Chapter 4 Mental HealthEthical and Legal Issues

Key Concepts from Chapter 1» Autonomy

» Nonmaleficence» Veracity» Torts and contracts» HIPAA and PHI» Duty to warn» Informed Consent» Restraints and Seclusion» False Imprisonment» Types of Commitments» Malpractice and Negligence» Kinds of Lawsuits

Core Concepts

Ethics Bioethics Moral behavior Values Values clarifications

Right Absolute right Legal right

ETHICS

a branch of philosophy that deals with distinguishing right from wrong

Bioethics

• term applied to ethics when they refer to concepts within

the scope of medicine, nursing, and allied health

Moral behavior

• conduct that results from serious critical thinking about how individuals ought to treat others

Values

• personal beliefs about what is important and desirable

Values clarification

• a process of self-exploration by which people identify and rank their own personal values

Right

• a valid, legally recognized claim or entitlement, encompassing both freedom from government interference or discriminatory treatment and entitlement to a benefit or service

Absolute right

when there is no restriction whatsoever on the individual’s entitlement

Legal right

a right on which the society has agreed and formalized into law

Ethical ConsiderationsTheoretical Perspectives

UtilitarianismKantianismChristian ethicsNatural law theories

Ethical egoism

Utilitarianism

• an ethical theory that promotes action based on the end result that produces the

most good (happiness) for the most people

Kantianism

suggests that decisions and actions are bound by a sense of duty

Christian ethics

• Do unto others as you would have them do unto you.

Natural law theories

Do good and avoid evil. Human knowledge of the difference between good and evil directs decision making

Ethical egoism

Decisions are based on what is best for the individual making the decision

Ethical Considerations?1. An operating room nurse asks a psychiatric nurse, “How

can you work with the mentally ill day in and day out?” The psychiatric nurse replies, “It's just the right thing to do.” The psychiatric nurse is operating from which ethical framework?

a) Kantianism

b) Christian ethics

c) Ethical egoism

d) Utilitarianism

Correct answer: A

Kantianism focuses on the morality of actions. Actions are judged as right or wrong based on ethical principles. The nurse’s response indicates a Kantian perspective

Ethical Dilemmas

1) Situations that require individuals to make a choice between two equally unfavorable alternatives.

2) Taking no action is considered an action taken

Ethical Principles

AutonomyBeneficence

NonmaleficenceJusticeVeracity

Autonomy

Emphasizes the status of persons as autonomous moral agents whose rights to determine their

destinies should always be respected. (“Right to decide or choose for yourself.)”

Beneficence

Refers to one’s duty to benefit or promote the good of others

Nonmaleficence

Abstaining from negative acts toward another; includes acting carefully to avoid harm

Justice

Principle based on the notion of a hypothetical social contract between free, equal, and rational persons. The concept of justice reflects a duty to treat all individuals equally and fairly.

Veracity

principle that refers to one’s duty to always be truthful.

A Model for Making Ethical Decisions

• Assessment• Problem identification• Plan• Implementation• Evaluation

Ethical Issues in Psychiatric/Mental Health Nursing

• The right to refuse medication (As long as they are competent and are not putting themselves or others at risk by refusing treatment.)

• The right to the least restrictive treatment alternative (Can’t restraint, medicate, or seclude a patient for our benefit!)

Key Concept

Even if a patient is committed involuntarily… we can not force treatment on them unless a court of law deems them incompetent to make their own decisions. Until that time, they can make their own treatment decisions. However they may still have to stay for observation depending on the length of their involuntary commitment

Legal Consideratio

ns• The Nurse Practice Act defines the

legal parameters of professional and practical nursing

• Types of laws

– Statutory law– Common law

Classifications Within Statutory

and Common Law

• Civil law: protects the private and property rights of individuals and businesses– Torts– Contracts

• Criminal law: provides protection from conduct

deemed injurious to the public welfare

Legal Issues in Psychiatric/Mental Health Nursing• Confidentiality and Right to Privacy

HIPAA Doctrine of privileged communication Exception: A duty to warn

• Informed Consent• Restraints and Seclusion

False imprisonment

Duty to Warn

• Important concept. If we as HCP’s know that a client is planning on hurting someone (this means anyone)… we have a duty to warn those at risk and or the police as appropriate.

