Nursing Ethics and Legal Responsibilities

Legal and Ethical Issues Concerning Nursing Practice

• Nursing practice is governed by state laws and regulations, including licensure requirements and scope of practice definitions.
• Nurses must understand and uphold patients' legal rights, including informed consent, privacy, and confidentiality.
• Nurses can be held legally accountable for negligence or errors in patient care.
• Accurate and timely documentation is crucial for legal protection and can be used as evidence in court.
• Nurses often face situations where legal and ethical considerations intersect.
• Nurses are often required by law to report certain situations, such as suspected abuse or neglect.
• Nurses may face criminal charges related to their professional conduct.
• Understanding legal and ethical intersections is essential for safe, ethical, and legally compliant nursing practice, while providing optimal patient care.

Objectives

• Understand how nursing intersects with the legal system
• Describe issues related to voluntary versus involuntary commitment
• Recognize patient rights and the nurse's role in protecting those rights
• Identify concerns related to the nurse-client relationship

10 Major Ideas

• Patient Rights
• Safety
• Restraints
• Ethics/Ethical decision-making & Legal issues
• Informed consent/confidentiality
• Patient Advocacy
• Documentation

Ethical Principles in Psychiatric Nursing

• Autonomy: Respecting the patient's right to make their own decisions
• Beneficence: Acting in the best interest of the patient
• Non-maleficence: Avoiding harm to the patient
• Justice: Providing fair and equitable treatment to all patients
• Fidelity: Maintaining trust and keeping promises to patients
• Veracity: Honesty and truthfulness in communication

Case Example

• John, a 28-year-old man with a history of major depressive disorder and generalized anxiety, struggles with suicidal thoughts.
• He is admitted to a psychiatric hospital and Dr. Patel discusses treatment options, including medication and CBT.
• Dr. Patel supports John's choice to try therapy first; respecting John's right to participate in treatment options and respect his choice.
• He is fully informed about options to avoid distress or side effects associated with medications.

Legal Status and Rights

• Voluntary patients generally have more rights than involuntary patients, including the ability to request discharge (though there may be subject to a short hold period), and greater control over treatment decisions.
• However, the line between a voluntary and involuntary status can be blurry.

Admission Process

• Voluntary admission typically requires the patient to sign consent forms.
• Involuntary commitment usually involves a legal process, often initiated by a mental health professional or law enforcement.
• Emergency involuntary holds (EDO) may precede longer-term commitment.

Civil Commitment

• Action involves involuntary commitment in a hospital or mental health facility to protect the individual and their well-being, like a parent protecting a child.
• An individual can voluntarily admit themselves to a facility; staff will determine whether or not treatment and extended stay are needed.

Criteria for Involuntary Commitment

• Danger to Self: Individual poses a clear and imminent risk of serious harm to themselves (suicidal behavior or intent).
• Danger to Others: Individual poses a significant risk of harm to others (threats or violent behavior).
• Grave Disability: Individual is unable to care for basic needs (e.g., food, clothing, shelter) due to mental illness.
• Severe Mental Illness: Individual has a mental illness that severely impairs judgment, behavior, or reality.
• Lack of Insight: Individual is unaware of their condition (anosognosia) and refuses treatment despite risk.
• Inadequate Alternatives: Less restrictive interventions have been tried, and the individual's situation requires a structured hospital environment.

Procedures in Involuntary Commitment

• A family member, mental health professional, or primary care practitioner can request a court order for evaluation.
• The judge agrees, and an initial evaluation is ordered by mental health professionals or physicians.
• Two professionals (psychiatrist and mental health professional) evaluate the individual's mental state, capacity for self-care, and risk of harm.
• A formal hearing follows with testimony from examiners, family, friends, and the individual, often with legal representation for the person.

Involuntary Commitment in Texas

• Emergency detention involves taking the person to an inpatient mental health facility for evaluation which can last up to 48 hours, initiated by a peace officer.
• Alternatively, an adult can file an application for emergency detention with the court and the involved individuals. 

Length of Stay (LOS) and Discharge

• Voluntary patients can theoretically leave at will, but may face a short hold period if they request discharge.
• Involuntary patients are held for a set period determined by law, varying by jurisdiction.
• Extending involuntary commitment usually requires additional legal proceedings.

Treatment

• Involuntary patients may be forced to take medications or undergo other treatments against their will, requiring a court order to override civil rights.

Perception and Stigma

• Involuntary commitment can be stigmatizing and traumatic for patients.

Ethical Considerations

• Balancing patient autonomy with the need to protect individuals.
• Concerns about coercion and the use of involuntary treatment.
• Debate over the effectiveness and potential harm of forced treatment.
• Understanding these issues is vital for mental health professionals as the voluntary/involuntary distinction significantly impacts patient care, rights, and outcomes.

