Psychiatric Nursing: Legal & Ethical Rights

• Psychiatric mental health nursing involves legal and ethical considerations
• The objectives are to define legal and ethical rights of mentally ill patients and understand medical laws and the roles of psychiatric nurses

Laws and Regulations

• The U.S. Constitution, federal and state statutes, and precedent-setting legal cases all impact psychiatric nursing practice
• "Good Samaritan" statutes are part of federal and state statutes
• The Joint Commission on Accreditation of Health Care Organizations (JCAHO) and Centers for Medicare and Medicaid Services (CMS) are important

Standards of Care

• The American Nurses Association provides "Standards of Nursing Practice" and a "Code for Nurses"
• "A Patient's Bill of Rights" was created by the American Hospital Association in 1973

Nursing Associations

• The American Psychiatric Nurses Association (APNA) exists
• The International Society of Psychiatric-Mental Health Nurses (ISPN) also exists

Negligence

• Four elements must be present
• The first is duty to care
• The second is obligation of reasonable care, including standard of care
• The third is breach of duty
• The fourth is injury caused by breach of duty

Malpractice

• Malpractice claims include failing to prevent harm or maintain the standard of care

Accountability

• Accountability includes delegating authority to unlicensed assistive personnel
• Hospital policy and procedures must be followed
• Scope of practice, training, orientation, limitations and responsibilities all factor in

Duty to Warn

• The Tarasoff v. The Regents of the University of California (1976) case established a duty to warn
• Mental Health Professionals have a duty to warn a third party of intended harm or possible danger
• Failure to warn, if coupled with injury, can result in civil damages for malpractice
• It's important to balance protecting confidentiality with warning society

False Imprisonment

• False imprisonment is the intentional, unjustified, nonconsensual detention or confinement of a patient, per ATI, 2004
• This includes voluntary admit
• This also includes discharge AMA (Against Medical Advice)
• Use of restraints can lead to false imprisonment
• Mechanical restraints can lead to false imprisonment.
• Chemical restraints can lead to false imprisonment.

Autonomy & Liberty

• Patients must be treated in the least restrictive setting
• Patients should have active participation in treatment

Aggression

• Assault involves nonconsensual threat
• Battery involves actual touching
• Nurses cannot threaten bodily harm to coerce patients
• Nurses cannot physically restrain or touch an adult patient to prevent them from leaving or forcing procedures

Advance Directives

• The Patient Self-Determination Act of 1991 exists
• Individuals have the right to choose medical treatment in life-threatening conditions
• Living Wills & Health Care Directives can be created
• A Durable Power of Attorney can be assigned.

Voluntary Admission

• A patient consents to confinement in the hospital and signs conditions of admission

Commitment/Involuntary Admission

• Commitment or involuntary admission is implemented on the basis of:
• Dangerousness to self (DTS)
• Dangerousness to others (DTO)
• Grave disability (GD)
• This may involve inability to provide food, clothing, and shelter
• Or inability to have a plan for self care

Competency

• Competency is a legal determination that an adult patient can make reasonable judgments about treatment, including courts ruling adults as incompetent
• A guardian may be appointed to make decisions
• Patients continue to participate in healthcare decisions as tolerated

Informed Consent

• Patients have the right to be given enough information to make a decision, understand it, and communicate their decision
• In emergencies, treatment can be provided without informed consent

Advocating for Informed Consent

• Nurses ensure major elements are addressed
• Knowledge: providing adequate information
• Competency: ensuring cognition is intact with legal representation
• Free Will: ensuring voluntary consent free of pressure or coercion

Confidentiality

• Protecting private patient information is vital
• The Health Insurance Portability and Accountability Act (HIPAA, 1996) protects patient information
• Aspects include psychiatric hospitalization, chemical dependency, and HIV testing

Patient's Rights for Mental Health

• Patients have the right to treatment in the least restrictive setting
• Patients have the right to refuse treatment
• Patients have the right to review medical records
• Patients have the right to refuse medication
• Patients have the right to wear their own clothes
• Patients have the right to keep & use own possessions
• Patients have the right to spend a reasonable amount of own money
• Patients have the right to access/storage
• Patients have the right to see visitors daily
• Patients have the access to telephone for confidential calls
• Patients have the right to access letter writing materials and mail
• Patients have the right to refuse shock treatment (Electroconvulsive Therapy)
• Patients have the right to refuse psychosurgery
• Patients have the right to a patient's rights advocate

Denial of Rights

• Denial of rights requires physician/provider order
• It is also required if it is contraindicated for treatment

Seclusion & Restraint

• The goal is to provide a safe environment for patients, families, and staff
• Seclusion & restraints should be a last resort for safety purposes

Seclusion

• This involves placing a patient in a locked room.
• This involves placing a patient in a room with the door held shut.
• This involves placing a patient in a room in which freedom is restricted.
• This involves separating a patient from the group.

Restraints

• Responsibility of the Registered Nurse includes:

  • Emergency intervention to provide safety, prevent injury & manage the assaultive patient

  • Document behaviors & triggers prior to R&S

  • List alternative strategies implemented before R&S

  • Obtain MD order within one hour (Type of restraint used, rationale for use & time limited); order is good for 24 hours; emergency medications Cocktail: Antipsychotic, Anticholinergic & Benzodiazepine IM

  • One hour face-to-face assessment with MD

  • R&S used for the shortest time possible

  • When in R&S patients constantly monitored

  • Document safety, comfort & basic needs interventions Q15 minutes

  • ROM & VS Q2 hours; trial releases from restraints

  • Patients debriefed after restrictive interventions

  • Patients may request notification of family when R&S is used

  • Deaths reported to the Federal Drug Administration (FDA)

  • Maximum time frames: -Children (1-8):1 hr; Adolescents (9-17):2 hrs; Adults(18 & over): 4 hrs.

Lanterman-Petris-Short Act (LPS)

• LPS is the California law that prescribes procedures for involuntary hospitalization and preserves rights of mentally disordered patients in the state

LPS Due Process

• 5150: 72 hour detention for evaluation and intensive treatment (DTS, DTO, GD)
• 5250: 14 days; intensive treatment (DTS, DTO, GD)
• 5352: 30 days; temporary conservatorship (GD)
• 5350: 1 Year full conservatorship (GD)
• 5361: 1 Year reappointment of conservator (GD)

LPS Additional Court Actions

• Probable Cause Hearing (PCH)
  • Certification Review Hearing (on unit)
• Writ of Habeous Corpus (court with escort)
  • Patient presents case to Judge
• Reise Hearing (either @ facility or court)
  • Judge mandates medication administration
  • Patient loses the right to refuse medication
• Tarasoff Advisement (filed with court) Duty to warn third party of threats of harm/violence Officially breach confidentiality of patient

Role of the Nurse

• To advocate for a therapeutic milieu
• To provide patients, family members, and treatment team members with information concerning legal and ethical rights
• To assist with understanding and integration of treatment options

Common Sources of Liability

• Client suicide
• Improper treatment
• Misuse of psychotropic medications
• Breach of confidentiality
• False imprisonment
• Injuries or problems related to ECT
• Sexual contact with a client
• Failure to obtain informed consent
• Failure to report abuse
• Failure to warn potential victims