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.). Performing an abortion is legal but may not be considered ethical by other health care professionals or … They go on to warn that there is no magical definition of competency, and that the problems posed by so-called ‘incompetent’ persons are very often problems of personal prejudices and social biases, or of other difficulties associated with trying to find the ‘right’ words. 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. Lack of awareness and education about PADs (on the part of consumers and clinicians alike) has also been identified as a contributing factor ( Peto et al 2004 ). Master’s, post-master’s or doctoral preparation is required for entry-level practice (AANP, 2006). 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. Staff on the ward in which he is an involuntary patient are divided about what they should do. #Best Practices This article will examine some of the ethical and legal issues correctional nurses must address in their practice. People with serious mental illnesses can often experience periods of profound distress during which their capacity to make prudent and self-interested decisions about their care and treatment options can be seriously compromised. Thus, the right to make informed and self-determining decisions has the distinction of provoking controversy in the field – a controversy that has been classically described as: On account of the tension between patient autonomy and therapeutic paternalism in psychiatric contexts – and the extraordinarily difficult and sometimes tragic situation in which this has often placed people (consumers and caregivers alike) – advocates and commentators have searched for ways to reconcile or at least accommodate the opposing values at issue ( Dresser 1982 ). • Liability risks for psychiatric mental health nurse practitioners are reviewed. These risks may be accentuated in cases where the PADs are ‘competence-insensitive’ and service providers wrongly judge the point at which a PAD applies and apply it prematurely ( Bielby 2014 ). 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 the world. oral or intramuscular psychotropic medication, or electroconvulsive therapy). a. Ethics is an important aspect of healthcare and is very common in theme in nursing (Beidler, 2005). in regard to what is important in life). #Patient Safety. A variation of this test was further developed and advanced by Grisso and Appelbaum (1998 : 31), and includes assessing patients for their abilities to: understand information relevant to treatment decision-making, appreciate the significance of that information for [their] own situation, especially concerning [their own] illness and the probable consequences of [their] treatment options, reason with relevant information so as to engage in a logical process of weighing treatment options. Family nurse practitioners (FNPs) often are the first to see patients with mental health issues. 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 ). irrevocability during a crisis (also known as a ‘Ulysses contract’ – see below) ( Swartz et al 2006 : 67). Explore ways in which the nursing profession might improve its advocacy of people with mental health problems and severe mental illnesses. It teases out the ethical challenges that mental health nurses can face on a daily basis. Such nurses need guidance direction and information to assist them in their new roles. 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. 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 ). Research conducted by the Council on Accreditation of Nurse Anesthesia Educational Programs (COA), (Cook, 2013) reports recent graduates of accredited certified registered nurse anesthetist • Liability risks for psychiatric mental health nurse practitioners are reviewed. 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. John McEwan, a former Australian water-skiing champion, was left a ventilator-dependent quadriplegic after a diving accident at Echuca, Victoria. 4 The fifth and final competency test is that of actual understanding . 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. Upon the completion of this chapter and with further self-directed learning you are expected to be able to: Discuss critically why a charter of rights and responsibilities specific to mental health care is required. 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). integrations of care through health providers working in partnership with clients and families. Consider, for example, the following case (personal communication). To complicate this matter further, there is also no substantial agreement on what constitutes rationality , which, as has been argued elsewhere, is very much a matter of subjective interpretation. Dresser further cautions that, in the absence of an opportunity for patients to withdraw consent to treatment, PADs in reality could well stand as a ‘coercive treatment mode that would take us a step backward – or at least sideways – from a more sensitive and realistic solution to a very difficult situation’ ( Dresser 1982 : 854). Responsibility as Patient Advocate . 