Mental Health Clients' Rights

• Treated with dignity, respect, and consideration for personal autonomy.
• Freedom from discrimination based on race, ethnicity, age, gender, sexual orientation, disability, or other protected characteristics.
• Protection from physical, sexual, or emotional abuse and inhumane treatment.
• Confidentiality of personal information and communications, within legal limits.
• Right to give informed consent or refuse any service/treatment.
• Freedom from unnecessary restraint or seclusion.
• Inform of and refuse any unusual or hazardous procedures.

Intentional Torts

• Nurses aren't immune to criminal prosecution if they break the law.
• Examples include negligent homicide, insurance fraud, theft of narcotics, manslaughter, and falsifying medical records.

Assault

• Causing fear or apprehension of physical harm in a patient.

Battery

• Touching a patient without consent or beyond the scope of consent. 

False Imprisonment

• Confining or restraining a patient against their will without proper justification.

Invasion of Privacy

• Violating a patient's right to privacy and confidentiality.

Defamation (Slander/Libel)

• Making false statements about a patient or disclosing private information without authorization.

Legal Requirements for Assault

• Assault is a valid claim if the alleged victim is aware of potential harm and the actions reasonably induce fear of bodily harm.

Legal Requirements for Battery

• Battery is the intentional, wrongful physical contact without consent. 

• The victim must be aware of potential harm in assault; in battery, the victim does not need to be aware.

Unintentional Torts

• Negligence: Failing to exercise ordinary care.
• Malpractice: Specific form of negligence by licensed healthcare professional.
• Fraud: Deceiving a patient for personal gain.

Psychiatric Nursing & Ethical Considerations

• Obtaining proper informed consent.
• Respecting patient autonomy.
• Maintaining confidentiality.
• Proper assessment and monitoring of patients.
• Properly documenting patient care and communications.
• Following proper procedures for involuntary commitment and restraint.
• Properly administering medication and monitoring side effects.

The Nurse-Client Relationship

• Confidentiality and duty to warn
• Protecting patient's confidentiality unless a duty to warn/report exists.
• Recognizing the therapist-client relationship concerns
• Legal and ethical obligation to clients in the context of the nurse-client relationship.
• The therapist's responsibility to warn if present danger to another exists, even if the threat is nonspecific (e.g. from Tarasoff v Board of Regents case).

Key Principles of the Tarasoff Ruling

• Duty to Protect: Mental health professionals have an obligation to take reasonable steps to protect identifiable individuals threatened.
• Duty to Warn/Notify Authorities: Warning the potential victim or notifying authorities who can protect them.
• Assessment of Threat: Professionals must evaluate seriousness and credibility of threats.
• Balancing Confidentiality and Public Safety: Prioritizing public safety and balancing it with patient confidentiality. 

Implications for Nursing Practice

• Threat Assessment: Nurses must be vigilant in assessing and documenting potential threats made by patients.
• Reporting Protocols: Nurses must familiarize themselves with facility protocols for reporting threats and concerns.
• Collaboration: Working closely with the healthcare team, including mental health professionals.
• Documentation: Thorough and accurate documentation of patient statements, behaviors, and nurse actions.
• Ethical Considerations: Balancing patient confidentiality with the duty to protect potential victims.
• Legal Awareness: Understanding state-specific laws regarding the duty to warn.

Restraints

• Last resort measure used after other de-escalation techniques fail.
• Alternatives like verbal de-escalation, medications, and environmental modifications should be attempted first.
• Restraints are only used for immediate safety risk.
• Follow facility policies and relevant laws/regulations.
• Physician order is required.

Key Points About Applying Restraints

• Orders are time-limited, renewed based on reassessment.
• Restraints removed as soon as patient is no longer a danger.
• Documentation with rationale, alternatives attempted, patient response.
• Patient informed of reasons for restraint use.
• Post-incident debriefings for identifying future prevention methods.
• Awareness of physical and psychological risks for restraint use. 

Patient's Rights in Psychiatric Settings

• Patients admitted to psychiatric facilities maintain their civil rights.
• Rights to information, treatment decisions, least restrictive environments, choice of providers, confidentiality, nondiscrimination.
• Treatment is determined by professionals, not third-party payers. 

Key Considerations in Ethical/Legal Situations

• Patient rights and autonomy (respecting patient's decisions when competent).
• Safety and duty of care (protecting patients from harm).
• Least restrictive environment (using least restrictive interventions possible).
• Ethical principles (beneficence, non-maleficence, justice).
• Legal requirements.
• Informed consent (providing adequate information for informed decisions).
• Confidentiality (except when a duty to warn exists).
• Patient advocacy (advocating for patient rights).
• Documentation, of the entire process (clinical reasoning, ethical considerations and decision-making).

Table Talk: Discussion Points

• Assessing immediacy and credibility of threat.
• Identifying potential victims.
• Legal/ethical implications to the nurse.
• Appropriate steps for the nurse to take.
• Balancing patient confidentiality with duty to protect.

Specific Scenarios (Examples)

• High school student threatened to bring gun to school
• Patient alleging food poisoning by spouse
• Patient with paranoid delusions believing neighbor is spying.