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’. 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 ). Ft. Washington, PA 19034. 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 ). ETHICAL CODES FOR PSYCHIATRIC NURSE PRACTITIONERS Paul D. Friedman, M.A., Ph.D., J.D. 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. ETHICAL ISSUES IN ADVANCED PRACTICE NURSING. 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. 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 … 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. Since first being proposed in the early 1980s, PADs have evolved and tend to take one or both of the following two forms, notably: an instructional directive ‘that provides specific information about a patient’s treatment preferences’. As a result of the defense’s counsel’s strategy, the claim was resolved. Examine the notions of competency and its implications for persons with impaired decision-making capacity. The more experienced staff members in this case insist that the patient should be given his medication forcibly by intramuscular injection. 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. In relation to these criteria, he goes on to clarify that the patient’s task in consent situations is to: clearly indicate their preferred treatment options; grasp the fundamental meaning of the information being communicated by their attending doctor (apropos the nature of patient’s condition, nature and purpose of proposed treatment, possible benefits and risks of that treatment, and alternative approaches (including no treatment) and their benefits and risks); acknowledge (have insight into) their medical condition and likely consequences of the treatment option available (noting that ‘delusions or pathologic levels of distortion or denial are the most common causes of impairment’); engage in a rational process of manipulating [sic] the relevant information (this criterion focuses on the process by which a decision is reached, not the outcome of the patient’s choice, since patients have the right to make ‘unreasonable’ choices). Ethical issues are wide-ranging, from organ donation, genetic engineering, assisted suicide, withholding treatment in end-of-life care, or. 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.. Ethical decision making concerning in nursing practice environment. The patient was a 59-year old female who had undergone inpatient bilateral salpingo-oophorectomy three days before being discharged to home care. Findings: The results indicated that nurses needed additional education in psychiatric ethics. The judgment amount could have been in excess of $4 million. “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. 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). • Liability risks for psychiatric mental health nurse practitioners are reviewed. 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). with patients. In attempting to secure protection of the rights of the mentally ill from abuse and neglect, a human rights model of mental health care ethics has been adopted. 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. The health care professional in turn could be judged, criticised and possibly even censured on grounds of having infringed the patient’s rights. It also has obvious relevance for people admitted to mental health care facilities for psychiatric care and treatment. Students in the Advanced Clinical Nursing class that I taught were assigned to write a paradigm case--a story that reflected an ethical dilemma that they had experienced in their clinical practice. The nurse maintains competence in nursing. Criteria stipulated in other jurisdictions are reflective of these original proposals. iThese d… In response to the insured, the psychiatrist indicated that the patient’s diagnosis was his responsibility and he would manage her care. Insufficient personnel, excessive workload, working conditions, lack of supervision, and in-service training were identified as leading to unethical behaviors. 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. 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. These and like criteria remain problematic, however. 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). This case study involves a nurse practitioner in an in-patient alcohol/drug treatment setting. VI. In other words, competence is always ‘task specific’ and determining or measuring competence is thus always ‘context dependent’. The American Psychiatric Nurses Association (APNA) is your resource for psychiatric-mental health nursing. 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 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. Given this, determining competence in health care contexts fundamentally involves determining a person’s ability to make particular choices and decisions under particular conditions ( Buchanan & Brock 1989 : 311–65; see also Light et al 2016 )). 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. 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? Significantly the issue of competency rarely arises in contexts where the patient agrees with and consents to a doctor’s recommended or prescribed treatment. This case study involves a nurse practitioner in an in-patient alcohol/drug treatment setting. 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. Research conducted by the Council on Accreditation of Nurse Anesthesia Educational Programs (COA), (Cook, 2013) reports recent graduates of accredited certified registered nurse anesthetist the lack of capacity of ‘the system’ to organise therapeutic alliances and care around service user preferences ( Nicaise et al 2013 : 2). It is therefore important that nurses are equipped with the skills and knowledge to understand ethics within their practice. Conclusions A proposal for a code of ethics for NPs is presented. 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. patient autonomy. 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. 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. 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. 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). Master’s, post-master’s or doctoral preparation is required for entry-level practice (AANP, 2006). Nursing staff of many specialities are taking on and developing their roles in new and advanced practice areas. #Best Practices 300 W. Clarendon, Suite 400 Phoenix, Arizona 85013-3424 (602) 252-8888 WWW.EXPERTETHICS.COM pfriedman@expertethics.com 2. Attention will also be given to the vexed issue of the ethics of suicide prevention, suicide intervention and suicide postvention. Depending on the state, FNPs could face legal implications for prescribing to family and friends. He further clarifies that the doctor’s commensurate task in consent situations is to: ask the patient to indicate a treatment choice; encourage the patient to paraphrase disclosed information regarding their medical condition and treatment options; ask the patient to describe their views of medical conditions, proposed treatment and likely outcomes; ask the patient to compare treatment options and consequences and to offer reasons for selection of the option chosen. One reason for this is the systemic barriers to their use including a ‘lack of resources deployed to assist patients in preparing PADs (unless assistance is provided, completion rates for PADs tend to be low), and a lack of “buy-in” and acceptance of PADs by clinicians’ ( Swanson et al 2007 : 78). 