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. It is therefore important that nurses are equipped with the skills and knowledge to understand ethics within their practice. For example, in what is believed to be the first published national study of its kind, an Australian survey of 143 psychiatrists found that less than 30% supported PADs which involved treatment refusals (e.g. Findings: The results indicated that nurses needed additional education in psychiatric ethics. cessation of medication, remaining out of hospital and not being the subject of an involuntary admission to a psychiatric facility) ( Sellars et al 2017 ). For example, as Buchanan and Brock (1989 : 318) comment: It is precisely in situations such as these that attending health care professionals need a reliable framework within which to decide how best to act – notably: (1) whether to respect a patient’s preferences even though the patient is deemed ‘incompetent’, or (2) whether to override patients’ preferences in the interests of protecting or upholding what has been deemed by others to be in the patient’s overall ‘best interests’. 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. iThese d… Insufficient personnel, excessive workload, working conditions, lack of supervision, and in-service training were identified as leading to unethical behaviors. With reference to the idea of psychiatric advance directives in mental health: define what a psychiatric advance directive is, discuss critically the different theoretical frameworks and forms that psychiatric advance directives can take, discuss critically the different functions that psychiatric advance directives might serve, examine the purpose of ‘Ulysses contracts’. In short, those who did not support PADs placed more importance on clinical outcomes than on upholding patient autonomy. [1,8] Ethical issues related to PMH nursing in the literature can be summarized as: obtaining informed consent from the patient; compulsory treatment and hospitalization; using seclusion and restraint; respect for patients’ privacy and confidentiality; and research in … Ethical code or nursing care -related problems included (a) neglect, (b) rude/careless behavior, (c) disrespect of patient rights and human dignity, (d) … 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. The psychiatrist further stated that the patient was in the correct treatment setting. He believed that an alcohol and drug program was not appropriate for the patient, who needed psychiatric inpatient treatment. Nursing staff of many specialities are taking on and developing their roles in new and advanced practice areas. • Recommendations to ensure best practices and avoid legal issues are suggested. 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. On at least two occasions, he reported his findings and concerns to his supervisor, the patient’s psychiatrist and the facility co-owner. 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. Attempts were made to offer a reasonable settlement, but the plaintiff’s demands greatly exceeded the nurse practitioner’s policy limits. Specifically, Buchanan and Brock (1989 : 84–6) suggest that the whole issue hinges on: setting and applying accurately standards of competency to choose and decide; and. Nonetheless PADs have been touted as having the capacity to realise a number of benefits including: ‘decrease hospitalizations, reduce coercion in treatment, and improve relationships between consumers, families and clinicians’ ( Peto et al 2004 ; Sellars et al 2017 ; Zelle et al 2015a ), and destigmatising patients with mental illness on account of giving them the same rights to refuse psychiatric treatment as patients who wish to refuse general medical treatment ( Atkinson et al 2004 ). The growing role of psychiatric mental health nurse practitioners is discussed. This paradigm shift in mental health is challenging traditional evaluation criteria and conventional justifications for involuntary treatment. community treatment order (CTO) contexts) ( Corring et al 2017 ; Nagra et al 2016 ; Molodynski et al 2014 ). 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 . Nurses are highly accountable to patients, the public, employers, and the entire profession. 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. 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. #Nurse Practitioners acute psychiatry. Being a patient advocate and acting ethically is one of the foundations of nursing (Kalb & O’Connor-Von, 2007). The health care professional in turn could be judged, criticised and possibly even censured on grounds of having infringed the patient’s rights. 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. The growing role of psychiatric mental health nurse practitioners is discussed. The claim of a moral right usually entails that another person has a corresponding duty to respect that right. Moreover, despite the efforts of mental health consumer groups and other mental health advocates, people with mental health problems and psychosocial disabilities continue to experience the infringement of many of their basic human rights (including the right to mental health and to mental health care). These and like criteria remain problematic, however. The facility required full payment at the time of admission and asserted that it was capable of caring for and treating her multiple problems and symptoms. • FNPs should be aware of treating outside the scope of practice for mental illness. In the weeks following his discharge from hospital, John McEwan continued to express his wish to be allowed to die ( Social Development Committee 1987 : 310–11). In contrast, the correctional nurse may face ethical situations daily. 