Legal Issues in Psychiatric/Mental Health Nursing • Commitment issues

– Voluntary admissions– Involuntary commitments

Emergency commitments The mentally ill person in need

of treatment Involuntary outpatient

commitment The gravely disabled client

Legal Issues in Psychiatric/Mental Health Nursing• Nursing liability

– Malpractice and negligence– Types of lawsuits that occur in psychiatric

nursing• Breach of confidentiality• Defamation of character

– Libel (a written false statement that damages one’s reputation)

– Slander (false spoken statement that damages one’s reputation.)

Legal Issues in Psychiatric/Mental Health Nursing (cont’d)

• Nursing liability (Very Important!)– Invasion of privacy– Assault and battery – False imprisonment

Defined: Nursing liability– Assault and battery

• Battery: touching someone without permission. Example: holding a patient back from leaving or taking a BP on a client who said they did not want that.

• Assault: saying or acting in a way that makes a person think you are going to touch them without consent. Example: telling someone you will stop them from leaving the floor.

As a last resort, an agitated, physically aggressive client is placed in four-point restraints. The client yells, “I’ll sue you for assault

and battery.” The unit manager determines that the nurses are protected under which condition?

a) The client is voluntarily committed and poses a danger to others on the unit. b) The client is voluntarily committed and has a history of being a danger to others. c) The client is involuntarily committed because of a history of violent behavior. d) The client is involuntarily committed and is refusing treatment.

Correct answer: AAs a threat to others, the

client can be restrained despite objections and voluntary commitment

A nurse gave a client 5 mg of haloperidol (Haldol) for agitation. The client’s chart was clearly

stamped “Allergic HALDOL.” The client suffered anaphylactic shock and died. How would the nurse’s actions be labeled?

a) Intentional tort b) Negligence c) Battery d) Assault

Correct answer: B

The nursing action was an unreasonable and careless act. The nurse was negligent and could be held liable for the client’s death.

Avoiding Liability

• Respond to the client• Educate the client• Comply with the standard of care• Supervise care• Adhere to the nursing process• Document carefully• Follow up as required• Develop and maintain a good

Interpersonal relationship with client and family

Legal Rights even Clients with mental illness have:

• Right to human treatment which include not only psychiatric care but medical care

• Right to due process of law• Right to vote• Right to refuse treatment• Right to be informed• Right to privacy• Right to be treated with dignity and respect• Right to be treated without discrimination

3 years ago Anna’s dog Lucky, whom she had for 16 yrs, was run over by a car and killed. Ann’s daughter reports that since that time, Anna has lost weight, rarely leaves her home, and just sits and talks about Lucky. Anna’s behavior would be considered maladaptive because

a. It has been more than 3 yrs since Lucky diedb. Her grief is too intense over just the loss of a dogc. Her grief is interfering with her functioningd. People in this culture would not comprehend such

behavior over the loss of a pet

Answer: C

Based on the information in quest. 1, Anna’s grieving behavior would most likely be considered to be

a. Delayedb. Inhibitedc. Prolongedd. Distorted

Answer: D

Anna is diagnosed with major depressive disorder. She is most likely fixed in which stage of the grief process?

a. Denialb. Angerc. Depressiond. Acceptance

Answer: B

Anna who is 72 yrs old, is of the age when she may have experienced many losses coming close together. What is this called?

a. Bereavement overloadb. Normal mourningc. Isolationd. Cultural relativity

Answer: A

Anna, age 72, has been grieving the death of her dog, Lucky for 3 yrs. She is not able to take care of her activities of daily living and wants only to make daily visits to Lucky’s grave. Her daughter has likely put off seeking help for Anna because

a. Women are less likely than men to seek help for emotional problems

b. Relatives often try to “normalize” the behavior rather than label it mental illness

c. She knows that all older people are expedted to be a little depressed

d. She is afraid that the neighbors “will think her mother is crazy”

Answer: B

Anna’s dog Lucky got away from her while they were taking a walk. He ran into the street and was hit by a car. Anna cannot remember any of these circumstances to his death. This is an example of what defense mechanism?

