms, constant attention to restraint and seclusion is needed, and nurses must stay informed on frequent changes.
• Restraints can be physical, chemical, or manual interventions
• Seclusion involves isolating a patient in a room
• Maintaining patient safety is the primary goal through guidelines
• False imprisonment may be a result if a patient is competent and can't legitimately be medically restrained.

Admissions

• An individual can voluntarily seek mental health treatment and can leave at any time unless professionals deem them as a danger to themselves or others.
• Involuntary inpatient hospitalization must meet required legal guidelines for the mental health facility to administer.
• Specific criteria for admitting include the individual must be:
• An imminent danger to themself
• A danger to others
• Gravely disabled
• Probable cause must be given and the individual must also have the right to a hearing
• Emergency commitments occurs in mental health care when someone are being considered a danger to themselves.
• Time Bound reviews and court meetings are made to be evaluated if the person should be discharged or not.

Involuntary Commitment

• "Mentally ill and in need of treatment: commitments are for people who seem "mentally ill" and their commitment is longer because of the length for assessment and treatment plans.
• Must be presented with valid evidence
• There are due process rights
• Involuntary outpatient commitment (IOC) requires people with mental illnesses to participate in treatment on an outpatient basis through court order.
• There are particular criteria, such as a diagnosed mental illness, that must be met
• The goal of an IOC is to prevent people from becoming more unwell
• Example of Kendra's law in NY, was a result of an individual with schizophrenia who pushed a woman into the subway.
• Gravely disabled are those impaired or unable to care for their needs, and are in danger of hurting themselves: gravely disabled.
• If a person is "gravely disabled" the court may appoint a guardian, conservator, or committee to to handle their finances and well-being
• There is a trend towards using coercive methods of mental health like restraints and medications.

Nursing Liability

• Mental healthcare workers are legally and ethically obligated to provide high-quality care based on "standards of care."
• Legal Liability and Negligence:
• Negligence means not acting with reasonable care which can by like a prudent person under similar circumstances.
• Malpractice means when a healthcare professional fails to meet the standard of their specific professional competence.
• Malpractice happens when someone is directly injured under the care of the negligent healthcare professional, and can be caused by wrongdoing or ignorance.
• Most states have specific laws about malpractice, but where those don't exist, the "common law" is used based on past case law.

Elements of a Malpractice Lawsuit

• These are the elements that a plaintiff needs to prove:
• Duty
• Breach of Duty
• Injury
• Cause
• Expert witnesses are usually brought in in a malpractice case to confirm whether or not the nurse's actions were acceptable.
• Nurses can face legal action, and malpractice is at its heart.
• Malpractice lawsuits are civil actions, seeking financial compensation.
• Nurses can also be sued for defamation and invasion of privacy.
• Revealing information that is harmful can lead to a defamation lawsuit, which is why a nurse can only base their work in what is factual.
• Nurses are not to search for patients without proper justification, which can result in invasion of privacy.

Avoiding Liability

• Nurses should take proactive actions to minimize malpractice risks.
• Those actions include the following:
• Effective communication
• Accurate documentation
• Adhering to the standard of care
• Understanding patients
• Practicing within scope