Legal and Ethical Study Guide ADN-MGCCC

• The study of philosophical ideals of right and wrong behavior
• Provides guidelines for safe and compassionate care
• The study of good conduct, character, and motives
• Concerned with determining what is good or valuable for all people
• Reflects the personal virtues, priniciples, and standards that govern professional behavior
• Ethical issues are profoundly influenced by cultural and personal values
• Rely on personal values and values of the client

• Built on the foundation of professional ethics in health care
• The field of bioethics guides discourse about difficult issues that arise in health care
• The study of bioethics has developed in the last several decades
• How ethics applies to healthcare: Cloning, Genetic enhancement

Deontology

Utilitarianism

Feminist Ethics

Ethics of Care

An action is right or wrong independent of its consequences; measures effect that an act will have

The value of something is determined by its usefullness with the main emphasis on the outcome or consequences of the action

Looks at presence of principle regardless of outcome

• These value the role of relationships
• Argues that it is impossible to remain unbiast or not influenced by relationships to people

Care is central activity of human behavior, it includes the obligations to appreciate, understand, and even share the pain or condition of a client

A personal belief about worth of a given idea, attitude, custom, or object that sets standards that influence behavior

Values influence behavior and change over time

Values are based on experiences, religion, education, and culture

Strongly influenced on how and by who we were raised

• Values are acquired in many different ways
• Understanding of values begins in early childhood and is influenced by the way one is reared
• Cultural aspects influence values
• Society or life outside the family may influence one's values
• Individual experiences also influence one's values

The belief that ones own culture is superior

To articulate a point of view, it is helpful to clarify values

To adopt a new value one must be aware of existing values

Choosing

Prizing

Acting

Code of ethics to which nurses must adhere

Nurses must commit to standards beyond personal preference, to which individuals, professions, and societes agree

Nurses Code of Ethics

Accountability

Responsibility

Ethical Dilemma

• The ability to answer for one's own actions
• Ex:) You have diabetic patient and you need to teach them how to do insulin injections; you should show them until they get it and can return demonstration

• The nurse acts according to the professional code of ethics
• - Client - Society - Profession - Facility

GOAL: Prevention of injury to client

Duty to perform actions well and thoroughly (Give meds & follow up)

Refers to the characteristics of reliability and dependability

Distinguish between right and wrong

Do what you say

Will gain trust of all parties

Has to have one or more of these characteristics:

Cannot be resolved souly through a review of scientific data

It is perplexing - You cannot easily think logically or make a decision about the problem

The answer to the problem will have a profound relevance to several areas of human concern

• The code describes ideals for professional conduct
• Defines the priniciples by which nurses function
• Provides guidelines for nurses to follow in dealing with the many ethical issues that occur in today's health care system
• Based on code for nurses and social contract based on trust
• Prohibits nurses acting to end life of client.

Autonomy

Beneficence

Nonmaleficence

Justice

Independence; clients have a right to make their decisions in healthcare (patient right)

Nurses must respect client's values, choices, and right to make own decisions - They are in charge of their own destiny

Nurses much recognize that autonomy may be limited for client's and families during illness - they may need guidance and help from physician

You can educate them to make the right decision for them

Client's right of self-determination, independence, and self-reliance

Individuals are able to act for themselves to their level of capacity

Taking positive actions to help others and promoting good

Nurses must meet the needs of others

• Consider benefit vs. risk or harm
• Ex) Immunization benefits outweighs the risks of not being immunized

• Avoidance of hurt or harm - "First do no harm or least amount of harm possilbe"
• Ex)Bone Marrow Transplant

Acceptable standards of ethical research are applicable to pallative care to insure acceptable risk/benefit ratio

• Many medications and treatments will ease suffering, but also, have related side effects. Decisions in symptom control consider providing benefit while minimizing harm. Must weigh the benfit and/or risk of the treatment.
• Ex) Chemotherapy/Radiation can create many risks and much harm

Refers to fairness and equity

• Distributing benefits, risks, and costs fairly
• Ex) Organ transplant- have lists that are based on need

Veracity

Confidentiality

Fidelity

The duty to tell the truth

Guides nurses to practice truthfulness, as part of the nursing code of ethics

Veracity may be challenged during the delivery of health care.

The duty to protect privileged information

A critical ethical/legal issue with professional-client relationships. Nurses are involved in very intimate, private relationships with clients and their families

• Client's must feel comfortable in a nurse's trust and feel fully supported in times of illness, and dying
• Ex) HIPPA: Never copy med records or take pictures of them!!!

• The duty to keep promises and follow through with the care that we give to clients
• Ex) Pain meds

Exercises loyalty and agreeing to keep promises

The nurse must adhere to the strictest observance of loyalty and commitment to the client

You must take care of a patient even though you may not agre with plan of care

Are choices between equally unsatisfactory alternatives

• Step 1- Review scientific data to determine if a dilemma exists
• Step 2- Gather all information relevant to the case
• Step 3- Examine and determine personal values
• Step 4- Verbalize the problem
• Step 5- Consider the possible course of action
• Step 6- Negotiate the outcome
• Step 7- Evaluate the action

The nurse incorporates his/her personal values and the perceived values of the client to resolve the issue

• The nurse must be an advocate or the client:
• The nurse must ensure that quality care is being provided
• The nurse must ensure that the client/family understand the options available
• The nurse must ensure that client/family wishes are being clarified and met

• Advances in medical technology
• Changes in social and family systems
• Aging population
• Medical futility- Treatment that will not improve patients homes Ex) Hospice/End of life care
• Fear of litigation
• Lack of professional knowledge- Ask for help
• Unlimited array of health care choices

