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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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Professional Negligence
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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Professional Negligence
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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Professional Negligence
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