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ethical issues for psychiatric nurse practitioners


This need of protection has also been recognised at an international level as evident from the United Nations General Assembly’s adoption in 1991 of the Principles for the protection of persons with mental illness and for the improvement of mental health care and, a decade later, by the World Health Organization’s release of The world health report 2001: mental health: new understanding, new hope ( WHO 2001a ). Of those who reported they did not support PADs, the key rationale was concern for the ‘clinical profile of the patient and the professional imperative regarding the psychiatrist’s duty of care’ ( Sellars et al 2017 : 70). There is, however, one notable caveat to this stance: because the rights of people with mental illness are disproportionately vulnerable to being infringed in health care contexts (both psychiatric and non-psychiatric), a more nuanced approached to the issue is required. Defense experts placed the value at $2.7 million. Dr. Zilber is chair of the Ethics Committee of the Colorado Psychiatric Society, a consultant to APA’s Ethics Committee, and a private practitioner in Denver. This paradigm shift in mental health is challenging traditional evaluation criteria and conventional justifications for involuntary treatment. accepted ethical themes (deontological, teleological, and areteological), the ethical triangle by Potter, the American Academy of Nurse Practitioners (AANP) standards of practice for NPs, and codes of ethics from the American Nurses Association (ANA) and the American Medical Association (AMA). A similar stance was taken in New Zealand with the Ministry of Health releasing its Rising to the challenge: the mental health and addiction service development plan 2012–2017 (New Zealand Ministry of Health 2012 ). He determined that while the patient had a long-past history of alcohol use and required medication for pain management, she did not have a current substance abuse disorder. What else then should health care professionals do? Depending on the state, FNPs could face legal implications for prescribing to family and friends. He believed that an alcohol and drug program was not appropriate for the patient, who needed psychiatric inpatient treatment. In this chapter an attempt will be made to contribute to this positive project by providing an overview of stated rights and responsibilities in mental health care. The Journal for Nurse Practitioners is proud to announce the Marilyn Edmunds JNP Writing Award, which honors excellence in writing and encourages writing for publication.. Congratulations to Cinthya Sotelo, DNP, FNP-C, for her article “Ovarian Ectopic Pregnancy: A Clinical Analysis” in the March 2019 issue. Phone: 1-800-247-1500 The rights and responsibilities of people who seek assessment, support, care, treatment, rehabilitation and recovery – encompassing the right of people (including children) to ‘participate in all decisions that affect them, to receive high-quality services, to receive appropriate treatment, including appropriate treatment for physical or general health needs, and to benefit from special safeguards if involuntary assessment, treatment or rehabilitation is imposed’ (p 12). The growing role of psychiatric mental health nurse practitioners is discussed. The MSN Psychiatric Mental Health Nurse Practitioner track includes 18 courses totaling 45 credit hours. In defence of his refusal, the patient argues ‘reasonably’ that the adverse side effects of the drugs he is being expected to take are intolerable, and that he would prefer the pain of his mental illness to the intolerable side effects of the drugs that have been prescribed to treat his mental illness. Also of critical concern is finding a competency test which is comprehensive enough to deal with diverse situations, which can be applied reliably and which is mutually acceptable to health care professionals, lawyers, judges and the community at large. It is therefore important that nurses are equipped with the skills and knowledge to understand ethics within their practice. For example, if a patient claims the right to make an informed consent concerning prescribed psychotropic medication or electroconvulsive therapy (ECT), this imposes on an attending health care professional a corresponding duty to ensure that the patient is fully informed about the therapeutic effects and the adverse side effects of the treatments in question as well as to respect the patient’s decision to either accept or refuse the treatment, even where the health professional may not agree with the ultimate decision made. However, this law did not extend to nurse practitioners. The psychiatrist further stated that the patient was in the correct treatment setting. Given the nurse practitioner’s positive expert reviews and the plaintiff’s unreasonable settlement demand, the decision was made to vigorously defend this case, and the trial commenced. Ethics is an important aspect of healthcare and is very common in theme in nursing (Beidler, 2005). In a UK study, whereas 89% of voluntary organisations and more than two-thirds of stakeholder groups surveyed thought that PADs were needed, only 28% of psychiatrists surveyed thought they were ( Atkinson et al 2004 ). At the time of discovery he was disconnected from his ventilator. Certified Registered Nurse Anesthetists (CRNAs), Compensation and Other Disclosure Information. Being a patient advocate and acting ethically is one of the foundations of nursing (Kalb & O’Connor-Von, 2007). the lack of capacity of ‘the system’ to organise therapeutic alliances and care around service user preferences ( Nicaise et al 2013 : 2). Victoria), patient preferences can still be overridden under defined circumstances ( Callaghan & Ryan 2016 ; Maylea & Ryan 2017 ). Due to state joint and several liability laws, if the nurse practitioner were found personally responsible for as little as 1 percent of the patient’s damages, he could theoretically be held personally liable for the entire amount of any jury verdict. Also, in another incident shortly before his death, he talked openly with his general practitioner about ‘hiring someone to blow his [John McEwan’s] brains out or kill him as he felt his wish to die was being frustrated’ ( Social Development Committee 1987 : 316). Alternatively, a depressed and so-called ‘irrational’ person might refuse a particular psychiatric treatment, such as psychotropic drugs, electroconvulsive therapy or psychosurgery, out of a very ‘rational’ and well-founded fear of what undesirable effects these treatments might ultimately have. For instance, there remains the problem of how to determine what is a harm, what is a low / minimal and high / maximal risk of harm, and who properly should decide these things – the answers to which involve complex value judgments. An important question to arise here is: ‘If statements on mental health rights and responsibilities fall short of providing clear-cut guidance in cases of this nature, is there any point in having them?’ The short answer to this question is, yes. An involuntary psychiatric patient refuses to take the psychotropic medication he has been prescribed. a proxy directive , in which a patient ‘appoints a surrogate decision-maker who has legal authority to make treatment decisions on behalf of the patient when incapacitated’ ( Srebnik 2005 : S42). Similarly in the United Kingdom – for example, Section 3(1) of the UK Mental Capacity Act (2005) stipulates that, in order to be deemed rationally incompetent, a patient must be suffering from a condition that makes him or her unable to: understand information relevant to the decision, use or weigh that information as part of the process of making the decision, or. One problem with this test, however, is whether, say, the blinking of a patient’s eyelids can be relied upon as evidencing a choice; in a life-and-death situation one would need to be very sure that a patient’s so-called ‘evidencing a choice’ is more than just a reflex. DRAFT Psychiatric–Mental Health Nursing: Scope & Standards of Practice 6 2012 workgroup SCOPE DRAFT for National Review 11/20/12 Preface1 2 In 2011, the American Psychiatric Nurses Association (APNA) and the International 3 Society of Psychiatric–Mental Health Nurses (ISPN) appointed a joint task force to 4 begin the review and revision of the Scope and Standards of Psychiatric–Mental Health The American Psychiatric Nurses Association (APNA) is your resource for psychiatric-mental health nursing. They are registered nurses with specialized, advanced education and clinical competency to provide health and medical care for diverse populations in a variety of primary care, acute and long-term care settings. The plaintiff’s family filed a lawsuit on behalf of the plaintiff, naming the alcohol and drug rehabilitation facility and healthcare professionals responsible for her care, including the insured nurse practitioner. Criteria stipulated in other jurisdictions are reflective of these original proposals. Health care professionals practice in an environment that is complex, with many regulations, laws and standards of practice. The origin of the term ‘Ulysses contract’ is not clear although it probably originated in a commentary by Ennis (1982 : 854) in which reference is made to ‘Odysseus at the mast’, published in response to Szasz’s (1982) original article on ‘The psychiatric will’ (see also Hastings Center Report 1982a ). According to media reports, this act led to a psychiatrist certifying him as rationally incompetent, thereby enabling John McEwan to be treated (fed) against his will. “There is an ethical problem in that the close relationship could cloud the practitioner’s judgment,” Buppert said in the Legal and Professional Issues for Nurses section of Medscape Nurse. Nevertheless, as Buchanan and Brock’s highly cited work Deciding for others: the ethics of surrogate decision-making (1989) has shown, it is possible to devise at least a prima-facie working framework to guide professional ethical decision-making in this sensitive, complex and problematic area. Since then a substantive paradigm shift has occurred, which has seen PADs incorporated into mental health legislation in the Australian Capital Territory (2015), Queensland (2016), Victoria (2014) and Western Australia (2014), with the Australian Capital Territory legislation regarded by commentators as the most progressive (see comparative table in Ouliaris & Kealy-Bateman 2017 : 576). 1). Insufficient personnel, excessive workload, working conditions, lack of supervision, and in-service training were identified as leading to unethical behaviors. Family nurse practitioners (FNPs) often are the first to see patients with mental health issues. First published in 1991, with a 2012 revised edition of the statement launched in early 2013, this document stands as an influential guide for other public policy initiatives and statements such as the National mental health policy (released in 2008 and committed to by all Australian governments), and successive national mental health plans (including the most recent Fifth national mental health and suicide prevention plan released in 2017 , the National standards for mental health services 2010 and the National carer strategy in 2011 ( Australian Government Department of Health 2010 , 2011 , 2017 ) and other documents (e.g. This myth has been taken by PAD proponents as analogously justifying psychiatric patients abdicating their ‘freedom’ to substitute decision-makers during periods of incapacitation: although restrained during these periods, like Ulysses, their autonomy nonetheless remains intact. The idea of a Ulysses contract derives from Homer’s story of the mythological character Ulysses (known as Odysseus in Greek mythology) who escaped being seduced to his death by the ‘sweet songs’ of the Sirens, the magical women of Cyrene, who cast spells on the sailors of ships so that their vessels would be wrecked and subsequently could be scavenged. Whatever the faults, weaknesses and difficulties of such statements, they nevertheless achieve a number of important things; like bills and charters of patient rights generally, they help to remind mental health patients / consumers, service providers, caregivers and the general