a. Rationalizationb. Suppressionc. Deniald. Repression

Answer: D

Lucky sometimes refused to obey Anna and indeed did not come back to her when she called to him on the day he was killed. But Anna continues to insist, “He was the very best dog”. He always minded me. He always did everything I told him to do. This represents the defense mechanism

a. Sublimationb. Compensationc. Reaction formation

d. Undoing Answer: C

Anna has been a widow for 20 yrs. Her maladaptive grief response to the loss of her dog may be attributed to which of the following? Select all that apply

a. Unresolved grief over loss of her husbandb. Loss of several relatives and friends over the last

few yrs.

c. Repressed feelings of guilt over the way in which Lucky died

d. Inability to prepare in advance for the loss

Answer: A, B, C, D

For what reason would Anna’s illness be considered a neurosis rather than a psychosis?

a. She is aware that her behavior is maladaptiveb. She exhibits inappropriate affect (emotional tone)c. She experiences no loss of contact with realityd. She tell the nurse “there is nothing wrong with me!”

Answer: C

Which of the following statements by Anna might suggest that she is achieving resolution of her grief over Lucy’s death?a. I don’t cry anymore when I think about Luckyb. It’s true, lucky didn’t always mind me.

Sometimes he ignored my commands

c. I remember how it happened now. I should have held tighter to his leash.

d. I won’t ever have another dog. It’s too painful to lose them.

Answer: B

NURSE JONES DECIDES TO GO AGAINST FAMILY WISHES AND TELL THE CLIENT OF HIS TERMINAL STATUS BECAUSE THAT IS WHAT SHE WOUL WANT IF SHE WER THE CLIENT,

WHICH OF THE FOLLOWING ETICAL THEORIES IS CONSIDERED IN THIS DECISION?

a. Kantianismb. Christian ethicsc. Natural law theoriesd. Ethical egoism

Answer: B

Nurse Jones decides to respect family wishes and not tell the client of his terminal status because that would bring

the most happiness to the most people. Which of the following ethical theories is considered in this decision?

a. Utilitarianismb. Kantianismc. Christian ethicsd. Ethical egoism

Answer: A

Nurse Jones decides to tell the client of his terminal status because she believes it is her duty to do so. Which of the following ethical theories is considered in the decision?

a. Natural law theoriesb. Ethical egoismc. Kantianismd. Utilitarianism

Answer: C

The nurse assists the physician with electroconvulsive therapy on his client who has refused to give consent. Which of the following legal actions might the nurse be charged because of this nursing action?a. Assaultb. Batteryc. False imprisonmentd. Breach of confidentiality

Answer: B

A competent, voluntary client has stated he wants to leave the hospital. The nurse hides his clothes in an effort to keep him from leaving. With which of the following legal action might the nurse be charged?a. Assaultb. Batteryc. False imprisonmentd. Breach of confidentiality

Answer: C

Joe is very restless and is pacing a lot. The nurse says to Joe, “If you don’t sit down in the chair and be still I am going to put you in restraints!” what legal action might the nurse be charged?

a. Defamation of character

b. Battery

c. Breach of confidentiality

d. Assault

Answer: D

An individual may be considered gravely disabled for which of the following reasons? All that apply

a. A person, because of mental illness, cannot fulfill basic needs

b. A mentally ill person is in danger of physical harm based on inability to care for self

c. A mentally ill person lacks the resources to provide the necessities of life.

d. A mentally ill person in unable to make use of available resources to meet daily living requirements.

Answer: A,B,D

Which of the following statements is correct regarding the use of restraints? Select all

a. Restraints may never be initiated without a physician’s orderb. Orders for restraints must be reissued by a physician every 2

hrs. for children and adolescentsc. Clients in restrains must be observed and assessed every hr.

for issues regarding circulation, nutrition, respiration, hydration, and elimination.

d. An in-person evaluation must be conducted within 1 hr. of initiating restraints.

Answer: B, D

Guidelines relating to “duty to warn” state that a therapist should consider taking action to warn a third party when his or her client (select all that apply)a. Threatens violence toward another individualb. Identifies a specific intended victimc. Is having command hallucinations

d. Reveals paranoid delusions about another individual

Answer: A, B

Attempting to calm an angry client by using “talk therapy” is an example of which of the following client’s rights?

a. The right to privacyb. The right to refuse medication

c. The right to the lease-restrictive treatment alternative

d. The right to confidentiality

Answer: C