NURS24998 Issues and Trends in Nursing & Health Care Fall 2022 PDF

NURS24998 Issues and Trends in Nursing & Health Care Fall 2022 2017 sheridancollege.ca Recap Last Class Ethical Principles: Autonomy Beneficence Non-maleficence Justice; distributive justice Veracity Confidentiality Fidelity Ethical Theories: Major Theories: 1. Consequentialism: Utilitarianism -Key...

NURS24998 Issues and Trends in Nursing & Health Care Fall 2022 2017 sheridancollege.ca Recap Last Class Ethical Principles: Autonomy Beneficence Non-maleficence Justice; distributive justice Veracity Confidentiality Fidelity Ethical Theories: Major Theories: 1. Consequentialism: Utilitarianism -Key concept: the greater societal good 2. Deontological -Key concepts: duty-based ethics; moral behavior 3. Communitarianism -Key concepts: abstract universal principles not adequate, use of history and tradition and concrete moral communities Virtue ethics The ethic of care Feminist ethics sheridancollege.ca Module 2 Legal and Professional Issues Learning Outcomes: To describe the sources of the law. To distinguish between the types of law and be able to describe the difference between public and private law in Canada. To describe advanced directives and how they should be applied while providing nursing care. Understanding of the nurse’s role in Medical Assistance in Dying(MAiD). To have an understanding of the role of the coroner and related nursing responsibilities. sheridancollege.ca Why Does the Law Matter? How is the law different than what our professional standards or professional ethical standards suggest? sheridancollege.ca Definition of Law Moral beliefs of a population. Set of rules that define our rights and obligations and set penalties for people who violate them. Laws decide how the government will enforce any rules or penalties. Laws ensure safety of citizens, protect property, prohibit discrimination, regulate professions, protect economic and environmental interests of society and ensure proper distribution of goods and services. (Burkhardt et al., 2018) sheridancollege.ca Law and Nursing Nurse practice acts and regulatory acts describe the activities and scope of practice. It scrutinizes nursing actions and omissions thus basic knowledge about new and longstanding laws and legal processes need to be known. Knowledge in legal principles is also a necessary component of ethical decision making. (Burkhardt et al., 2018) sheridancollege.ca How are Ethics and the Law related? Laws reflect “rightness” or “wrongness” of acts and like ethics, built upon a moral foundation. Laws convert morality into social guidelines with specific punishments for offences. Ethics and law are not always congruent: Some illegal acts can be considered ethical by some Some acts are unethical but legal (Burkhardt et al., 2018) sheridancollege.ca 4 Sources of Law Relevant to Nursing 1. 2. 3. 4. Common Law Constitutional Law Statutory/Legislative Law Administrative Law sheridancollege.ca 4 Sources of Law Relevant to Nursing Cont. 1. Common Law (case law) Originated in England and is a system of laws derived from decisions of courts and judges Case law-precedent past cases are important in our system Doctrine-guides from legal scholars and experts Custom-accepted practice (E.g., diplomatic immunity) (Burkhardt et al., 2018) sheridancollege.ca 4 Sources of Law Relevant to Nursing Cont. 2. Constitutional Law - are formal sets of principles and rules that can describe what the government can do as well as the rights of all people E.g., Charter of Rights and Freedoms 3. Statute/Legislative Law- are formal laws that are written and enacted by the federal and provincial bodies. E.g., Nursing Act; RHPA, Labour Act; Highway Traffic Act, Bill C-14 4. Administrative Law-operation of government agencies. These agencies do the work of the government and regulate activities. E.g., Ministry of Labour, College of Nurses, education, public health, social welfare. (Burkhardt et al., 2018) sheridancollege.ca Canadian Charter of Rights and Freedoms Fundamental Rights Democratic rights Equality rights Language rights Mobility rights Legal rights - * most important Freedoms Freedom of religion & conscience Freedom of thought & expression Freedom of the press Freedom of peaceful assembly Freedom of association sheridancollege.ca Types of Law Public Law: Defines a person’s rights and obligations in relation to government. Includes criminal law. - E.g., Tax law, Criminal Code of Canada, Human Rights Private Law/Civil: Person’s legal rights and obligations in activities that involve other people. Branches of private law include contract law, tort law, property law, labour law etc. - E.g., Slander, Breach of Confidentiality (Burkhardt et al., 2018) sheridancollege.ca