• Abortion
• AIDS
• Environmental Contamination
• Access to Health Care
• Euthanasia
• Organ Transplant's
• Genetic Cloning
• End of Life Care

Value Clarification- Individual appraisal of values

Client Advocate

Use of Ethics are Resource

• Consent
• Confidentiality
• Disclosure
• Capacity
• Surrogate

The main ethical issue involved in consent is that it is voluntary, uncoerced, and that the client is competent

• Only what you have to; to who needs to know
• Ex) Do NOT bring another SN into your patients room and do not talk about it at lunch

• DNR: Confirms & expresses that no measures be carried out to artificially prolong life, such as, CPR or related advanced life support systems
• Confirms that no measures to prolong life be carried out
• Has to be written and signed document
• Client has to be legally competent to consent- exception can write DNR is resecitation is futile
• After being given appropriate information by physician who must be affiliated with hospital
• Written consent requires 2 witnesses
• Has to be reviewed, every 3 days in acute care and 60 days in long term care, by physician.

Times when there are conflicts regarding belief of the beneficial nature of treatment

Unlikely to produce benefit to client

These conflicts often involve failure in communication or misunderstandings over prognosis or benefit vs. burden of treatment options. There are important cultural and religious influences in these matters

Nurses must respond to clients in an ethical and legal manner

Interdisciplinary collaboration is essential

Prevent, relieve, or reduce symptoms of a disorder

Goal: Preservation of dignity

Sources of Law

Standards of Care

• Statutory Law
• Nurse Practive Acts
• Regulatory Law/Administrative Law
• Common Law
• Criminal Law
• Felony
• Misdemeanor
• Civil Law

• Legal guidelines for nursing practice
• Nurse Practice Acts
• State Boards of Nursing
• Other regulatory Administrative Bodies
• American Nurses Association (ANA)
• Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

• Americans with Disabilites Act (ADA)
• Emergency Medical treatment and Active Labor Act (EMTALA)
• Mental Health Parity Act
• Advanced Directives
• Uniform Anatomical Gift Act (1987)
• Health Insurance Protability and Accountability Act (HIPPA)
• Restraints

Behavior control: Defined as wrongful confinement of an client in such a way that he/she has no escape or exit

• Restraints- Must know how and when to use correctly
• Competent Person
• Excessive Medication
• Documentation Ex) Skin Integrity, patient assessment frequently

• Licensure
• Good Samaritan Laws
• Public Health Laws
• The Uniform Determination of Death Act- Standards for determination of death
• Physician-Assisted Suicide- Permitted in Oregon; we cannot participate because of code of nurse's

Clients are informed of their rights to refuse care and make advance directives

• Includes living wills and Durable Power of Attorney for Health Care Appointment
• Prepared while client is competent
• Describes client's preferences
• Copy in home, physician and hospital records

Health care institutions are required to provide written info to clients about rights and right to refuse

• Done prior to illness and are based on individuals self determination
• A written document for the client to plan & communicate their care & treatment choices, when they can no longer speak for themselves
• Forms & laws differ state by state
• Nurse is responsible for his/her awareness of state laws
• Nurse advocates for respecting client's advanced directives
• Must document in chart if patient has signed an advanced directive
• Offers legal protection for the client's rights. Courts and legislatures have recognized these as valid indicators of client's previously expressed desires
• Give immunity to healthcare professionals who, in good faith follow directives

Living Wills

Durable Power of Attorney for Health Care

• A written document that reflects a client's wishes in the event of a terminal illness or condition
• Prepared while client is competent
• Describes the client's preference in the event that they become incapable of making decisions or communicating decisions in event of a terminal illness or condition
• Copy should be in the client's home, physician's record, hospital record and with surrogate/proxy
• Specifies interventions client does NOT want so life will not be prolonged

• Specifies powers the person has
• The client must choose a durable power of attorney while competent
• In some states, not required if living will and proxy form available
• A document specifies powers the client gives to the person(s) holding the power of attorney
• Designates an agent, surrogate or proxy to make healthcare decisions when the client is no longer able to make them therselves.

Appointed by client if he/she is unable to make decisions

Client's right to choose and change

Proxy must agree

• Tort- A civial wrong made against a person or property
• Intentional Tort:
• -Assault -Battery -Invasion of Privacy -Defamation of Character
• Unintentional Tort:
• -Negligence -Malpractice
• Consent
• -Informed consent
• Abortion Issues
• -Roe vs. Wade
• Student Nurses
• Malpractice Insurance
• Abandonment & Assignment Issues
• -Short staffing- be careful about doing more than you can do; speak up and document if you are uncomfortable
• -Floating- If you have never done it, DON'T GO!
• -Physician's Orders- Always follow

Threatening

Ex) Threatening a client with medications (chemical restraints)

A threat carried out

Always associated with assault; it is assault carried out

Ex) Client refuses treatment and you do it anyway

Process of obtaining permission from a client to perform a specific test or procedure after describing all material, risks, side effects, and benefits

The main issues in consent are that it is voluntary, and that the client is competent and understands all components

Nurses/Witness signature states that the patient signature is authentic and patient is competent

Avoidance of Negligence

• Report of Abuse
• -Legal Immunity

• Informed Consent
• -Emancipated Minor- Legally an adult by pregnancy, marriage, or high school graduation
• -Matured Minor's Doctrine- Permits minors to give consent for their children if they're mature enough to understand risks and benefits of procedure

ALWAYS DOCUMENT- Be descriptive just in case you ever have to go to court years later!