community that people with mental health problems (including mental illnesses and mental health problems) have special moral interests and entitlements that ought to be respected and protected, they help to inform stakeholders (patients / consumers, service providers, caregivers and the community) of what these special entitlements are and thereby provide a basis upon which respect for and protection of these can be required, they help to delineate the special responsibilities that stakeholders (patients / consumers, service providers, caregivers and the community) all have in ensuring the promotion and protection of people’s moral interests and entitlements in mental health care and in promoting mental health generally. The main purpose of providing this information and alerting service providers to their preferred options is to ensure the continuity of their care, although research demonstrating this purpose remains inconclusive. Some studies have suggested that, overall, clinicians are broadly supportive of the ‘advance-consent’ function of PADs (termed ‘prescriptive function’); however, clinicians are more reticent about their ‘advanced-refusal’ function (termed ‘proscriptive function’) – especially if used to refuse all future treatment ( Swartz et al 2006 ). This annual award was established in 2019 in recognition of … Legal & Ethical Issues that Health Care Professionals Face. Also, although applying the criteria developed may inevitably result in a health care professional assuming the essentially paternalistic role of being a surrogate decision-maker for a given patient, this need not be problematic provided the model of surrogate decision-making used is patient centred – that is, committed to upholding the patient’s interests and concerns insofar as these can be ascertained. This is in contrast with a non-patient or ‘other’-centred decision-making model, which would have as its rationale preventing harm to others , and which embraces an ethical framework ‘for deciding about others for others’ benefits ’ ( Buchanan & Brock 1989 : 327, 331). ethics. The enactment of formal legislation regulating PADs has a protracted history dating back to the USA, which has the longest history of their use, with Minnesota in 1991 becoming the first American state to enact legislation giving recognition to the ‘advance psychiatric directive’ allowing its citizens to ‘draft directives for intrusive mental health treatments’ ( Cuca 1993 : 1165). Patients will be offered new services from highly skilled advanced nurse practitioners. Like Gert and colleagues (1997) , cited earlier, they argue that statements of competence (i.e. Determining whether a person has the competency to make an informed decision about whether to accept or reject a recommended treatment is not a straightforward matter, however. This case study involves a nurse practitioner working in a medical clinical environment. #Best Practices Prior to 2014 there seemed to be little optimism that PADs will be formally adopted in Australian jurisdictions as a legal mechanism for promoting and protecting the rights of mentally ill people to participate effectively in decision-making concerning their psychiatric care and treatment. The test of choice based on ‘rational’ reasons is a little more difficult to apply. Earlier in this chapter, under the discussion of competency to decide, the case was given of an involuntary psychiatric patient who was held down and given an intramuscular injection of psychotropic medication against his will (see pp 213–14 ). iThese d… Because one of the most ethically confronting issues in mental health care is the coercive treatment 2 of persons admitted as involuntary or non-voluntary patients to a psychiatric facility or program, particular attention will also be given to the issues of informed consent and competency to decide, and ongoing proposals to develop and operationalise ‘psychiatric advance directives’ (PADs) in jurisdictions around … Of these four functions, the Ulysses contract is arguably the most reflective of the moral justification of PADs. It will be recalled that this incident resulted in the patient being left highly mistrustful of nursing staff and even less willing to comply with his prescribed oral medication. Rights and responsibilities of the community – encompassing the responsibility of communities to be adequately informed and educated about mental health issues, and to uphold the rights of mental health consumers and their carers. Claire Zilber, M.D., is the author of the Psychiatric News column “Ethics Corner” and has written about a number of contemporary ethics issues that psychiatrists commonly encounter. Rights and responsibilities of carers and support persons – encompassing the rights and responsibilities of carers and support persons in relation to the rights to: respect the human worth and dignity of people; privacy and confidentiality; seek and receive appropriate training and support; participate in and contribute to the development of social, health and mental health policy. The issue of patients’ rights to and in health care, discussed in the previous chapter, has obvious relevance and application for people with mental illness admitted to hospital for the care and treatment of non-psychiatric conditions (e.g. Healthcare providers have an ethical obligation to disclose information that patients need for informed decision making. The patient’s bill of rights calls for full disclosure of a medical error ( … This, in turn, has contributed to a lack of competence on the part of both health service providers and service users to honour and implement PADs (Nicaise et al 2013: 2). But what are PADs, and are they capable of achieving the outcomes that their proponents anticipate and expect? Individual Coverage Ethical Concerns For the nurse in a traditional medical setting, ethical decisions occur occasionally and at times the nurse may face ethical dilemmas. Such nurses need guidance direction and information to assist them in their new roles. known about the ethical conflicts and causes of these conflicts experienced by these clinicians in their daily practice. It also has obvious relevance