Chapter 6 Legal and Ethical Guidelines for Safe Practice Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

Overview  A nurse who works in a mental health setting is responsible for:  Practicing ethnically  Competently  Safely  And in a manner that is consistent with all local, state and federal laws. Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 2

Ethical Concepts  Ethics: The study of philosophical beliefs about what is considered right or wrong in a society  Bioethics: Used in relation to ethical dilemmas surrounding health care  Ethical dilemma: Conflict between two or more courses of action, each with favorable and unfavorable consequences Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 3

Ethical Issues for Clients in Mental Health Settings  Ethical issues are philosophical ideas regarding right and wrong.  Nurse are frequently confronted with ethical dilemmas regarding client care (bioethical issues).  Ethics are philosophical and they involve values and morals, there is frequently no clear-cut simple resolution to a dilemma.  Only ethical principles can be used to decide ethical issues. Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 4

Five Principles of Bioethics (Ethical Issues for Clients)  Beneficence: The duty to promote good  Autonomy: Respecting the rights of others to make their own decisions  Justice: Distribute resources or care equally  Fidelity (non-maleficence): Maintaining loyalty and commitment; doing no wrong to a patient  Veracity: One’s duty to always communicate truthfully Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 5

Civil Rights of Persons with Mental Illness  Guaranteed the same civil rights as other citizens such as:  The right to human treatment and care, such as medical and dental care  The right to vote  The right to due process of law, including the right to press changes against another person  Informed consent and the right to refuse treatment  Confidentiality  A written plan of care/treatment that includes discharge follow-up as well as being able to participate in the development of that plan  Able to communicate with others outside the facility  Freedom from harm r/t physical or pharmacologic restraint, seclusion and any physical or mental abuse or neglect Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 6

Types of Commitment to a Mental Facility  Voluntary Admission - Inpatient care sought by a patient or patient’s guardian through a written application to the facility.  Involuntary Admission - Admission to a psychiatric facility without a patient’s consent.  Emergency involuntary – this is usually temporary for up to 10 days. This is usually imposed by primary care providers, mental health professionals or police officers to aid in preventing harm to self or others.  Observational or temporary involuntary commitment – this is where the client needs to be observed and a diagnosis and a treatment plan need to be established.  Long-term or formal involuntary commitment is similar to a temporary commitment but must be imposed by the state. Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 7

Case Study  A 27-year-old male is court committed by his parents to your unit with a diagnosis of paranoid schizophrenia. He lashes out at staff when they attempt to give him his medications. He states, “You are trying to poison me.” His family asks if you can “force” him to take his medications. Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 8

Case Study (Cont.)  How would you respond to this family? Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 9

Tort Law  Tort – A civil wrong for which money damages may be collected by the injured party (plaintiff) from the responsible party (the defendant)  Intentional tort – Willful or intentional acts that violate another person’s rights or property  Assault  Battery  False imprisonment Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 10

Tort Law (Cont.)  Unintentional tort – Unintended acts against another that produce injury or harm  Negligence  Malpractice Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 11

Five Elements to Prove Negligence  Duty  Breach of duty  Cause in fact  Proximate cause  Damages  Foreseeability or likelihood of harm is also evaluated. Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 12

Orders and documentation  Seclusion or restraint  Orders are never written as PRN or as a standing order.  Orders are to manage self-destructive or violent behavior  These orders must be renewed every 24 hours with limits depending on age of patient.  Adults 18 years or older – limited to 4 hours;  Children and Adolescents 9 to 17 years – limited to 2 hours; and  Children under 9 years have a 1 – hour limit  After 24 hours, a physician or other licensed person responsible for the patient’s care must personally assess.  Restraint or seclusion is discontinued as soon as safer and quieter behavior begins.  If the behavior begins, then another new order must be obtained. Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 13

Nurse’s duty when patient is in Restraint  Nurse must do the following when her patient is in restraint:  document restraint or seclusion in the treatment plan or plan of care;  noting the behavior leading to restraint or seclusion, and the time the patient is placed in and released from restraint.  the patient in restraint must be assessed at regular and frequent intervals (e.g., every 15 to 30 minutes)  for physical needs (e.g., food, hydration, and toileting), safety, and comfort;  these observations must also be documented every 15 to 30 minutes.  while in restraints, the patient must be protected from all sources of harm. Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 14

