Legal and Ethical Issues
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.
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
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
Types of Admissions
• Voluntary admission- patient is agreeable to
in house treatment
• Involuntary admission- patient admitted
without their consent through legal processes
Involuntary Admissions
To retain without the right is false imprisonment
Magistrate’s order – check chart to understand what’s going on for the
admission
1) Evaluation/emergency care (ED) –form filled out by police/others;
usually for 48 to 72 hours- gives time to assess & find illness (UTI)/mental
2) 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.
3) Extended/indeterminate care- legal system involved; long term;
may be 30-90 days
4) Magistrates warrant – legal sworn statement issued about a
patient through judge, by a family member, signs document that
pt is incompetent.
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
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
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
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.
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
***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
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
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
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
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.
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?
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
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
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
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
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
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
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