for people admitted to mental health care facilities for psychiatric care and treatment. In response to the insured, the psychiatrist indicated that the patient’s diagnosis was his responsibility and he would manage her care. Violation of ethical principle and law. The nurse assumes responsibility and accountability for individual nursing judgements and actions. The legal ramifications and violation of law for practicing PAD are as followed; FNP’s cannot legally or ethically make the diagnosis to determine terminal illness, for the purpose of qualification in PAD (Stokes, F., 2017. • Scope of practice shapes what FNPs can do when diagnosing/treating mental illness. Such nurses need guidance direction and information to assist them in their new roles. The nurse practitioner demonstrated appropriate concern for the patient and reported his findings regarding her past and current use of narcotic pain drugs to his supervising psychiatrist. Family nurse practitioners (FNPs) often are the first to see patients with mental health issues. Many a time nurse practitioners find themselves in ethical dilemmas about what to do in certain situations and tend to follow their instincts as the best course of action to pursue, and this could help to … This article will examine some of the ethical and legal issues correctional nurses must address in their practice. Advanced practice registered nurses (APRNs) are active in a variety of clinical, educational, and executive roles, with varying degrees of involvement in and influence over clinical practice. This question becomes even more problematic when it is considered that persons deemed ‘rationally incompetent’ (or, at least, cognitively impaired) can still be quite capable of making ‘reasonable’ self-interested choices, and, further, that the choices they make – even if ‘irrational’ – are not always harmful ( Williams 2002 ; see also Light et al 2016 ; Stier 2013 ). Case Study: Failure to manage the patient’s care in order to maximize individual recovery and quality of life, Failure to advocate and promote a system and climate that is conducive to providing ethical care, Failure to utilize ethical principles to advocate for access and parity of services for mental health problems, psychiatric disorders, and substance use disorder services, (Monetary amounts represent only the payments made on behalf of the treating nurse practitioner.). The plaintiff sought economic, noneconomic and punitive damages, as well as plaintiff’s attorney fees. patient autonomy. This can be established by asking patients probing questions and inviting them to reiterate the information they have received. For many, the answer lies in the systematic development and formal adoption of psychiatric advance directives (PADs). As discussed in the previous chapter under the subject heading ‘The analytic components and elements of an informed consent’, an essential criterion to satisfying the requirements of an informed consent is competency to decide . The test of reasonable outcome of choice is again as it sounds, and focuses on the outcome of a given choice, as opposed to the mere presence or absence of a choice. Underpinning this caveat is the reality that in most jurisdictions around the world there are legislative provisions that enable people with severe mental health illness to be detained, restrained, coerced and / or treated without their consent . The problem also may arise of patients perceiving a risk as a benefit. John McEwan, a former Australian water-skiing champion, was left a ventilator-dependent quadriplegic after a diving accident at Echuca, Victoria. Here objections can be raised concerning just how sophisticated a patient’s understanding needs to be. The psychiatrist’s judgment was revoked a few days later, however, when John McEwan ‘agreed to end his hunger strike and accept a course of antidepressants’ (p 2). PMHNPs encounter such unethical dilemmas, since they compromise the legal rights of a patient (Annamalai, & Tek, 2015). Research conducted by the Council on Accreditation of Nurse Anesthesia Educational Programs (COA), (Cook, 2013) reports recent graduates of accredited certified registered nurse anesthetist • FNPs should be aware of treating outside the scope of practice for mental illness. Patients will be offered new services from highly skilled advanced nurse practitioners. 250 Governance – encompassing the responsibility of governments and other stakeholders to ensure that mental health initiatives (including service provision, mental health legislative reform, and other forensic matters) are appropriately resourced and supported. Findings: The results indicated that nurses needed additional education in psychiatric ethics. Defense experts and the defense attorneys judged the nurse practitioner’s actions to be appropriate and within the standard of care, deeming his potential liability in the matter to be 2 percent or less. Ethical issues happen when choices need to be made, the answers may not be clear and the options are not ideal. in clinical contexts) usually refer to a person’s competence to do something , in this instance, to choose and make decisions ; according to this view, competence is, therefore, ‘choice and decision-relative’. In defence of their position, they argue that the patient’s complaints are justified – the adverse side effects of his psychotropic drugs have indeed been ‘awful’, and are commonly experienced by other patients as well; and that he has experienced a decline in his psychiatric condition before, and hence knows what to expect. Further, they argue, if he is given the medication against his will, an even greater harm will follow: specifically, he will trust the nursing staff even less than he does already, and will be even less willing to comply with his oral medication prescription than he is now. A number of objections can be raised here. To put this more simply, PADs stand to serve the basic functions of: prescription (advance consent to treatment options), proscription (advance refusal or rejection of treatment options), surrogate decision-maker designation 4 (identification and advance nomination of substitute decision-makers). The