Ethics Legalities

8/12/2019 Ethics Legalities

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Ethics and Legalities in Nursinghttps://www.ncsbn.org/Professional_Boundaries_2007_Web.pdf

Vicki Thornley, MSN, RN, CNE

and Alicia Anger MSN,RNN-401

Fall 2010


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Objectives

Definitions as applied to ethical decisions nursesmake during care of clients

ANA Code of ethics

Advance Directives - MPA

Ethical dilemma steps


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Foundation

Ethicsphilosophical ideals of right and wrongbehavior.

Ethics is not religion or law

Nurses have a duty to practice ethically andmorally

Tells us how human beings should behave, not

necessarily what they do. Not a religion, not law,but both of these can be the basis of ethicaldecisions that you make.

The word duty is a legal term


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Ethical Issues

Moral uncertainty/conflict When the nurse is unsure which moral principle to apply, or even

what the problem is. Common with new nurses, theyre not surewhat they are supposed to be doing

Moral distress

When the individual knows the right thing to do but organizationalconstraints keep them from doing it

Moral outrage An individual witnesses an immoral act by another but feels

powerless to stop it

Moral/ethical dilemma Occurs when two or more clear principles apply but they support

inconsistent courses of action

Self-awareness

Not an ethical issue, but is absolutely vital in ethical decisionmaking


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Ethical Frameworks Utilitarianmost good, least harm

Most common approach, First do no harm is related to this. Attemptsto produce the greatest good with the least harm.

Rights basedbest protects the rights and respects the moralrights of those affected Begins with idea of human dignity and freedom of choice. The pt has

the right to make the decision.

Duty based- duty to do or to refrain from doing something Decisions are made because there is duty!

Common goodbest for community/society Decisions should be made on what is good for the community as a

whole, not necessarily for the individual. Where many of our nationslaws are base

Virtueactions consistent with certain ideal virtues Decisions should be directed at maintaining virtues (honesty, courage,

compassion, etc.). A person using this approach may ask themselves, IfI carry out these actions, what kind of person will I be?


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Principles Ethical Reasoning

Autonomy

Beneficence

Nonmaleficence

Confidentiality

Double Effect

Fidelity

Justice

Paternalism

Respect for Persons

Sanctity of Life

Veracity


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Autonomy

Definition: autos = self, nomos = rule

Individual rights

Privacy

Freedom of choice

Pt has the right to make decisions for themselves.

May see this come up with consent for treatment

issues, informed consent. Pt has right to knowprocedure, complications, other options, that they

can opt to not have the procedure/treatment.

Framework is rights based


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Beneficence & Nonmaleficence

Duty to do good

goodness, kindness,

charity

Includesnonmaleficence

Centerpiece for caring

Duty: NOT TO CAUSE

harm

Duty: PREVENT harm

Duty: REMOVE harm

More binding than

beneficence

Because youre goingbeyond just trying to do

good to that pt, youre

trying to prevent harm


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Confidentiality

Keep privileged information private

Exceptions

Protecting one persons privacy harms another or

threatenssocial good (direct threatto another

person)

Drug abusein employees, elder and child abuse

HIPAA


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Double Effect

Some actions can be morally justified even though

consequences may be a mixture of good and evil

Must meet 4 criteria:

The action itself is morally good or neutral

The agent intends the good effect and not the evil (the evil may beforeseen but not intended)

The good is not achieved by the evil

There is no favorable balance of good over evil


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Fidelity

Duty to be faithful to ones commitments

includes implicit and explicit promises

Make a promise, follow thru

Implicitthose promises that are implied, notverbally communicated

Like when pt comes into the hospital, they expect tobe cared for

Explicitthose that we verbally communicate

Like if you tell them youll be back with pain meds,youd better come back


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Justice

Seeks fairness

More specifically,distributive

justice refers todistribution ofbenefits andburdens

Distributive JusticeConcepts

Equally disbursed

according to Need

Effort

Societal contribution

Merit

Legal entitlement


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Paternalism

When one individual assumes the right to make

decisions for another

Limits freedom of choice Think about parents making decisions for children

Ex. Withholding pertinent information from a pt.

Like elderly dx with terminal cancer, and family asksto not tell them that its terminal so they will still be

motivated to fight


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Respect for Persons

Closely tied to autonomy

Promotes ability of individuals to make

autonomous choices and should be treated

accordingly

Autonomy is preserved thru advanced

directives.


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Sanctity of Life

Life is the highest good

All forms of life, including mere biologic

existence, should take precedence over

external criteria for judging quality of life

If life is the highest good, is it ethical to keep a

brain dead person alive?