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). Certified Registered Nurse Anesthetists (CRNAs), Compensation and Other Disclosure Information. 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. As Dresser (1982 : 842) cautioned over three decades ago, if insufficiently informed persons enter into commitment contracts ‘only to please their psychiatrists, the contracts would become an avenue for the abuse of psychiatric paternalism, thus decreasing individual liberty’. achieving a balance between (i) protecting and promoting the patients’ wellbeing (human welfare), (ii) protecting and promoting the patients’ entitlement to and interest in exercising self-determining choices, and (iii) protecting others who could be harmed by patients exercising harm-causing choices. ethics. Enforced treatments in such cases may, however, compound their distress and make future treatment difficult, especially if the patient later feels (i.e. 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. Other barriers that have been identified include: concerns about the ‘legal and ethical issues relating to the liability for implementing or overriding (PAD) statements’. It is therefore important that nurses are equipped with the skills and knowledge to understand ethics within their practice. Meeting the insurance needs of nursing professionals for more than 40 years. 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 ). Health care professionals practice in an environment that is complex, with many regulations, laws and standards of practice. As Gibson (1976) pointed out in an early article on the subject, rationality cannot escape the influences of the social patterns and institutions around it and, for this reason, any value-neutral account of rationality is quite inadequate. Discharge orders included a home care referral for wound care and assessment of perceived changes in the patient’s mental status. 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. To date, however, the anticipated benefits of PADs have yet to be realised. Legal & Ethical Issues that Health Care Professionals Face. The program begins with nine, three-credit core courses that focus on specific roles of the advanced nurse in the healthcare system prior to transitioning into specialty courses specific to the track.. These providers are likely to be confronted with a variety of ethical issues as they balance quality care with their patients' rising cost concerns. ETHICAL ISSUES IN ADVANCED PRACTICE NURSING. Ethical issues are wide-ranging, from organ donation, genetic engineering, assisted suicide, withholding treatment in end-of-life care, or. There was no reason to suspect that John McEwan’s wishes were irrational. First, as discussed previously in Chapter 6 , people with mental illness are among the most stigmatised, discriminated against, marginalised, disadvantaged and hence vulnerable individuals in the world. The insured was not working on the day of the suicide attempt. #LegalCases Despite this reticence, the PAD is increasingly being regarded as an important instrument that enables respect of not only the patient’s wishes, but also their values (i.e. Patients will be offered new services from highly skilled advanced nurse practitioners. 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. Defense experts placed the value at $2.7 million. Post-verdict jury interviews included juror comments that the nurse practitioner should have notified the patient or her family that she should not have been admitted to an alcohol and drug treatment facility, or taken more aggressive steps to have her transferred to an appropriate setting. The nurse practitioner maintains accurate, legible, and confidential records. The patient was a 59-year old female who had undergone inpatient bilateral salpingo-oophorectomy three days before being discharged to home care. 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. 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). With regard to setting and applying accurately standards of competency to choose and decide, Buchanan and Brock suggest that, among other things, ethical professional decision-making in this problematic area should be guided by the following considerations (1989: 85): In other words, the extent to which an attending health care professional is bound morally to respect the choices of a person deemed ‘rationally incompetent’ depends primarily on the severity of the risks involved to the patient if her or his choices are permitted. Patients will be offered new services from highly skilled advanced nurse practitioners. Moreover, the nurse practitioner suffered emotional distress and anxiety from the entire matter and was eager to settle the claim without further legal action. The patient’s bill of rights calls for full disclosure of a medical error ( … mental disorders. 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. 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. In many instances, people with serious mental illnesses might not comply with, and might even refuse altogether to accept, recommended psychiatric treatment (e.g. 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). 