Private Law /Civil Branches Contract Law: Rights and obligations of people who make a contract (branch of Private Law). - E.g., Employment contract, Nurse-patient relationship is an implied contract Tort Law: A tort is a civil wrong committed against a person or property. A person suffers because of someone else’s action, either intentional or unintentional. - E.g., bodily harm, invade another’s privacy, damage a person’s property or reputation (slander and libel) (Burkhardt et al., 2018) sheridancollege.ca Tort Law Intentional Tort Willful act that violates another’s rights. Fraud, invasion of privacy, assault, battery, false imprisonment, slander and libel Battery: “Intentional bringing about of harmful or offensive & non- consensual contact with the person of another; can be an effect on another’s dignity.” Assault: “Intentional creation of the apprehension of imminent harmful or offensive contact.” Assault and Battery: occurs simultaneously when an individual threatens to harm someone and then physically harms that person. (Burkhardt et al., 2018) sheridancollege.ca Tort Law Continued New Tort Claim: Intentional infliction of emotional distress Allows claim against someone who acts in heinous, reckless, or extreme way to bring about emotional distress in the plaintiff. Instances when a threat is not imminent or the threat of harm is in the future so not considered assault. E.g., Harassing, stalking, bullying, cyberbullying or sharing of digital sexual images without consent (Burkhardt et al., 2018) sheridancollege.ca Tort Law Continued Unintentional Tort Negligence in Nursing: Failure to provide a standard of care that is reasonable. Failure to act within professional standards, or failure to foresee consequences that a professional person, having the necessary skills and education should foresee. What are some potential examples in nursing practice? (Burkhardt et al., 2018) sheridancollege.ca Negligence Four Attributes of Negligence: 1. Duty of care existed. 2. There was a breach in the duty of care or failure to perform the duty, standard not met. 3. There are damages suffered - injury or harm. 4. There is a cause and effect of this breach. The negligent conduct is the cause of the damages. (Burkhardt et al., 2018) sheridancollege.ca Case History A mother made a routine prenatal visit to the hospital. While in the waiting room the mother complained to the nurse of severe abdominal pain. Over the next hour and a half the mother complained of pain five times, each time she was told that she would have to wait to be examined. When the mother was finally examined her unborn child's fetal heart rate was only 60 to 70 beats per minute. An emergency cesarean section was performed but the baby was born severely depressed, hypoxic, suffered from severe brain injury and developed seizures within the first hour. Does this fit the criteria for negligence? sheridancollege.ca Health Care Consent Act Review 1996 Statute Law Rule of informed capable consent to treatment or admission to a care facility Principles: Autonomy (protects), Veracity Values: Choice, Truth Permits intervention by the Public Guardian and Trustee (PG&T) as a last resort (supersedes other decision makers if applied). What does capable person mean? Who determines this? (Burkhardt et al., 2018) sheridancollege.ca Health Care Consent Act Continued Legal capacity to consent: ü The ability to understand the significance of behaviours and the influences on behaviours or decision-making abilities ü The ability to appreciate the foreseeable consequences of decision-making processes ü Age and mental competence of the person to understand the information provided, along with the risks, benefits, value of alternatives and consequences of the decision once made (Burkhardt et al., 2018) sheridancollege.ca Health Care Consent Act Continued Age of Consent- no minimum age At any age, if a child does not agree with treatment (and parents’ consent), a court order is necessary to decide. When children are perceived to have an advanced level of understanding they may be deemed to be ‘mature minors.’ Usually above the age of 13 but in some incidences have been as young as seven (case by case basis). CAS may be involved if child needs protection. (Burkhardt et al.,2018) sheridancollege.ca Informed Consent Four Elements of Informed Consent: 1. Given voluntarily -No pressure or coercion -Free will to revoke at any time 2. Informed -Person giving consent must understand the procedure or treatment. 