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Veracity

The obligation to tell the truth and not to lie or

deceive others


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Ethics and Professional Practice

ANA Code of ethics & ICN

Code

TX BON Rules & Regs

NCSBN ProfessionalBoundaries

Informed consent

Durable power of attorneyfor healthcare guardian

Euthanasia

Assisted suicide

Death

Disasters


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Identifying Boundary Crossings

Excessive self-disclosure When the nurse discusses personal feelings or aspects of

their personal life in front of the pt

Secretive behavior

When the nurse keeps secrets with the client or when thenurse becomes guarded when someone questions theirinteractions

super nurse

When the nurse believes only he or she can meet the needsof the client

Selective communication

When the nurse fails to explain actions or actions of care


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Identifying Boundary Crossings

Singled out client treatment/client attention tothe nurse

Nurse spends inappropriate amts of time with theclient, client may give gifts to the nurse

Flirtations

Never, ever, appropriate, or ok, ever, ever

You and me against the world behavior

Nurse views client in a protective manner

Failure to protect the client

Nurse doesnt recognize sexual feelings towards theclient


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Nurses Challenge

Be aware

Be cognizant of feelings and behaviors

Be observant of the behavior of otherprofessionals

Always act in the best interest of the client

https://www.ncsbn.org/Professional_Boundaries_2007_Web.pdf


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Capacity to Form Consent

Decision-making capacity (not competency)

determined by: Appreciation of right to make the choice

Understanding of risks/benefits of procedure

Understanding of risks/benefits of opting out ofprocedure

Ability to communicate decision

Communication may not always be verbal, can be

written or whatever

Needs to have interpreter avl! Cant just use the

family or whatever

Use layman jargon. Normal words Dont say layman

jargon.


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Advance Directives Include

Directive to Physician and Family or Surrogate Most common. Allows pt to document wishes for tx or withdrawal, also

commonly known as Living Will

Medical Power of Attorney Allows the pt to designate another person as their decision maker

Out of Hospital Do-Not-Resuscitate Order Allows competent adults to refuse life sustaining procedures when out of the

hospital setting. Can include not wanting to be taken to ER, let me sit here anddie

Declaration of Mental Health Treatment Allows a court to determine incapacity and allows the pt to refuse electro

convulsive therapy (ECT) and psychoactive drugs

Sometime generically called Living Will Not same as DNR (do not resuscitate)

These are written during hospitalization after the doc and the pt (or ptsurrogate) decide to withdrawal life sustaining treatments.

Advanced Directives are documents that state in writing the ptswishes for healthcare interventions if they should become

incapacitated.


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Other Contingencies

Directives unavailable / never done Autonomy versus best interest of clients

Substituted judgment

Legal standard that presumes the surrogate is capable ofmaking decisions for that pt

Dementia clients

Dementia diagnosis doesnt necessarily mean the pt is

incapable of making their own decisions. Esp in the first fewstages of dementia. Pt is very alert and very aware and very

much can make that decision for themselves.


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Withholding/Withdrawing Care

Can withhold inhumane treatment if it is

virtually futile in extending life usually DNR

Allowing to die vs making die

E th i


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Euthanasia

Definitionintentional termination of life (at therequest of that person who wishes to die)

Active vs. Passive Generally illegal May be legal under certain circumstances Activeinvolves purposefully causing the persons death (doc

or nurse). Dr. Kevorkian. Usually involved with law problems Passiveinvolves hastening of death by altering some formof support, taking a pt off a vent, generally accepted bymedical community

Terminal sedation

Doctrine of Double Effect (the whole intent of the act, thing) Do a thing with one intent, but causes something else to

happenmorphine OD Procedure used in dying pts to relieve suffering. Pts who are

in extreme pain may chose terminal sedation


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Assisted Suicide

Patient actively seeks physician/nurse to help

them commit suicide

Criminal offense in all states but Oregon,

Washington, and Montana

Usually pt is given prescriptions in amts that are

legal and the pt decides if they want to use it.


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Defining Death

Uniform Determination of Death Actpatient is

dead if any one of the following conditions are

met:

Cardiopulmonary death

Neurological death

Whole brain deathFlat EEG

Not PVS(persistent vegetative state)


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Ethical Dilemmas

the action or situation involves actual or

potential harm to someone or some thing

a possibility of a violation of what we generally

consider right or good

is this issue about more than what is legal or

what is most efficient?


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How to Process an Ethical Dilemma

1. Determine whether or not a dilemma exists

2. Gather all relevant information

3. Reflect on your values on the issues

4. Verbalize problem5. Consider all possible courses of action

including referral to ethics committee

6. Negotiate outcome

7. Evaluate action, not the outcome.


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Conclusion

Know yourself and your values

Protect your patient by intervening if you

identify an ethical question

Know your facility policy for access to the

ethics committee

Know your responsibilities with regard to

informed consent

Respect the patients advance directives

d f hi


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Excerpts: ANA Code of Ethics

The nurse, in all professional relationships,

practices with compassion and respect for

the inherent dignity, worth, and

uniqueness of every individual,

unrestricted by considerations of social oreconomic status, personal attributes, or

the nature of health problems.


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Distinction between Law and Ethics

Concepts Law Ethics

Source External Internal

Concerns Conduct and

Actions

Motive, attitude,

culture

Interests Society Individual

Enforcements Courts, BON Ethics Committee

and professional

organizations


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What is law?