Contradictions to Seclusions & Restraints  Extremely unstable medical and psychiatric conditions*  Delirium or dementia leading to inability to tolerate decreased stimulation*  Severe suicidal tendencies*  Severe drug reactions or overdoses or need for close monitoring of drug dosages*  Desire for punishment of patient or convenience of staff*  *Unless close supervision and direct observation are provided.  From Simon, R. I. (2001). Concise guide to psychiatry and law for clinicians (3rd ed., p. 117). Washington, DC: American Psychiatric Press. Copyright © 2001 by American Psychiatric Press. Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 15

Duty to Warn and protect third parties  Negligence, irresponsibility, or impairment  Duty to intervene and duty to report Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 16

Failure to protect patients  A common legal issue in psychiatric mental health nursing is the failure to protect the safety of patients.  Examples:  A suicidal patient is left alone with the means of self-harm, the nurse who has a duty to protect the patient will be held responsible for any resultant injuries.  Leaving a suicidal patient alone in a room on the sixth floor with an open window is an example of unreasonable judgment on the part of a nurse.  Patients should be protected from other patients. One patient sued a hospital when she was beaten unconscious by another patient who entered her room looking for a fight. Her lawsuit alleged that there was inadequate staffing to monitor and supervise the patients under the hospital’s care. Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 17

Documentation of Care  A record’s usefulness is determined by evaluating—when the record is read later—how accurately and completely it portrays the patient’s behavioral status at the time it was written.  Example: if a psychiatric patient describes intent to harm himself or another person and his or her nurse fails to document the information—including the need to protect the patient or the identified victim—the information will be lost when the nurse leaves work. If the patient’s plan is carried out, the harm caused could be linked directly to the nurse’s failure to communicate the patient’s intent. Even though documentation takes time away from patient care, its importance in communicating and preserving the nurse’s assessment and memory cannot be overemphasized. Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 18

Medical Records  Used by the facility for quality improvement  Used as evidence  Electronic documentation Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 19

Question 1 Which individual with mental illness may need involuntary hospitalization? A.A person with alcoholism who has been sober for 6 months but begins drinking again B.An individual with schizophrenia who stops taking prescribed antipsychotic drugs C.An individual with bipolar disorder, manic phase, who has not eaten in 4 days D.Someone who repeatedly phones a national TV broadcasting service with news tips Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 20

Question 1.Legal and clients’ rights are suspended when a client is hospitalized involuntarily. A. True B. False C. Not sure Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 21

Question 2.A client plans to have electroconvulsive therapy (ECT). Which member of the team is responsible for obtaining the client’s informed consent? A. Physician B. Psychologist C. Case manager D. Registered nurse Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 22

Question 3.A nurse was the case manager for a client with serious mental illness for 6 years. The client died by suicide 1 week ago. Today, the client’s spouse asks, “I always wondered if my spouse was a victim of sexual abuse in childhood. What can you tell me about that?” Can the nurse disclose information to the surviving spouse? A. Yes B. No C. Not sure Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 23

Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 24 FALSE IMPRISONMENT, NEGLIGENCE, AND MALPRACTICE: PLUMADORE V. STATE OF NEW YORK (1980) Delilah Plumadore was admitted to Saranac Lake General Hospital for a gallbladder condition. During her medical workup, she confessed that marital problems had resulted in suicide attempts several years before her admission. After a series of consultations and tests, the attending surgeon scheduled gallbladder surgery for later that day. After the surgeon’s visit, a consulting psychiatrist who examined Mrs. Plumadore told her to dress and pack her belongings because she was going to be admitted to a state hospital at Ogdensburg. Subsequently, two uniformed state troopers handcuffed Mrs. Plumadore and strapped her into the back seat of a patrol car and transported her to the state hospital.

Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 25 On arrival, the admitting psychiatrist realized that the referring psychiatrist lacked the authority to order this involuntary admission. He therefore requested that Mrs. Plumadore sign a voluntary admission form, which she refused to do. Despite Mrs. Plumadore’s protests regarding her admission to the state hospital, the psychiatrist assigned her to a ward without physical or psychiatric examination. She did not even have the opportunity to contact her family or her medical doctor and remained in the hospital for the weekend. The court awarded $40,000 to Mrs. Plumadore for malpractice and false imprisonment on the part of health care professionals and negligence on the part of the troopers. This settlement was greatly influenced by the fact that she had an acute medical illness that was left untreated for days due to being locked in a psychiatric ward.