scope of nursing has evolved from the early role of a nurse carrying out orders at a doctor’s bidding. Currently almost two-thirds of the states in the USA have legal processes in place for allowing and managing PADs (Zelle et al 2015b). Within contemporary medical ethics recognition of the principle of self governance or respect for autonomy has altered the nature of interactions between patients and health professionals in all sectors of the health system. The less experienced staff members on the ward disagree with this reasoning, however, and argue that, even though the patient’s psychiatric condition is deteriorating, and this is a preventable harm, the patient is nevertheless able to make an informed decision about this and therefore his wishes should be respected. • FNPs should be aware of treating outside the scope of practice for mental illness. The claim of a moral right usually entails that another person has a corresponding duty to respect that right. 4 As part of their professional role, APRNs must be able to recognize ethical conflicts and serve as mediators or resources for patients, families, or other nurses who are … It was (and continues to be) believed that, when completing PADs during periods of ‘competency’, persons with severe mental illnesses will be enabled to feel ‘empowered’ and to have a sense of ‘self-determination’ ( Nicaise et al 2013 : 8; see also Berghmans & van der Zanden 2012 ). Notwithstanding his minor role in the care of the patient, as well as the fact that there were positive expert opinions regarding the care he provided, the plaintiff’s attorney was unwilling to release the insured from the case or even to offer a reasonable settlement demand. Because of unresolved uncertainties concerning how the concept of competency is to be interpreted and applied by clinicians, and the tendency to overlook what Banner describes as the ‘inherent normativity of judgments made about whether a person is using or weighing information in the decision-making process’, there remains the ever-present risk of patients failing on the criteria ‘to the extent that they do not appear to be handling the information given in an appropriate way, on account of a mental impairment disrupting the way the decision process ought to proceed’ ( Banner 2012 : 3078; see also Stier 2013 and Light et al 2016 – both referred to earlier). More patients are receiving healthcare services from nurse practitioners (NPs) and physician assistants (PAs). Being previously warned of the evil intentions of the Sirens, Ulysses took the precaution of commanding his sailors to bind him to the mast of his ship (effectively restraining him), and to plug their ears with wax so that they could not hear and hence be seduced to their deaths by the Sirens. Ethical Codes for Psychiatric Nurse Practitioners [Compatibility Mode] 1. Decisions that would cause “concern” might include refusing medication that would prevent an adverse outcome, refusing prevention or treatment that is standard of care, refusal to follow recommended diet, refusal to follow safe sex practices, or refusal of continuous positive airway pressure. Even if there were agreement on what constitutes rational competency, there remains the problem of ‘whereby the definition of competence changes in different clinical situations’ ( Gert et al 1997 : 135). As a result, discussion ensued about appealing the jury’s decision. More patients are receiving healthcare services from nurse practitioners (NPs) and physician assistants (PAs). Identify eight domains deemed relevant to the rights and responsibilities of both users and providers of mental health care services. Case Study: Failure to manage the patient’s care in order to maximize individual recovery and quality of life, Failure to advocate and promote a system and climate that is conducive to providing ethical care, Failure to utilize ethical principles to advocate for access and parity of services for mental health problems, psychiatric … Nevertheless, Buchanan and Brock (1989) provide an important basis for identifying the following three factors which need to be taken into consideration when deciding whether to override a mentally ill person’s decisions, namely: (1) whether the person is a danger to herself or himself, (2) whether the person is in need of care and treatment, and (3) whether the person is a danger to others. Specifically, an approach is required that places strong emphasis on consolidating the mental health interests of those who have or who are at risk of developing mental illnesses and which also emphasises the ‘special’ responsibilities that health care providers have towards this vulnerable group. For example, if a patient with severe mental illness decides to refuse hospitalisation, the extent to which an attending health professional is obliged morally to respect this decision will depend on how severe the risks to the patient are of not being hospitalised – for instance, whether a failure to hospitalise the patient will result in her or him suiciding, or will result only in her or him being left in a state of moderate, although not life-threatening, depression. She survived the attempt, but suffered severe anoxia and permanent brain damage. ETHICAL CODES FOR PSYCHIATRIC NURSE PRACTITIONERS Paul D. Friedman, M.A., Ph.D., J.D. As noted earlier, SDM places the person who is being supported at the front of the decision-making process ( ALRC 2014 ). Psychiatry is no exception. in regard to what is important in life). #LegalCases Psychiatric advance directives have been defined as ‘documents that allow users with severe and chronic mental illnesses to notify their treatment preferences for future crisis relapses and to appoint a surrogate decision-maker for a period of incompetence’ ( Nicaise et al 2013 : 1). Conclusions A proposal for a code of ethics for NPs is presented. A New Zealand survey of 110 mental health service users and 175 clinicians had similar findings ( Thom et al 2015 ). This case scenario demonstrates the difficulties that can be encountered when accepting / rejecting a patient’s ability to choose and decide care and treatment options, and deciding when