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. 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. 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 ). 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. 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. 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. Ethical decision making concerning in nursing practice environment. The American Psychiatric Nurses Association (APNA) is your resource for psychiatric-mental health nursing. mental disorders. “Nurse Practitioner Perspective on Education and Post- Graduate Training,” and believes the principles espoused in that document apply to all APRN roles. 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. 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 ). 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. More patients are receiving healthcare services from nurse practitioners (NPs) and physician assistants (PAs). Ethical issues happen when choices need to be made, the answers may not be clear and the options are not ideal. 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’s permanent condition dictates that she cannot be left alone and requires full-time assistance with all aspects of her personal care. 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. This article will examine some of the ethical and legal issues correctional nurses must address in their practice. 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. 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. 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. Nurses are guided by a code of ethics that provide them with the basis to make ethical decisions. 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. Ethical Concerns For the nurse in a traditional medical setting, ethical decisions occur occasionally and at times the nurse may face ethical dilemmas. #Malpractice 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. 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. While drawing primarily on the Australian experience, this discussion nonetheless has relevance for nurses working in other countries. PMHNPs encounter such unethical dilemmas, since they compromise the legal rights of a patient (Annamalai, & Tek, 2015). 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 ). Ethics regards standards of moral judgement and professional conduct. moral/ethical issues encountered by a PMHNP essay example. 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. 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. 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. This case study involves a nurse practitioner in an in-patient alcohol/drug treatment setting. 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. In contrast, the correctional nurse may face ethical situations daily. Coercive measures commonly used in mental health care contexts have been classified as basically involving four types: ‘seclusion, mechanical constraint, physical restraint / holding, and forced medication’ ( Krieger et al 2018 ; Tingleff et al 2017 ); these can be imposed in either institutional or community health care settings (e.g. 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. Individual Coverage Insufficient personnel, excessive workload, working conditions, lack of supervision, and in-service training were identified as leading to unethical behaviors. Psychiatry is no exception. Such nurses need guidance direction and information to assist them in their new roles. 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. John McEwan, a former Australian water-skiing champion, was left a ventilator-dependent quadriplegic after a diving accident at Echuca, Victoria. Findings: The results indicated that nurses needed additional education in psychiatric ethics. 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. #Patient Safety. 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 ). The claim of a moral right usually entails that another person has a corresponding duty to respect that right. 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. 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. Such nurses need guidance direction and information to assist them in their new roles. This annual award was established in 2019 in recognition of … 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). This chapter explores mental health nursing practice within an ethics context. Identify eight domains deemed relevant to the rights and responsibilities of both users and providers of mental health care services. The MSN Psychiatric Mental Health Nurse Practitioner track includes 18 courses totaling 45 credit hours. It teases out the ethical challenges that mental health nurses can face on a daily basis. 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. integrations of care through health providers working in partnership with clients and families. Being a patient advocate and acting ethically is one of the foundations of nursing (Kalb & O’Connor-Von, 2007). She further suggested that, at most, rationality should be regarded as a value , rather than a property that all ‘normal’ people have ( Gibson 1976 : 193). The problem also may arise of patients perceiving a risk as a benefit. Certified Registered Nurse Anesthetists (CRNAs), Compensation and Other Disclosure Information. 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 nurse practitioner is a responsible advocate for patient welfare and upholds ethical and legal standards. Health care professionals practice in an environment that is complex, with many regulations, laws and standards of practice. 4 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. 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 ). The scope of nursing has evolved from the early role of a nurse carrying out orders at a doctor’s bidding. For many, the answer lies in the systematic development and formal adoption of psychiatric advance directives (PADs). It is to providing a brief overview of PADs – their origin, their rationale, their basic function, the perceived risks and benefits of adopting them, and the possible enablers and disablers to their uptake – that this discussion now turns. The scope of nursing has evolved from the early role of a nurse carrying out orders at a doctor’s bidding. 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’. 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’. 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 … Just what such a framework would – or indeed should – look like is, however, a matter of some controversy. 