1. Legal and Ethical Issues

2. Learning Outcomes
Describe the rights of the patient in a psychiatric setting.
Describe the types of admissions of patients on a mental health unit.
Discuss the legal and ethical issues of seclusion and restraints.
Identify the legal terms pertinent to psychiatric nursing.
Explain the meaning of standard of care.

3. Rights of Patient’s
Mental health patients retain all civil rights afforded to all people except the right to leave the hospital in the case of involuntary commitment

4. Bill of Rights Chapter 9
Least restrictive environment- at home, hospital if possible.
Confidentiality- HIPAA, pt gives code for callers they allow, release of info signed
Access to attorney/courts- 24-7, private rm for meeting, can go to court if feel held against will
Access to belongings- shampoo, clothes- in bends
Informed of rights- know why they r there, meds
Refuse medications/treatment
Visitors- at visiting hours, certain limited
Telephone- with some limits
Writing materials/uncensored mail- in certain areas- open in front of case worker or nurse

5. Types of Admissions
Voluntary admission- patient is agreeable to in house treatment
Involuntary admission- patient admitted without their consent through legal processes

6. Involuntary Admissions To retain without the right is false imprisonment Magistrate’s order – check chart to understand what’s going on for the admission
Evaluation/emergency care (ED) –form filled out by police/others; usually for 48 to 72 hours- gives time to assess & find illness (UTI)/mental
Order of protective custody (OPC)- legal papers filed in court; vary from days to weeks
2 different drs have assessed & court decides to lock up – 7d to 14d pt must be released after the time/OPC is up.
Extended/indeterminate care- legal system involved; long term; may be days
Magistrates warrant – legal sworn statement issued about a patient through judge, by a family member, signs document that pt is incompetent.

7. Involuntary Hospitalization
Laws are determined by each state; know the laws of the state where you practice
Persons detained in this way lose only the right to freedom; all other rights are intact
Persons held without their consent must present an imminent danger to themselves or others

8. Release From the Hospital
Patients hospitalized voluntarily have the right to request discharge at any time and must be released unless they represent a danger to themselves or others; if such a danger is present, then commitment proceedings must be instituted to keep them in the hospital
Patients who are no longer dangerous must be discharged from the hospital

9. Mandatory Outpatient Treatment
Requires that patients continue to participate in treatment on an involuntary basis after their release from the hospital into the community
Examples include taking prescribed medications, keeping appointments with healthcare providers for follow-up, and attending specific treatment programs or groups

10. Conservatorship
Legal guardianship is separate from civil commitment for hospitalization
A hearing can be held to determine whether the person is competent. An incompetent patient cannot provide his or her own shelter, food, and clothing; cannot act in his or her own best interests; and cannot run his or her own business and financial affairs. If a patient is found incompetent, a guardian is appointed to speak for the patient.

11. Competency An incompetent patient can no longer:
Enter into legal contracts with a signature
Sign checks
Use a credit card
Make a will
Open bank accounts
Sell property
Get married
Give consent for surgery

12. ***Least Restrictive Environment Legal- file suite- keeping them & they don’t want to be kept
Treatment must be provided in the least restrictive environment appropriate to meet the patient’s needs
Physical restraint or seclusion (assess 1st- take high priority) in a locked room can be used only when the person is imminently aggressive or threatening to harm himself- hit or threatened someone then use this methods
Any pt in seclusion or restraints take high priority

13. Least Restrictive Environment (cont’d)
Restraint and seclusion, if used, must be in place for the shortest time necessary
Many regulations govern the monitoring of clients in seclusion or restraint for their safety

14. Restraints/Seclusion
Restraint: application of force without the patient’s permission (human, mechanical, chemical)
Seclusion: involuntary confinement in specially constructed, locked room equipped with security window or camera

15. Restraints/ Seclusion
Face to face evaluation in 1 hour, every 8 hours
Physician’s order every 4 hours
Documented assessment by nurse every 1-2 hours
Close supervision of patient
Debriefing session within 24 hours after release from restraint or seclusion

16. Confidentiality
Regulated by the Health Insurance Portability and Accountability Act (HIPPA) of 1996
Both civil (fines) and criminal (prison sentences) penalties exist for violation of patient privacy
If the pt states that after discharge they plan to take an overdose of meds… The nurse must advise the team/phys know.

17. Duty to Warn Third Parties Do have the right to warn the person that is being threatened – error on the side of safety
Duty to warn a third party is an exception to client confidentiality
Clinicians must warn identifiable third parties of threats made by a client
Is the client dangerous to others?
Is the danger the result of serious mental illness?
Is the danger serious?
Are the means to carry out the threat available?
Is the danger targeted at identifiable victims?
Is the victim accessible?

18. Nursing Liability
Nurses are expected to meet standards of care developed from:
ANA’s Code of Ethics for Nurses with Interpretive Statements
ANA’s Scope and Standards of Psychiatric-Mental Health Nursing Practice
State nurse practice acts
Federal agency regulations
Agency policies and procedures
Job descriptions
Civil and criminal laws

19. Tort: A wrongful Act That Results in Injury, Loss, or Damage Have to watch what say & do – assault & battery
Unintentional Torts
Negligence: harm caused by failure to do what is reasonable and prudent
Malpractice: breach of duty directly causes injury or loss to the client
Intentional Torts
Assault: causes person to fear being touched in an offensive manner)
Battery: harmful or unwanted actual contact)
False imprisonment: unjustifiable detention

20. Prevention of Liability DOCUMENT any unusual events so that if you have to go to court you have notes to refresh what occurred
Nurses can minimize the risk of lawsuits through safe, competent nursing care and descriptive, accurate documentation

21. Ethical Principles Knowing rules & policies on the floor you are working is key
Autonomy: right to self-determination and
independence
Beneficence: duty to benefit others or promote good
Nonmaleficence: do no harm
Justice: fairness
Veracity: honesty, truthfulness
Fidelity: honor commitments and contracts

22. Ethical Dilemmas in Mental Health
Ethical dilemma is a situation in which ethical principles conflict or there is no one clear course of action.
Many dilemmas in mental health involve the client’s right to self-determination and independence (autonomy) and concern for the “public good” (utilitarianism)
ANA Code of Ethics for Nurses guides choices about ethical actions

23. Ethical Decision-Making
Ethical decision-making includes:
Gathering information
Clarifying values
Identifying options
Identifying legal considerations and practical restraints
Building consensus for the decision reached
Reviewing and analyzing the decision

24. Self-Awareness Issues
Talk to colleagues or seek professional supervision
Spend time thinking about ethical issues and determine what your values and beliefs are regarding situations before they occur
Be willing to discuss ethical concerns with colleagues or managers