and how to override a patient’s preferences. Assessing risk and permitting choices of patients deemed ‘rationally incompetent’, Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), United Nations General Assembly’s adoption in 1991, Australian Health Ministers Advisory Council (AHMAC) 2013, Australian Government Department of Health 2010, Australian Government Department of Health 2012, Australian Law Reform Commission (ALRC) 2014, Ethics, dehumanisation and vulnerable populations, Moral theory and the ethical practice of nursing, Nursing ethics futures – challenges in the 21st century, Ethics, bioethics and nursing ethics : Some working definitions. (Whether or not the risk of suicide does provide strong grounds for overriding a patient’s decision to refuse hospitalisation and treatment is another question, and one which is considered shortly in this chapter.). Within his scope of practice, he was able to make a determination of mental illness. [emphasis original]. This test asks how well the patient has actually understood information which has been disclosed. There is, however, still work to be done, noting that provisions for PADs have not yet been incorporated in the mental health legislation of all Australian jurisdictions and that, even where it has been (e.g. They argue in defence of this decision that the patient’s condition is deteriorating rapidly, and that if he does not receive the medication prescribed he will ‘spiral down into a psychiatric crisis’ (in other words a total exacerbation of his condition), which would be even more intolerable and harmful than the unpleasant side effects he has been experiencing as a result of taking the psychotropic drugs in question. As Gert and colleagues (p 132) go on to explain, we need to appreciate that persons as such are ‘not globally “competent” but rather “competent to do X”, where X is some specific physical or mental task’. Just what such a framework would – or indeed should – look like is, however, a matter of some controversy. Although barriers to the implementation of PADs persist, research has found that consumers continue to have a high interest in and demand for PADs. In short, those who did not support PADs placed more importance on clinical outcomes than on upholding patient autonomy. Philosophical disputes about what constitutes ‘rationality’ and ‘competency to decide’ have particular ramifications for people who have what has been termed ‘fringe decision competence’ ( Hartvigsson et al 2018 ), who are cognitively impaired and / or who, because of the manifestations of severe mental illness, are involuntarily admitted to psychiatric facilities for treatment. The nurse exercises informed judgment and uses individual competence and qualifications as criteria in seeking consultation, accepting responsibility and delegating nursing activities to two others.(p. More insights from some of the best minds in nursing. Later, after recovering from this incident, the patient was, as predicted by the less experienced nursing staff, grossly mistrustful of the nursing staff on the ward, and even less willing to comply with his oral medication prescription. Moreover, the nurse practitioner suffered emotional distress and anxiety from the entire matter and was eager to settle the claim without further legal action. ETHICAL ISSUES IN ADVANCED PRACTICE NURSING. At four o’clock in the morning on 3 April 1986, John McEwan was found dead by his nursing attendant. The researchers reported that, although most (93%) of both clinicians and users supported the idea of PADs, they differed significantly on the preferred content of such directives – particularly with regard to the use of seclusion as a method of de-escalation. patient autonomy. An important problem here, particularly in psychiatric contexts, is that severe mental illness can significantly affect the capacities needed for competent decision-making (for instance, understanding, reasoning and applying values), and hence the ability generally of severely mentally ill persons to make sound decisions about their own wellbeing – including the need for care and treatment. The nurse exercises informed judgment and uses individual competence and qualifications as criteria in seeking consultation, accepting responsibility and delegating nursing activities to two others.(p. The primary objective of the 2012 revised version of the Mental health statement of rights and responsibilities document is to inform stakeholders of the rights of people experiencing a mental illness to have access ‘to timely assessment, individualised care planning, treatment and support’ and the related rights and responsibilities that consumers, carers, support persons, service providers and the community all have in relation to these rights ( Australian Government Department of Health 2012 : 3). The insured was a board certified psychiatric nurse practitioner who was working as an independently contracted (i.e., non-employed) nurse practitioner for the co-defendant facility. On this point, with reference to the provisions contained on the CRPD, Callaghan and Ryan (2016 : 610) explain: Several years ago, a consumer advocate pleaded: It has taken a very long time but, it would seem, this advocate’s plea is at last being heard. Depending on the legal regulations governing a given PAD, a directive can contain provisions for either ‘opting-out’ (refusing) treatment (both general and specific – e.g. A second consideration is that many people with mental illness have experienced high rates of trauma during their lifetime. #Malpractice Rights and responsibilities of people who provide services – encompassing rights and responsibilities in regards to upholding the highest possible standards of mental health care, including the development and implementation of social, health and mental health policy and service delivery policies and guidelines. Advanced practice registered nurses (APRNs) are active in a variety of clinical, educational, and executive roles, with varying degrees of involvement in and influence over clinical practice. They make the additional value judgment that it would be ‘better’ for the patient if his psychiatric condition