Law

Rules of conduct

Authored & enforced by formal authorities

Hold people Accountable for compliance

Purpose of Nursing Law

Protectpatient and nurse

Scope of practice (define it)


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Sources of Law

Constitution: establishes a basis for a

governing system (highest law that gives

authority to the other branches)

Statutes: laws that govern

Administrative agencies: given authority to

create rules and regulations to enforce

statutes (like texas board of nursing)

Court decisions: interpret statutes and

determine consequences


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Types of Court Cases & Laws

Criminal law:crimes committed against an individual or society,

innocent until proven guilty beyond a reasonable doubt.

Consequences range from fine to jail to death penalty

Civil law:one individual sues another for money b/c of a

perceived loss. Guilty verdict is based on the belief that the

accused is more likely than not to have caused the injuries.

Consequence is usually $$

Administrative law:individual is sued by a state/federal

agency responsible for enforcing statutes. Based on a clear and

convincing standard.


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Professional Negligence

Negligence: the omission to do something that a reasonable and

prudent person in a reasonable situation would or would not do

Prudent: the average judgment, foresight, intelligence and skill

expected of a person of similar training or experience

Malpractice: failure of a person with professional training to act in a

reasonable and prudent manner


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Five components necessary for professional

negligence to occur:

1. Standard of care

2. Failure to meet standard

3. Foreseeability of harm

4. Correlation b/t care and harm must be proven

5. Actual patient injury must occur


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Reducing the Risk:

Know the law

Document everything

Refrain from negative comments

Question authority

Stay educated

http://www.nurseweek.com/features/00-05/malpract.html


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Reducing the Risk cont.:

Manage risks

Dont hurry through discharge

Be discreet

Use restraints wisely

Be kind

http://www.nurseweek.com/features/00-05/malpract.html


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Liability

Liable: to be legally responsible by law

Personal liability: every person is liable for

his/her own conduct

Joint liability: nurse, physician, and

employing organization are liable

Respondeat superior liability: the master is

responsible for the acts of his servants

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I id t R t


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Incident Reports

Incident reports cant be used in court, unless they (lawyers andwhat not) find out that it exists. They are intended for internalshit only, within the hospital, monitoring trends, prevention offuture occurrences, etc.

Dont put them in the chart! You can document the fall, whatyou did to make it better, but not that you filled out the actualincident report form.

Dont tell the pt or family that youre filling one out! Youre notkeeping them from any information about the incident, youre

just not telling them about the form

Dont document on pts chart that you filled one out!

Notify nurse management teams and what not when you fill itout.

Remember, there is no law about having to fill out an incidentreport. Its just the hospitals policy to keep tabs on all the shitthat goes wrong inside its walls


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Incident Reports

Unusual / unexpected incidentsDo

Document incident information, treatment & follow up

on chart Notify Nsg Management & Risk Management

DO NOT

Leave copy on chart Discuss with pt / family

Document form completion in chart


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Intentional Torts

Assault & Battery

Assault is the behavior that makes a person fearful of harm

Battery is an intentional physical contact with a person thatcauses injury

False Imprisonment Any unlawful confinement within fixed boundaries, can be

physical, emotional, or chemical

Defamation of character (slander)

Communicating to a 3rdparty information that can hurtcharacter, self esteem, blah blah blah. Being truthful reducesrisks of being charged with this

Invasion of privacy


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Types of Consent

Informed consent

Implied consent

Pt unable to consent

Treatment is in patients best interest

Express consent

Witness pt signature

Assure pt received information


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Informed Consent

Language pt understands

Patient competency

Requires full disclosure (procedure process,

risks and benefits)


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Medical Records

Although the patient owns the information in

the medical record, the actual record belongs to

the facility that originally made record & is storing

it


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Causes of License Suspension

Professional negligence

Practicing w/o a license

Obtain license by fraud

Felony convictions


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Causes of License Suspension

Not reporting substandard medical care

Providing patient care under the influence of

drugs/alcohol Giving narcotics w/o order

Falsely portraying self to public or any HCP as a

nurse

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Legal Responsibilities of a

Nurse Leader

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The Patient

Self-Determination Act

Requires health care organizations that receive

federal funding to provide education for staff and

patients on issues concerning treatment and end-of-life

issues. (They have to ask about Advanced Directives

and what not on admission and inform them about it)


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Whistleblower Act

To prevent employers from taking retaliatory

action against nurses such as suspension,

demotion, harassment or discharge for

reporting improper patient care or businesspractices


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Health Insurance Portability and

Accountability Act

Protects the privacy of health information

Administrative Simplification plan

All related to electronic medical records, simplifying

exchange of info and what not, by 2014 all hospitals

have to have this

Privacy Rules

kf


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Diverse Workforce

Title VII (Civil Rights Act-1964): Protects against

discrimination based on race, color, creed, national

origin, religion or sex

Age Discrimination in Employment: no

discrimination over age 40

American with Disabilities Act: no

discrimination against physical or mental impairment

regarding hiring


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Diverse Workforce

Equal Pay Act:no discrimination against women

Occupational Safety & Health Act: safe and

healthy work environment

Family & Medical Leave Act: provides job

security for taking leave of absence

Ethics Legalities

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