1. Patient Rights and Legal Issues Chapter 4

2. Ethics and Psychiatric Nursing • Bioethics – “medical ethics” • Ethical principles • Autonomy • Beneficence • Justice • Veracit • Fidelity

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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.

11. 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 orauthorization

12. 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)

13. 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.

14. Required Nursing Documentation • Observations of subjective/objective responses • Interventions implemented • Evaluation of outcomes of interventions

15. 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”).

16. Laws and Psychiatry • NGRI - Not Guilt by Reason of Insanity • GBMI - Guilty but Mentally Ill • Forensic Commitment

17. 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

18. 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

19. 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.

20. 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

21. TRUE OR FALSE: • THE CLIENT HAS THE RIGHT TO REVIEW THE • RECORDS PERTAINING TO HIS OR HER CARE • THE CLIENT’S RIGHT TO REFUSE TREATMENT IS • BASED ON COMPETENCY • COMPETENCE IS THE EQUIVALENT TO RATIONALITY • 4. MOST STATES PROVIDE FOR EMERGENCY • SHORT-TERM HOSPITALIZATION OF 7 – 10 DAYS • BREACH OF CONFIDENTIALITY IS APPROPRIATE • IF THE CLIENT IS ABOUT TO INJURE SOMEONE • GUILTY BUT MENTALLY ILL CLIENTS ARE • COMMITTED TO THE MENTAL HEALTH SYSTEM

22. WHICH OF THE FOLLOWING STATEMENTS IS MOST • APPROPRIATE WHEN DOCUMENTING IN MENTAL • HEALTH NURSING? • Client is manipulating female staff • Client slept. Good night. • Client upset and withdrawn • Client states “I have no reason to live”

23. 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? • “The treatment will help me feel less sad all • the time. • “ I won’t be able to remember anything about the • procedure” • “ Just one treatment will help cure my depression • for good” • “They don’t know how this therapy works, just • that it does”