were prevented from deteriorating, and that their decision to administer his prescribed medication forcibly against his will is justified on these grounds. This is in contrast to clinicians, who have consistently been found to be somewhat ambivalent about and even afraid of them ( Amering et al 1999 ; Appelbaum 2004 , 2006 ; Atkinson 2004 ; Atkinson et al 2004 ; Elbogen et al 2006 ; Hobbs 2007 ; Kaustubh 2003 ; Kim et al 2007 ; Puran 2005 ; Srebnik & Brodoff 2003 ; Swanson et al 2006a , 2006b , 2006c , 2007 ; Swartz et al 2006 ; Varekamp 2004 ). The topic is complex, but in simple words, the code of ethics for nurses is a set of moral rules that defines a nurse’s relationship with patients, staff members, and the profession itself. Some commentators are especially worried about their moral authority (particularly if patients change their minds at some point) and their vulnerability to being abused and misused ( Spellecy 2003 ). Not only is there the problem of how to determine accurately what a harm is and how a given harm should be weighted morally when evaluating whether a patient’s choices should be respected or overridden; there is the additional problem that attending health care professionals may disagree radically among themselves about how these things should be determined – to a point that may even cause rather than prevent harm to the patient, as happened in this case. During such periods, the mentally ill can also be at risk of harming themselves and / or others. By taking these steps, Ulysses was able to investigate the power of the Sirens without being seduced to his death by them as well as ensure the safety of his ship and his crew as they sailed past them. This prompted the general practitioner who was medically responsible for him to inform the senior nursing assistant that: During one incident, while at home, John McEwan was observed to be angry at having been reconnected to the ventilator against his wishes. There is room to speculate that, had a PAD been in force at the time for this patient, a very different outcome might have resulted in this case. This case study involves a nurse practitioner in an in-patient alcohol/drug treatment setting. This is so despite what Callaghan and Ryan (2016 : 601) describe as a ‘revolutionary paradigm shift’ that is occurring as a result of Article 12 of the UN Convention of the Rights of Persons with Disabilities (CRPD) 1 ‘objecting to the automatic use of substituted decision-making whenever a person fails to meet a functional test of decision-making capacity’. Ethical decision making concerning in nursing practice environment. The need to do this becomes even more acute when the problem of determining and weighing harms is considered in relation to the broader demand to achieve a balance between protecting and promoting the patient’s wellbeing, protecting and promoting the patient’s autonomy, and protecting others who could be harmed if a mentally ill person is left free to exercise harm-causing choices (as happened in the Tarasoff case, considered in Chapter 7 ). Ethical issues are wide-ranging, from organ donation, genetic engineering, assisted suicide, withholding treatment in end-of-life care, or. by having his body tied to the mast of his ship), his autonomy (rational preference) was essentially left intact – including during the momentary period of his incompetence while under the bewitching spell of the magical Sirens. Underpinning the selection of this model is the view that ‘all people have fundamental human rights’ and that people with mental health problems or mental illness should not be precluded from having or exercising these rights just because of their mental health difficulties. Underpinning this search has been the commensurate pressing need to find a balance between promoting autonomy and preventing harm and, equally important, finding a way to advance a genuine ‘ “supported decision-making” model in which a person makes treatment decisions for themselves, with support where required’ ( Ouliaris & Kealy-Bateman 2017 : 574). This chapter explores mental health nursing practice within an ethics context. The promotion of mental health and the prevention of mental illness – encompassing the responsibilities of governments and health service providers to: promote mental health; support, develop, implement and evaluate programs for preventing mental health problems and illnesses; support the ongoing development of comprehensive, flexible, integrated, and accessible community, primary health and hospital-based social support, health and mental health services. It should be noted that competency is a key issue not just in psychiatric care, but in any health care context where judgments of competency are critical to deciding: (1) whether a patient can or should decide and / or be permitted to decide for herself or himself, and (2) the point at which another or others will need to or should decide for the patient – that is, become what Buchanan and Brock (1989) term surrogate decision-makers and what is variously referred to in Australian jurisdictions as involving ‘substitute decision-making’ and ‘supported decision-making’, with the latter placing the person who is being supported ‘at the front of the decision-making process’ ( Australian Law Reform Commission (ALRC) 2014 : 51). A little over a year after his accident, and despite still being ventilator dependent, John McEwan was discharged home. In contrast, the correctional nurse may face ethical situations daily. In a more recent work on competency, Light and colleagues (2016 : 34) argue that ‘all definitions of capacity [for decision-making] involve intrinsically normative judgments and inevitably reflect the influence of context and values’. Nurse practitioners because of their education and training, understand their … The nurse practitioner assessed the patient shortly after her admission. Ethics is an important aspect of healthcare and is very common in theme in nursing (Beidler, 2005). a. She was treated with pain medication and antidepressants. The patient’s permanent condition dictates that she cannot be left alone and requires full-time assistance with all aspects