3. Consent relates to specific providers and treatment 4. Capacity to consent must be assessed -Legally capable - client or legal substitute (Burkhardt et al., 2018) sheridancollege.ca Types of Consent Implied/Inferred ü Less concrete, inferred from a person’s presence and actions, as well as the context of the situation. Expressed or Explicit ü Verbal or written specific to the patient’s agreement to a particular treatment or procedure. (Burkhardt et al., 2018) sheridancollege.ca Nurses Role in Informed Consent Witness to voluntary signature If the client is not informed what should the nurse do? To “inform” of all the requirements of informed consent is outside the scope of nursing practice – unless it is a nursing procedure – surgical consent is “informed” by MD (Burkhardt et al., 2018) sheridancollege.ca Treating without Consent Exclusion: Emergency Doctrine Necessary justification Reasonable efforts Can proceed with all necessary treatment and document What are some examples or situations where this would be appropriate? (Burkhardt et al., 2018) sheridancollege.ca Substitute Decisions Act 1992 Substitute Decisions Act and amendments Addresses decision making regarding personal care and care of property in the case of a person who is deemed to be incompetent (CNO,2008) Power of Attorney (personal care or property) Hierarchy Principle of autonomy: prior capable wishes (Burkhardt et al., 2018) sheridancollege.ca *Hierarchy of Substitute Decision Makers* - Guardian (court appointed; last resort; once named has full authority) - Power of attorney (POA) - person appointed - Representative appointed by the Consent and Capacity Board (E.g., mental health issues) - Spouse/partner/relative - Child >16 yr. ; or parent (lawfully entitled - E.g., custody), or CAS - Parent with right of access - Brother/sister - Any other relative - Office of the Public Guardian and Trustee (PGT) sheridancollege.ca Advanced Directives Two parts: ü Proxy directive-the patient’s identified SDM or POA ü Instruction directive-set of instructions to be carried out, health care decisions, treatment, diagnostic care and interventions - Includes personal care decisions (hygiene, nutrition, hydration) - Documented and witnessed. Considered a form of informed consent for future interventions Can the advanced directive be overridden by the POA or appointed decision maker? (Burkhardt et al., 2018) sheridancollege.ca Inquest Public hearing conducted by a coroner before a jury of five community members An inquest is intended to explore the circumstances of a specific death or deaths Purpose of developing recommendations that will prevent future tragedy in similar circumstances. The duties, activities and powers of coroners are defined in the Coroners Act, 1990 (provincial jurisdiction) (Ministry of the Solicitor General, 2021) (Office of the Chief Coroner, 2021) sheridancollege.ca Death Investigation There are five questions that must be answered when investigating a death: - Who was the deceased? - Where did the death occur? - When did the death occur? - How did the death occur (E.g., the medical cause)? - https://www.enablelaw.com/news/expert-opin ion/what-to-expect-at-a-coroners-inquest/ By what means did the death occur? (classification or manner of death: natural, suicide, accident, homicide or undetermined) (Office of the Chief Coroner, 2021) sheridancollege.ca Types of Inquests Mandatory inquests-must be completed when a death occurs in certain circumstances E.g., on the job at a construction site, while a person is in custody or being detained, if the death resulted from use of force (police), child dies as a result of a criminal act of a person who has custody of the child, physically restrained and detained in a psychiatric facility, hospital, or secure treatment program Discretionary inquests-may be completed when a death occurs There is no time limit between the date of death and the convening of an inquest E.g., the coroner believes a jury could make useful recommendations to prevent further deaths or relative of a deceased requests an inquest by submitting a request in writing to the investigating coroner. (Ministry of the Solicitor General. 2021) sheridancollege.ca Inquest continued Inquisitorial process designed to focus public attention on the circumstances of death (Ministry of Community Safety and Correctional Services, 2016) Not considered to be a trial or adversarial process Nurses may be served with a summon to attend as a witness if they cared for the individual. - May be questioned about anything contained within the patient chart, or their actions. - “A witness should not bring nurses’ notes nor the patient’s chart to the inquest unless the subpoena requires this” (CNPS,2016). sheridancollege.ca Inquest Outcome After all witnesses have been heard, the coroner’s counsel and lawyers representing parties present closing statements. No finding of legal responsibility can be made nor any conclusion of law expressed. While a nurse may talk with a lawyer concerning