Professional Concept Psychiatric health Law & Ethics

1. Psychiatric Health Law and
Ethics
Marsha Utz, MSN, RN
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2. Psychiatric Health Law and Ethics
• Laws governing
• Admission
• Voluntary
• Involuntary
• Discharge
• Ethical treatment of psychiatric patients
• Self-advocacy for patients and family
members
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3. Current Admission Process
• Self
• Family
• Referral
Emergency Department (ED)
AND/OR
Emergency Petition (EP)
Document filled out by witness
Gives police authority to take person to ED
• Admission not assured
• Danger to self or others major factor
At the ED: mental health evaluation
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4. 4
Voluntary Admission
Patient agrees to admission
Recognizes need for treatment
Some insight
More likely to actively participate in
treatment
May leave ED against medical advice
(AMA), IF is not a danger to self or others

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6. During the 72-hour hold
• Patient may formally request discharge by submitting 3 day
notice
• Psychiatrist must be notified; treatment team will give
input…decide whether patient is safe to discharge
• May convince patient to stay…remain voluntary
• If patient if found unsafe or danger to self or others status
changed to involuntary
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7. Involuntary Admission
• Requires 2 Medical Doctors or
• 1 Medical Doctor & 1PhD Psychologist
or psychiatric nurse practionner
Certification
Process
• •Dangerous to self and /OR
• •Dangerous to others
Must Be
–Unable to care for self (Not a Criteria
in Maryland…developing)
–Must meet the 6 criteria for
commitment
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8. Committed Six Critea
• For commitment (in Maryland)
1. Person must have a mental disorder
2. Person must require inpatient treatment
3. Person is a danger to life or safety of self or others
4. Person is unable/unwilling to be admitted voluntarily
5. There is no other less restrictive SAFE treatment
6. 65 or over, must be evaluated by Geriatric Evaluation Team for least
restrictive environment
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9. Involuntary Status
• Certified means committed
• Does not agree to hospitalization
• Often resistant to treatment
• Against the patient’s will or
wishes
• Ethical issue treat without
patient’s permission? How can we
protect individuals and society?
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10. Notice of Hearing (NOH)
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Legal Document (6 copies)
• Must give original to patient within 12 hours
• States Date of Hearing
• Notifies patient of date of hearing
• Hearing MUST be held within 10 calendar days
• Each hospital has a hearing one day/week
Nursing Responsibilities:
Ensure that all information on NOH is correct
• Give NOH to patient
• May accompany patient to hearing

11. Hearing
• Purpose: determine if patient should remain in hospital
against his/her will
• Judge present, is a legal proceeding on unit
• Sworn in for testimony
•Attendees
• Administrative Law Judge –from the state of Maryland
• Public Defender –Md. (goal is to release patient)
• Treatment Team Members
• Family and/or friends
• Patient 11

12. Hearing Outcomes
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Retained (dangerous to self/others)
• May APPEAL (within 30 days) x 1
• Another Hearing then scheduled
Released
• NOT dangerous
• Sometimes paperwork not done correctly
• Public defender pleads and wins case
• Patient agrees to switch to voluntary status before hearing
Hearing cancelled