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. A little over a year after his accident, and despite still being ventilator dependent, John McEwan was discharged home. 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. 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. Psychiatry is no exception. patient autonomy. In an early work on the subject, Roth and colleagues (1977) argue, however, that the concept of competency is not merely a psychiatric or medical concept, as some might assume, but is also fundamentally social and legal in nature. In a nutshell, a nurse must: To this end, the document addresses the following eight domains: Inherent dignity and equal protection – encompassing the right of all people to respect the human worth and dignity of people with mental illnesses, and to support people who are mentally ill or intellectually disabled to exercise their rights when their own capacity to do so is impaired. “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. In Australian, New Zealand and other common-law jurisdictions, legislative provisions also enable psychiatrists to override a person’s will and preferences and admit (‘commit’) them involuntarily to hospital for treatment, which, in effect, grants psychiatrists the authority to ‘act as substitute decision-makers, rather than as advisers and service providers’ ( McSherry 2012 : 1). The lack of conceptual clarity in this instance risks ‘pushing ethics to their limits’ – especially in cases ‘where patients have not reached out for help’ yet treatments are imposed without their informed consent ( Gustafsson et al 2014 : 176). The question remains, however, of how these things can be decided in a morally sound and just way. Health care professionals practice in an environment that is complex, with many regulations, laws and standards of practice. In this case, the more experienced staff outnumbered the less experienced staff, and the patient was held down and forcibly given an intramuscular injection of the medication he had refused. injuries sustained as a result of a road traffic accident, an acute appendicitis, complications of diabetes, renal failure, etc.). ETHICAL CODES FOR PSYCHIATRIC NURSE PRACTITIONERS Paul D. Friedman, M.A., Ph.D., J.D. It has long been recognised at a social, cultural and political level that people suffering from mental illnesses and other mental health-related problems need to have their moral interests as human beings protected from abuse and neglect, which, for a variety of reasons, are especially vulnerable to being violated. As the Mental Health Consumer Outcomes Task Force argued almost three decades ago (1991: ix): In March 1991, the Australian Health Ministers acknowledged and accepted the above viewpoint and adopted, as part of Australia’s national mental health strategy, the final report of the Mental Health Consumer Outcomes Task Force, titled Mental health statement of rights and responsibilities . Relevant state law imposed a limitation on noneconomic damage awards in medical malpractice claims for physicians (psychiatric) and limits attorney fees. 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. 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. Ethics is an important aspect of healthcare and is very common in theme in nursing (Beidler, 2005). A second consideration is that many people with mental illness have experienced high rates of trauma during their lifetime. moral/ethical issues encountered by a PMHNP essay example. In summary, the notion of ‘rational competency’ is problematic because there is no precise definition of, or agreement on, what it is. 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. Nurse practitioners because of their education and training, understand their … At first glance, the content and intent of the Mental health statement of rights and responsibilities (2012) seem to provide an important basis for the protection of the human rights of people made vulnerable by mental health problems. Attention will also be given to the vexed issue … While drawing primarily on the Australian experience, this discussion nonetheless has relevance for nurses working in other countries. Within his scope of practice, he was able to make a determination of mental illness. 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). 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’. Insufficient personnel, excessive workload, working conditions, lack of supervision, and in-service training were identified as leading to unethical behaviors. Practice/Business Coverage What else then should health care professionals do? The judgment amount could have been in excess of $4 million. 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). 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. the capacity to communicate the decision made (after Kerridge et al 2013 : 384–6). For many, the answer lies in the systematic development and formal adoption of psychiatric advance directives (PADs). [1,8] Ethical issues related to PMH nursing in the literature can be summarized as: obtaining informed consent from the patient; compulsory treatment and hospitalization; using seclusion and restraint; respect for patients’ privacy and confidentiality; and research in psychiatric medicine… In seeking to redress the implications of these considerations, mental health advocates have increasingly sought to emphasise and champion a suite of rights and responsibilities that are specific to the context of mental health care. 