her/his rights as a witness, that lawyer cannot participate in the inquest without permission of the coroner - if the care given by the nurse is in question, the nurse should speak with a lawyer - generally, testimony given by a witness at an inquest cannot be used against the witness in any other legal proceedings except perjury (Office of the Chief Coroner, 2021) sheridancollege.ca Practice Application Sanchia Bulgin is a 17-year-old female with sickle cell anemia. She died after a routine gallbladder surgery. Sanchia was given morphine post-operatively, a drug she had known sensitivity to. She was inadequately monitored for signs of bleeding, shock, and hemorrhaged to death. A coroner’s inquest was completed. What do you think the nurse can be charged with under our laws? What do you think the coroner would recommend? (Burkhardt, Nathaniel, & Walton, 2014, p.163) sheridancollege.ca Death Investigations-Group Activity Use the number of your Breakout Room to find the corresponding document on SLATE under Module 2 Legal and Professional Issues. Review the document with your group. Answer the following questions: ü Who was the deceased? ü When did the death take place? ü Where did the death take place? ü How did the death occur? ü What means caused the death? ü What are two recommendations that will prevent future tragedy in similar circumstances? Select a speaker to report on your document review. sheridancollege.ca End-of-life Care Resources CNO recommends utilizing the following practice documents to help with decisions related to end-of-life care: ü Professional Standards ü Therapeutic Nurse-Client Relationship ü Consent ü Guidance on Nurses Roles in MAID (2021) https://www.cno.org/globalassets/docs/prac/41056guidance-on-nurses-roles-in-maid.pdf sheridancollege.ca Medical Assistance in Dying (MAID) Legislation: Bill C-14 establishes safeguards for clients and offers protection to health professionals who provide medical assistance in dying, along with people who assist in the process in accordance with the law (CNO,2016). Bill C-7 is the response to the Truchon decision, made amendments to the Criminal Code to expand the eligibility for Medical Assistance in Dying (CNO, 2021). - Unconstitutional to require that the natural death must be reasonably foreseeable to be eligible for MAID. (CNO, 2021) sheridancollege.ca Bill C-7 Safeguards Two-track approach to procedural safeguards: 1. One set of eased safeguards for people whose natural death is reasonably foreseeable 2. Second set of new and clarified safeguards for people whose natural death is not reasonably foreseeable. (CNO, 2021, p.4)) sheridancollege.ca RPN Role in MAID Can RPN’s assist an NP or physician with providing MAID? When giving information to patients about MAID what must the RPN ensure? What is conscientious objection? (CNO, 2021) sheridancollege.ca Stages in MAID Stage 1 Determine eligibility Stage 2 Ensure safeguards are met Stage 3 Obtain consent Stage 4 Provide MAID either by NP or physician or selfadministered by the patient (CNO, 2021) sheridancollege.ca Stage 1 Eligibility Criteria Eligibility criteria: -18 years of age -capable of making decisions about their health -have a grievous and irremediable medical condition -voluntarily request MAID -give informed consent after being informed of treatments available to relieve their suffering, including palliative care -eligible to received health benefits funded by government of Canada -cases where mental illness is the sole underlying medical condition are excluded. In effect until March 17, 2023 (CNO,2021) sheridancollege.ca Stage 2 Ensure Safeguards Track 1 Reasonably foreseeable natural death -patient written request signed by one independent witness -eligibility confirmed by 2 independent practitioners (NP or MD) -informed they can withdraw consent at any time and given an opportunity to withdraw or give expressed consent again immediately before MAID is provided -if the patient has an advanced consent agreement expressed consent is not needed again -all measures taken for patients with difficulty communicating to understand and communicate -immediately before the patient is given an opportunity to withdraw their request and ensure express consent (CNO, 2021) sheridancollege.ca Stage 2 Ensure Safeguards Track 1 Reasonably foreseeable natural death -written request required by the patient signed and dated after being assessed to be eligible -if the patient is unable to sign another person may sign with the patient present (18yrs old, understand the request, not be a beneficiary under the patient’s will, no financial or material benefit from the patient’s death) -request must be signed by an independent witness (18 yrs., not a beneficiary, no financial or material