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 ). “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. A patient could without contradiction ‘rationally’ choose suicide as a means of escaping an intolerable life characterised by suffering intractable and intolerable pain. 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. 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 ). For example, in Australian jurisdictions, ascertaining whether a patient has the capacity to make informed decisions requires that the following processes be examined and shown: the comprehension and retention of information about the treatment, the capacity to formulate a reasonable belief about the information that has been given, the capacity to weigh up that information in the balance so as to arrive at a prudent choice. known about the ethical conflicts and causes of these conflicts experienced by these clinicians in their daily practice. • Scope of practice shapes what FNPs can do when diagnosing/treating mental illness. ETHICAL CODES FOR PSYCHIATRIC NURSE PRACTITIONERS Paul D. Friedman, M.A., Ph.D., J.D. Responsibility as Patient Advocate . 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). [1,8] 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 … mental disorders. 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. 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 ). Like Gert and colleagues (1997) , cited earlier, they argue that statements of competence (i.e. 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. 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… Relevant state law imposed a limitation on noneconomic damage awards in medical malpractice claims for physicians (psychiatric) and limits attorney fees. Attention will also be given to the vexed issue … 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’. patient autonomy. 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 ). 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). 4 they help to remind all stakeholders (patients / consumers, service providers, caregivers and the community at large) that their relationships with each other are ethically constrained and are bound by certain correlative duties. What else then should health care professionals do? There was no reason to suspect that John McEwan’s wishes were irrational. 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 . This annual award was established in 2019 in recognition of … 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 . Ethical Codes for Psychiatric Nurse Practitioners [Compatibility Mode] 1. The quality of the patient’s choice in this instance is irrelevant. The nurse maintains competence in nursing. 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). discuss critically the ethics of suicide prevention, intervention and postvention. in regard to what is important in life). Subsequent literature published on the subject (too numerous to cite here) has reaffirmed these findings (to be discussed further under the following sections on anticipated risks and benefits of PADs). On at least two occasions, he reported his findings and concerns to his supervisor, the patient’s psychiatrist and the facility co-owner. oral or intramuscular psychotropic medication, or electroconvulsive therapy). These providers are likely to be confronted with a variety of ethical issues … 3 An estimated 77 percent of U. S. counties are reporting a significant shortage of professionals who can prescribe and manage medications. 8.1 . The test of choice based on ‘rational’ reasons is a little more difficult to apply. instruments provided for by this legislation can only be used to refuse rather than to give consent to treatment) ( Meredith 2005 : 9; Swartz et al 2006 ). One response is to insist on the development of reliable (research-based) criteria for deciding these sorts of problematic issues. Email: customer.service@nsocover.com, 1100 Virginia Dr., Ste. during a moment of restored competency to decide) that the fiduciary nature of the professional–client relationship has been violated. These views have been underscored in an insightful essay by Stier (2013) who explores the fundamentally normative nature generally of assessing, diagnosing and treating mental illness – including determining whether something is a mental illness (which relies on normative judgments about ‘normal’ versus ‘deviant’ behaviour), irrational (which includes judgments about ‘impaired reality testing’), or harmful and distressing (which relies on value-laden judgments about whether something is ‘bad and dysfunctional’). 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. 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. The nurse practitioner maintains accurate, legible, and confidential records. 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. Appelbaum likewise asserts that when a patient’s decisions are of a life-and-death nature a ‘relative high level performance with respect to the relevant criteria should be required’ ( Appelbaum 2007 : 1838). #Nurse Practitioners 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. 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. 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. 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 . Patients will be offered new services from highly skilled advanced nurse practitioners. 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). acute psychiatry. “Nurse Practitioner Perspective on Education and Post- Graduate Training,” and believes the principles espoused in that document apply to all APRN roles. 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). This can be established by asking patients probing questions and inviting them to reiterate the information they have received. Findings: The results indicated that nurses needed additional education in psychiatric ethics. 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. 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. 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. In the UK, for example, the passage through parliament of the Mental Capacity Bill 2004 (which was given Royal Assent in 2005, and came into force in 2007) authorises a limited form of PADs (i.e. However, this law did not extend to nurse practitioners. 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. Phone: 215-660-0241 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. This paradigm shift in mental health is challenging traditional evaluation criteria and conventional justifications for involuntary treatment. 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. The changes that are occurring are not merely cosmetic and reflect a substantive move away from models of clinical decision-making based on determinations of ‘best interests’ and ‘harm minimisation’ (and which have tended to be over-reliant on assessment of capacity and rational competency) towards a model of ‘supported decision-making’ (SDM). 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. Victoria), patient preferences can still be overridden under defined circumstances ( Callaghan & Ryan 2016 ; Maylea & Ryan 2017 ). 