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. Just what such a framework would – or indeed should – look like is, however, a matter of some controversy. An involuntary psychiatric patient refuses to take the psychotropic medication he has been prescribed. 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). 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. Email: [email protected], 1100 Virginia Dr., Ste. Besides, they make decisions that lead to deterioration of a patient’s health instead of ensuring recovery. Australia, Austria, Germany, Canada, Switzerland, the Netherlands and the United Kingdom) have introduced or are working to introduce and uphold PADs or ‘psychiatric wills’ ( Amering et al 1999 ; Atkinson et al 2003 ; Varekamp 2004 ). 4 Thus, there is an ever-present risk that, when admitted to a psychiatric facility as an involuntary or non-voluntary patient, their institutional experiences may trigger previous trauma, provoke feelings of fear, anxiety and anger and thereby aggravate their psychiatric symptoms (a burden which others who do not have a history of trauma or mental illness do not carry) ( Cusack et al 2018 ; Goulet et al 2017 ; McKenna et al 2017 ). A number of objections can be raised here. Ethical issues happen when choices need to be made, the answers may not be clear and the options are not ideal. Since the publication of the foundational works by Grisso and Appelbaum (1998) and Appelbaum (2007) , a number of competency assessment tools have been developed 3 ( Wang S-B et al 2017 ). 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. Although ‘gold standard’ evidence is lacking, the authors of a 2009 Cochrane Database Systematic Review on ‘Advance treatment directives for people with severe mental illness’ nonetheless concluded that advance directives were ‘well suited to the mental health setting for the purpose of conveying patients’ treatment preferences should they become unable to articulate them in the future’ ( Campbell & Kisely 2009 : 10). Discuss critically the notions of ‘surrogate / substitute decision-making’ and ‘supported decision-making’ in the case of people deemed to be rationally incompetent. Situations involving the enforced medical treatment of the mentally ill can cause significant distress to caregivers as well who, while wanting to respect the preferences of their patients, may nevertheless recognise that, without treatment, patients in distress (and their families or supporters) will not be able to be consoled and, worse, may remain unnecessarily in a state of ‘psychiatric crisis’. This case study involves a nurse practitioner in an in-patient alcohol/drug treatment setting. Research conducted by the Council on Accreditation of Nurse Anesthesia Educational Programs (COA), (Cook, 2013) reports recent graduates of accredited certified registered nurse anesthetist This, in turn, will depend on the competence, experience, wisdom and moral integrity of the decision-makers, and the degree of commitment they have to: (1) ensuring the realisation of morally just outcomes and (2) protecting and promoting the wellbeing and moral interests of those made vulnerable not just by their mental illnesses, but also by the inability of their caregivers to respond to the manifestation of their illnesses in an informed, morally sensitive, humane, therapeutically effective and culturally appropriate way. • Recommendations to ensure best practices and avoid legal issues are suggested. This case study involves a nurse practitioner in an in-patient alcohol/drug treatment setting. 1). 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). 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 ). (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.). Insufficient personnel, excessive workload, working conditions, lack of supervision, and in-service training were identified as leading to unethical behaviors. In a 2013 systematic review of the literature on the subject, Nicaise and colleagues (2013) identified three main theoretical frameworks or rationales for PADs: improvement in the therapeutic alliance between the users and clinicians. This is so even in jurisdictions which have progressive legislative provisions enabling patients to determine in advance their ‘will and preferences’ apropos care, treatment and supported decision-making options ( Callaghan & Ryan 2016 ; Hem et al 2018 ; Molodynski et al 2014 ; Tingleff et al 2017 ). 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 struggling with ethical dilemmas. Legal & Ethical Issues that Health Care Professionals Face. She was treated with pain medication and antidepressants. Currently almost two-thirds of the states in the USA have legal processes in place for allowing and managing PADs (Zelle et al 2015b). Phone: 1-800-247-1500 Despite the expectations reflected in the stated purposes and theoretical frameworks of PADs, their overall acceptance and uptake remain patchy. This is especially likely in cases where involuntary or non-voluntary hospitalisation involves unconsented, coercive institutional procedures such as seclusion, restraints, forced medication and forced feeding ( Borckardt et al 2007 ; Cusack et al 2018 ). This chapter explores mental health nursing practice within an ethics context. 