of her personal care. Commenting on the moral standards which should be met when deciding whether to respect or override the expressed preferences of a patient deemed ‘incompetent’, Buchanan and Brock (1989) have classically argued in their foundational text that it is important to be clear about what statements of competence refer to. Master’s, post-master’s or doctoral preparation is required for entry-level practice (AANP, 2006). Rather, it tends to be only in cases of ‘treatment refusals, especially those that appear to be irrational, that the question of a patient’s competence most frequently and appropriately arises’ ( Gert et al 1997 : 142; see also Light et al 2016 ). On at least two occasions, he reported his findings and concerns to his supervisor, the patient’s psychiatrist and the facility co-owner. Roth and colleagues (1977 : 282), for example, cite the case of a 49-year-old psychiatric patient who was informed that there was a one-in-three-thousand chance of dying from ECT. The patient was a 59-year old female who had undergone inpatient bilateral salpingo-oophorectomy three days before being discharged to home care. • Liability risks for psychiatric mental health nurse practitioners are reviewed. This chapter explores mental health nursing practice within an ethics context. A little over a decade later, in the cultural context of Australia, the need to assure the rights of people with mental illness and the ‘provision of recovery-orientated practice in mental health services’ was positioned as a core principle in the Australian Commonwealth Government’s National framework for recovery-oriented mental health services ( Australian Health Ministers Advisory Council (AHMAC) 2013 ) and the Council of Australian Governments’ (2012) Roadmap for national mental health reform 2012–2022 . The need of a highly nuanced approach to upholding the rights of persons with mental illness and related problems in health care rests on at least three considerations. In either case, timely and effective psychiatric treatment and care are imperative. An instructive example of this can be found in the much-publicised Australian case of John McEwan that occurred in the mid 1980s and which sparked an unprecedented public inquiry into the so-called ‘right to die with dignity’ ( Social Development Committee 1987 ). Nursing staff of many specialities are taking on and developing their roles in new and advanced practice areas. One response is to insist on the development of reliable (research-based) criteria for deciding these sorts of problematic issues. Ft. Washington, PA 19034. A patient could without contradiction ‘rationally’ choose suicide as a means of escaping an intolerable life characterised by suffering intractable and intolerable pain. The scope of nursing has evolved from the early role of a nurse carrying out orders at a doctor’s bidding. With reference to the ethics of suicide prevention, intervention and postvention: discuss the distinction between suicide, suicidal behaviour and parasuicide and why making this distinction is important, examine critically at least five criteria that must be met in order for an act to count as suicide rather than some other form of death (e.g. This can sometimes mean that, rather than providing a ‘psychiatric sanctuary’, an involuntary admission to a psychiatric facility may sometimes be experienced as a ‘psychiatric sentencing’ – akin to a penal incarceration. At one point, desperate to achieve his wish, he went on a hunger strike and instructed his solicitor to draw up a ‘living will’, which stated ‘that he did not wish to be revived if and when he fell into a coma’ ( Bioethics News 1985 : 2). On the basis of educated skill and past experience, the health professional is usually able to ascertain the level at which the patient has understood the information received and what data gaps or misunderstandings remain. The legal ramifications and violation of law for practicing PAD are as followed; FNP’s cannot legally or ethically make the diagnosis to determine terminal illness, for the purpose of qualification in PAD (Stokes, F., 2017. Comparable studies conducted in Australia and New Zealand have had similar findings. Responsibility as Patient Advocate . mental disorders. Nurses, like any other healthcare worker, must follow a predefined code of ethics in their practice.But what is the code of ethics for nurses? For example, a fully comatose patient would be unable to evidence a choice, unlike a semi-comatose patient or a brain-injured person, who could evidence a choice by opening and shutting their eyes or by squeezing someone’s hand to indicate ‘yes’ or ‘no’. In summary, the notion of ‘rational competency’ is problematic because there is no precise definition of, or agreement on, what it is. It is important to acknowledge that, despite their envisaged benefits, PADs are not without risk. Fulfilling a corresponding duty can involve either doing something ‘positive’ to benefit a person claiming a particular right or, alternatively, refraining from doing something ‘negative’ which could harm a person claiming a particular right. Legal and ethical issues are prevalent in the health care industry, and in particular for the nursing practice, where nurses have daily individual contact. community treatment order (CTO) contexts) ( Corring et al 2017 ; Nagra et al 2016 ; Molodynski et al 2014 ). Nurses are guided by a code of ethics that provide them with the basis to make ethical decisions. The nurse maintains competence in nursing. Defense counsel leveraged the possibility of an appeal to obtain a post-judgment settlement that included a total dismissal of the claim against the insured. Dr. Zilber is chair of the Ethics Committee of the Colorado Psychiatric Society, a consultant to APA’s Ethics Committee, and a private practitioner in Denver. discuss critically the possible risks and benefits of psychiatric advance directives. “There is an ethical problem in that the close relationship could cloud the practitioner’s judgment,” Buppert said in the Legal and Professional Issues for Nurses section of Medscape Nurse.

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