3 An estimated 77 percent of U. S. counties are reporting a significant shortage of professionals who can prescribe and manage medications. In a nutshell, a nurse must: • Recommendations to ensure best practices and avoid legal issues are suggested. The fifth and final competency test is that of actual understanding . Findings: The results indicated that nurses needed additional education in psychiatric ethics. More patients are receiving healthcare services from nurse practitioners (NPs) and physician assistants (PAs). Practice/Business Coverage At the time of discovery he was disconnected from his ventilator. Basically, it asks whether a given choice is the product of ‘mental illness’ or whether it is the product of prudent and critically reflective deliberation. Violation of ethical principle and law. Further, although PAD instruments should not ‘replace deliberation about possible future changes in the patients’ condition’ ( Widdershoven & Berghmans 2001 : 93), they are nonetheless seen as having an important role to play in eliciting and guiding communication about such matters (see also Spellecy 2003 ). The question remains, however, of how these things can be decided in a morally sound and just way. At four o’clock in the morning on 3 April 1986, John McEwan was found dead by his nursing attendant. 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. discuss critically the possible risks and benefits of psychiatric advance directives. 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’. a. This test asks how well the patient has actually understood information which has been disclosed. Being a patient advocate and acting ethically is one of the foundations of nursing (Kalb & O’Connor-Von, 2007). Nurses are highly accountable to patients, the public, employers, and the entire profession. 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). The plaintiff sought economic, noneconomic and punitive damages, as well as plaintiff’s attorney fees. 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. 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. 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 is therefore important that nurses are equipped with the skills and knowledge to understand ethics within their practice. 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. In summary, the notion of ‘rational competency’ is problematic because there is no precise definition of, or agreement on, what it is. Family nurse practitioners (FNPs) often are the first to see patients with mental health issues. 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. 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). 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 insured was not working on the day of the suicide attempt. ECT), or ‘opting-in’ (consenting to services as well as to specific treatments) ( Atkinson et al 2003 ; Swartz et al 2006 ). [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… Comparable studies conducted in Australia and New Zealand have had similar findings. Besides, they make decisions that lead to deterioration of a patient’s health instead of ensuring recovery. 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. ethics. 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 … Counsel determined that there were several appealable matters related to the trial and the judge’s rulings. Although barriers to the implementation of PADs persist, research has found that consumers continue to have a high interest in and demand for PADs. 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. The nurse assumes responsibility and accountability for individual nursing judgements and actions. The MSN Psychiatric Mental Health Nurse Practitioner track includes 18 courses totaling 45 credit hours. [emphasis original]. Health care professionals practice in an environment that is complex, with many regulations, laws and standards of practice. 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. In such instances, because of the psychiatric imperatives to treat their conditions (particularly if extremely distressed and ‘out of control’), the mentally ill are vulnerable to having medical treatments paternalistically imposed on them against their will. Legal & Ethical Issues that Health Care Professionals Face. Meeting the insurance needs of nursing professionals for more than 40 years. Defense experts placed the value at $2.7 million. Background: More patients are receiving healthcare services from nurse practitioners (NPs) and physician assistants (PAs). 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 nurse practitioner assessed the patient shortly after her admission. A second consideration is that many people with mental illness have experienced high rates of trauma during their lifetime. When told of this risk she replied, happily: ‘I hope I am the one!’. The settlement monies with defense cost were greater than $1 million. The round-the-clock day care he required was given by family members and friends who had received special training in how to care for him. 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’. Variously named ‘psychiatric wills’, ‘self-binding directives’ (SBDs), ‘advance directives’, ‘advance statements’, ‘advance agreements’, ‘advance instructions’, ‘crisis cards’ and ‘Ulysses contracts’, the idea of notifying treatment preferences in advance, or making a ‘psychiatric will’ (a term that is analogous to ‘living wills’), is credited with originating in the work of the eminent American psychiatrist, Thomas Szasz (1982) , and the identified need for psychiatric patients to have an instrument that enabled them to refuse unwanted treatment. Psychiatry is … There are three primary duties for nurses, among many others, which are the duty of autonomy, confidentiality, and duty of care to all patients. 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 . 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. 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). 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 … 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 cessation of medication, remaining out of hospital and not being the subject of an involuntary admission to a psychiatric facility) ( Sellars et al 2017 ). • Recommendations to ensure best practices and avoid legal issues are suggested. This framework is expressed diagrammatically in Fig. The growing role of psychiatric mental health nurse practitioners is discussed. 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. 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. 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. Within his scope of practice, he was able to make a determination of mental illness. In the case of suicide risk, the grounds for not honouring a patient’s decision do seem at least prima facie stronger than possible grounds for overriding the decision of a patient who is only moderately depressed. 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. 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. Consider, for example, the following case (personal communication). 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