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… This article will examine some of the ethical and legal issues correctional nurses must address in their practice. 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. A patient could without contradiction ‘rationally’ choose suicide as a means of escaping an intolerable life characterised by suffering intractable and intolerable pain. The patient’s permanent condition dictates that she cannot be left alone and requires full-time assistance with all aspects of her personal care. Significantly the issue of competency rarely arises in contexts where the patient agrees with and consents to a doctor’s recommended or prescribed treatment. 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. Widdershoven and Berghmans (2001 : 92) explain that: Later works have consistently reaffirmed this view ( Ouliaris & Kealy-Bateman 2017 ; Sellars et al 2017 ; Zelle et al 2015a ). More patients are receiving healthcare services from nurse practitioners (NPs) and physician assistants (PAs). It teases out the ethical challenges that mental health nurses can face on a daily basis. Mental health statement of rights and responsibilities ( Australian Government Department of Health 2012 : 3)). The patient was a 52-year-old woman who had been admitted to a privately-owned alcohol and drug rehabilitation inpatient facility with diagnoses of long-term depression, fibromyalgia and chronic pain. 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. ETHICAL ISSUES IN ADVANCED PRACTICE NURSING. The nurse maintains competence in nursing. Defense counsel vigorously contended to the court that the nurse practitioner should be included within the statutory framework, as he was being supervised by a covered professional. The settlement monies with defense cost were greater than $1 million. 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 … Third, even when persons with mental illness later acknowledge the need for their earlier involuntary or non-voluntary admission to hospital, they are sometimes left feeling very dissatisfied with the situation – not least because they feel that their humanity and dignity have been violated in the process. 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’. 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 ). 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’. patient autonomy. 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. Psychiatric mental health nurse practitioners (PMHNPs) are assuming increasing clinical responsibilities in the treatment of individuals with mental illness as the shortage of psychiatrists and their maldistribution continues to persist in the United States. [emphasis original]. ethics. 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 ). Comparable studies conducted in Australia and New Zealand have had similar findings. discuss critically the ethics of suicide prevention, intervention and postvention. euthanasia), consider arguments both for and against the proposition that people have a ‘right to suicide’, examine critically the conditions under which a person’s decision to suicide may warrant respect. 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. As previously indicated in this section, an integral and controversial component of psychiatric practice is involuntary care and treatment. Ethical Codes for Psychiatric Nurse Practitioners [Compatibility Mode] 1. 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 American Psychiatric Nurses Association (APNA) is your resource for psychiatric-mental health nursing. 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. This test asks how well the patient has actually understood information which has been disclosed. known about the ethical conflicts and causes of these conflicts experienced by these clinicians in their daily practice. Ft. Washington, PA 19034. ECT), or ‘opting-in’ (consenting to services as well as to specific treatments) ( Atkinson et al 2003 ; Swartz et al 2006 ). Insufficient personnel, excessive workload, working conditions, lack of supervision, and in-service training were identified as leading to unethical behaviors. Violation of ethical principle and law. Background: More patients are receiving healthcare services from nurse practitioners (NPs) and physician assistants (PAs). Arguably the most profound change (described as an ‘evolving revolution’ by Callaghan and Ryan 2016 ) has occurred in Australian jurisdictions. 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. 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). It should be noted, however, that these two models are not necessarily mutually exclusive and indeed could, in some instances, be mutually supporting (a man contemplating a violent suicide involving others is a danger not only to himself but also to the innocent others he plans to ‘take with him’). 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. A patient-centred model of surrogate decision-making, in this instance, would have as its rationale preventing harm to patients , and would embrace an ethical framework which is structured ‘for deciding for patients for their benefit ’ ( Buchanan & Brock 1989 : 327, 331). A New Zealand survey of 110 mental health service users and 175 clinicians had similar findings ( Thom et al 2015 ). She survived the attempt, but suffered severe anoxia and permanent brain damage. Roth and colleagues (1977) suggest that competency tests proposed in the literature basically fall into five categories: The test of evidencing a choice is as it sounds, and is concerned only with whether a patient’s choice is ‘evident’; that is, whether it is present or absent . PMHNPs encounter such unethical dilemmas, since they compromise the legal rights of a patient (Annamalai, & Tek, 2015). 