13. IF retained as involuntary
May appeal within
30 days
Another hearing
scheduled (NOH
given)
Another decision
made whether
patient is still
involuntary, or may be
released
If is retained as
INVOLUNTARY 2nd time,
now is on a more long-term
Involuntary Hospitalization
STILL can refuse
medication throughout
this whole process
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14. Medicating a patient against the
patient’s will
During an emergency, may give a one-time prn
to reduce aggression
Scheduled medications may be refused by
patient, whether voluntary or involuntary
MUST HAVE ANOTHER HEARING
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15. MED Panel hearing
• Given another NOH (notice of hearing)
• At this hearing (must be declared involuntary first) will now
determine whether patient will have forced medications
• May also be appealed x 1
• If so ruled, immediately after the hearing, patient is given
medication
• Often begins with IM
• Soon transitions to PO
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17. Insanity Defense
• Not Criminally Responsible (NCR) or Not Guilty by reason of
insanity (NGRI)
• Not Given a Defined Sentence
• Court Ordered Meds and Treatment
• Conditional Release
• Legal meaning but no medical definition
• patient is determined incompetent to stand trial due to mental
illness
• Person unable to control his or her actions or understand the
difference between right and wrong at time of crime (M’Naghten
Rule)
• The public perception is that the person accused of the crime
“gets off” and is free immediately.
• Three states ( Montana, Idaho, and Utah) that do not allow the
insanity defense
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18. Whether Admitted as a voluntary
or involuntary admission
• Patient brought to Inpatient Unit
• Belongings searched
• Admission completed
• Admission orders obtained
• At first, on Close Observations or 15 minute checks
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19. Patient rights during psychiatric
hospitalization
• Receive telephone calls
• Phone specifically for patient use only
• Visitors –
• during published visiting hours (unless
disruptive)
• Vote
• Receive and send mail (unopened)
• Clergy
• Lawyer
• Interpreter
• Patient Representative/Advocate
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20. Patient’s Rights in Hospital
• Treatment Rights
• Treated at Appropriate Level of Care
• ***Least Restrictive Environment****
• Participate in the Treatment Planning
• Give their Informed Consent
• Know their Diagnosis
Right to Treatment O’Connor v. Donaldson 1975
• Must be ACTIVE treatment, not custodial
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21. Patient’s Treatment Rights
• Confidentiality (HIPAA) within the treatment team
• Release of Information ONLY with pt’s permission
• No photographs
VERY IMPORTANT!!!!!
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22. Exception to confidentiality
Duty to warn (Tarasoff v. Regents of U.Cal. 1976)
• Patient makes a threat against specific
person(s), treatment team must notify
person(s)
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23. Competency
Competent: able to make informed decisions
• To be declared incompetent, two doctors must evaluate that
incompetency exists.
• Incompetent is a legal term indicating that a patient is unable
to “manage his/her own affairs
• Can no longer enter into legal contracts, vote or drive
If incompetent, a guardian decision-maker must be appointed
• VERY RARE for patients to be declared incompetent unless
• Mental retardation
• Brain damage
• Dementia
Temporarily….Under influence of anesthesia, sedation
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24. Nursing Interventions
• Based on right to least restrictive environment
• Help person regain behavior control
• When patient is dangerous to self or others
• When patients’ behaviors are disruptive to the milieu
All interventions require MD orders
• Zoning
• Be in Staff Eye-Sight
• One to One
• Close observations
• Chemical restraints (medications)
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25. Physical/Mechanical Restraints
• Rarely used in psychiatric units)
(primarily when harmful to self
• Out of restraints q2 hours
• Offered hydration, food,
restroom
• Range of motion (ROM), skin
check
• Types
• Mittens
• Wrist/Legs (2 point, 4 point)
• Geri-chair
• Papoose
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26. Seclusion
• Try to use alternatives first IF POSSIBLE
• Only when imminently harmful to others
• Physician Order after seclusion
• PRN medications given
• Short Duration (no more than 4 hours)
• Monitored continually for first hour
• Monitored q 15 minutes after
• Nothing in room except mattress on floor
• Window in door and camera
• Potentially very dangerous
• Completely INAPPROPRIATE for suicidal patients
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27. Involuntary Outpatient commitment
• Usually requires proof of mental illness and
dangerousness
• Not available in all states (not in Md.)
• Issue debated
• Need to protect society
• Individual rights
• Often used after mentally ill offenders are released
from jail 27

28. Psychiatric Nursing Liabilities
Civil law
Tort is a civil wrong made against person or property
Can be intentional or unintentional
Intentional
• Assault
• Battery
• False imprisonment
Unintentional
• Negligence
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29. Liability in Psychiatric Nursing
Civil torts : Intentional
Assault: is the intentional threat to bring about harmful or
offensive contact. No actual contact is necessary
Battery: intentional touching without consent, which may
cause injury
False imprisonment:
So, a nurse who threatens a patient or gives treatment
without consent can be charged with what?
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30. Unintentional Torts
Examples of negligence include:
Medication and IV errors
that result in injury
Malpractice
Negligence is conduct that falls below the
standards of care
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31. Liability Prevention
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32. Ethical Principles
• Autonomy: ” independence and the ability to be self directed”
• Patients choices available
• Involuntary commitment and forced medication must be
absolutely justified to protect patient
• Informed consent & ability to understand
• Beneficence: promote good, second prevent harm , and third
remove evil or harm
• Non-maleficence:
• Is the treatment causing more harm than good? Weigh the
risks /benefits
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33. Ethical
Principles
continued:
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Justice
• Fair and equal treatment
• What about the uninsured?
Fidelity
• Faithful to your promises
Veracity
• Be truthful
• Maintains trust
• Shows respect for patient
Confidentiality

34. Stigma and ethics
• Patients are not a DIAGNOSIS
• Diagnosis is not absolute
• Nursing diagnoses focus more on symptoms and needs
• Psychiatric nurses have for years tailored interventions
to symptoms
• Diagnosis in Psychiatry is inexact, and changes
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35. Confidentiality and ethics
• Nurses must maintain confidentiality at a very high
level in psychiatric/mental health settings
• DO NOT EVER talk about the patients’ names,
experiences, jobs, crimes, or any other identifying
information with anyone other than your clinical
instructor, course instructor or the treatment team
• This includes friends, significant others, and family
• Confidentiality standards are to prevent
discrimination and stigma
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36. Standards of Care
ANA Code of Ethics for Nurses :
• Practice with compassion and respect, primary
commitment is to the patient, promotes nurses to be
advocates to protect health, safety, and rights of the
patient. Nurses are to be responsible and
accountable, collaborate with other health care
professionals, and maintain competence in their field
of practice
ANA Standards of Professional Performance
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37. QUESTIONS
Marsha Utz, MSN, RN
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