benefit, not an owner or operator of a health care facility where the patient resides or is being treated). Are RPN’s allowed to act as an independent witness? (CNO, 2021) sheridancollege.ca Stage 3 Consent Track 1 Reasonably foreseeable natural death Types of Consent -General Consent-obtained by the NP or Physician -Advanced Consent-written arrangement in case of loss of capacity -Express consent (final)- immediately prior to MAID -Exception to final consent-patient creates a back up plan for self-administration with the practitioner. If the initial medication does not produce death the practitioner can administer the medication. This holds even if the patient loses capacity. (CNO, 2021) sheridancollege.ca Stage 2 Ensure Safeguards Track 2-Natural Death NOT Reasonably foreseeable -patient written request signed by independent witness -90-day assessment period (from assessment until day of MAID) -shorter period may be considered if loss of capacity to provide consent imminent -eligibility confirmed by two independent practitioners -one practitioner must have expertise in the patient’s condition -patient informed they can withdraw consent at any time (CNO, 2021) sheridancollege.ca Stage 2 Ensure Safeguards Track 2-Natural Death NOT Reasonably foreseeable - patient informed of means available to relieve their suffering, (counselling services, mental health and disability support services, palliative care). - offered consultations and has seriously considered the available services - all measures taken for patients with difficulty communicating to understand and communicate - immediately before the patient is given an opportunity to withdraw their request and ensure express consent (CNO, 2021) sheridancollege.ca Stage 3 Consent Track 2-Natural Death NOT Reasonably foreseeable Types of Consent - General consent- obtained by the NP or Physician - Express consent (final) - Exception to final consent-patient creates a back up plan for self-administration with the practitioner (CNO, 2021) sheridancollege.ca Stage 4 MAID Provided Self-administration Practitioner administered Death must be reported to the Office of the Chief Coroner Coroner will determine if an investigation is required Debrief for health care providers Self-care (CNO, 2021) sheridancollege.ca Case Example - A 45-year-old patient with ALS requests MAID. She lives in a rural community where few physicians are comfortable being involved in MAID. - She is not yet at the “end of life”—her treating physicians believe she could live another four years. However, she is concerned she could choke on her saliva and die at any time. She is not currently experiencing intolerable physical suffering but is suffering severe psychological distress. - She has questions about preparing an advance request for MAID in the event her pain medication affects her capacity to consent later. - Her husband supports her request, but her daughter opposes her mother’s choice. - Is the patient eligible for MAID? - Which track of safeguards would support the patient’s wishes? (CMPA,2021) sheridancollege.ca Points to Ponder.. What are some ways you can protect yourself from liability, while maintaining patient-centered care? What are the four key elements that must be proven to make a finding of negligence? sheridancollege.ca References Burkhardt, M., Nathaniel, A., Walton, N. (2014). Ethics and Issues in Contemporary Nursing, 2nd Canadian Edition. Toronto: Nelson. Burkhardt, M., Nathaniel, A., Walton, N. (2018). Ethics and Issues in Contemporary Nursing, 3rd Canadian Edition. Toronto: Nelson. Canadian Medical Protective Association (CMPA).(2021). The continuing evolution of medical assistance in dying. https://www.cmpa-acpm.ca/en/advicepublications/browse-articles/2021/the-continuing-evolution-of-medicalassistance-in-dying CNO.(2009). Ethics Standard. Retrieved from https://www.cno.org/globalassets/docs/prac/41034_ethics.pdf CNO.(2017). Guidance on nurses’ roles in medical assistance in dying. Retrieved from http://www.cno.org/globalassets/docs/prac/41056guidance-on-nurses-roles-in-maid.pdf CNO.(2021). Guidance on nurses’ roles in medical assistance in dying. 41056 Guidance on Nurses Roles in MAID (cno.org) sheridancollege.ca References Ministry of the Solicitor General. (2021). Death investigations. https://www.ontario.ca/page/death-investigations Office of the Chief Coroner. (2021). Death investigations. https://www.mcscs.jus.gov.on.ca/english/DeathInvestigations/office_coron er/coroner.html Potter, P.A., Perry, A.G., Ross-Kerr, J.C., Wood, M.J., Astle, B.J., & Duggleby, W. (Eds.). (2019). Canadian fundamentals of nursing (6th ed.). Toronto, ON: Elsevier Canada. sheridancollege.ca. NEXT WEEK: § Module 3 Community Health Nursing § Online Activities sheridancollege.ca