300 W. Clarendon, Suite 400 Phoenix, Arizona 85013-3424 (602) 252-8888 WWW.EXPERTETHICS.COM [email protected] 2. Of these, the MacArthur Competence Assessment Tools (MacCATs) developed and trialled by Appelbaum and Grisso ( Appelbaum & Grisso 1995 ; Grisso & Appelbaum 1995 ; Grisso et al 1995 , 1997 ) are generally regarded ‘as having the most reliability and validity for assessing competence related to functional abilities, and have been widely used in psychiatry’ ( Wang S-B et al 2017 : 56). 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). The scope of nursing has evolved from the early role of a nurse carrying out orders at a doctor’s bidding. The higher and more severe the risks involved, the higher and more rigorous should be the standards for determining the patient’s decision-making capacity, and the more certain attending health care professionals should be that the patient has met these standards. Early proponents of PADs in the US expected that their use would spread ( Appelbaum 1991 ). 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). It is imperative they have a sound understanding of various ethical, legal and professional issues they will face during their careers. Objective: To identify ethical concerns and conflicts NPs and PAs encounter related to managed care in the delivery of primary care to patients and the factors that influence ethical conflict. Psychiatric mental health nurse practitioners (PMHNPs) are assuming increasing clinical responsibilities in the treatment of individuals with mental illness as the shortage of psychiatrists and their maldistribution continues to persist in the United States. a. His requests for different and less drugs, and more counselling, went unheeded. Nursing staff of many specialities are taking on and developing their roles in new and advanced practice areas. 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 In regard to the consideration of being a danger to self, Buchanan and Brock (1989 : 317–31) correctly argue that what is needed are stringent criteria of what constitutes a danger to self ; in the case of the need for care and treatment, that what is needed are stringent criteria for ascertaining deterioration and distress ; and in the case of harm to others, that what is needed are stringent criteria of what constitutes a danger to others . In one US study, for example, although 66%–77% of consumer respondents stated they would like to complete a PAD if given the opportunity and assistance to do so, only 4%–13% had actually done so ( Swanson et al 2006b ). The patient (plaintiff) in this case was a 50-year-old male who first came to our insured nurse practitioner (NP) after researching his symptoms on the internet. #Malpractice Conclusions A proposal for a code of ethics for NPs is presented. The result could be declines in the quality of patient care; problematic clinical relationships; and moral distress, which is defined as knowing the right thing to do but not being allowed or able to do it. 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. Before his accident he had been a committed sportsman and for him the life of a helpless quadriplegic was intolerable. mental disorders. 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. 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). 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. Although barriers to the implementation of PADs persist, research has found that consumers continue to have a high interest in and demand for PADs. Also, although some studies have suggested that clinicians are broadly supportive of the ‘advance-consent’ function of PADs (termed ‘prescriptive function’), clinicians are more reticent about their ‘advance-refusal’ function (termed ‘proscriptive function’) – especially if used to refuse all future treatment ( Swartz et al 2006 ). Nurse practitioners (NPs) are licensed, independent practitioners who provide primary and/or specialty nursing and medical care in ambulatory, acute and long-term care settings. The moral force of the right’s claim in this instance is such that if an attending health care professional does not uphold or violates the patient’s decision in regard to the treatment options considered, that patient would probably feel wronged or that an injustice had been done. This chapter explores mental health nursing practice within an ethics context. Non-discrimination and social inclusion – encompassing the rights to: privacy and confidentiality; health, safety and welfare; equal opportunities to access and maintain health and mental health care, and other social goods; contribute to and participate in the development of social, health and mental health policy and services. 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. In response to the insured, the psychiatrist indicated that the patient’s diagnosis was his responsibility and he would manage her care. 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). 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.