Psychiatric

Health Law
and Ethics
NURN 215
 Psychiatric Health Law and Ethics

Laws governing
◦ Admission
◦ Voluntary
◦ Involuntary
◦ Discharge
◦ Ethical treatment of
psychiatric clients
◦ Self-advocacy for clients
and family members
 Current Admission Process

Emergency Department (ED)

Self
Family
Referral
AND/OR
Emergency Petition (EP)
Document filled out by witness
◦Gives police authority to take person to ED
◦At the ED: mental health evaluation
◦Admission not assured
◦Danger to self or others major factor
Voluntary Admission
Client agrees to admission
◦ Recognizes need for treatment
◦ Some insight
◦ More likely to actively participate in treatment
◦ May leave ED against medical advice (AMA), IF is not a danger to self or
others
Voluntary
Admission
During the 72-hour hold
Client may formally request discharge by submitting 3-day notice
Psychiatrist must be notified; treatment team will give input…decide whether
client is safe to discharge
May convince client to stay…remain voluntary
If client if found unsafe or danger to self or others status changed to involuntary
 Involuntary Admission
Certification Process
◦Requires 2 Medical Doctors or
◦1 Medical Doctor & 1PhD Psychologist or psychiatric nurse practionner

Must Be
•Dangerous to self and /OR
•Dangerous to others
–Unable to care for self (Not a Criteria in Maryland…developing)

–Must meet the 6 criteria for commitment

 Six Criteria
For commitment (in Maryland)
1. Person must have a mental disorder
2. Person must require inpatient treatment
3. Person is a danger to life or safety of self or others
4. Person is unable/unwilling to be admitted voluntarily
5. There is no other less restrictive SAFE treatment
6. If 65 or over, must be evaluated by Geriatric Evaluation Team for least restrictive
environment
Involuntary
“Certified” “Committed”
◦ Does NOT agree to hospitalization
◦ Does NOT think treatment is needed
◦ Often resistant to treatment
◦ Against the client’s will or wishes

Ethical issue: how can we treat without

client’s permission? How can we protect
individuals and society?
 Notice of Hearing (NOH)

Legal Document (6 copies)

◦Must give original to client within 12 hours
◦States Date of Hearing
◦Notifies client of date of hearing
◦Hearing MUST be held within 10 calendar days
◦Each hospital has a hearing one day/week
Nursing Responsibilities:
Ensure that all information on NOH is correct
Give NOH to client
May accompany client to hearing
 Hearing
Purpose: determine if client should remain in hospital against his/her will
◦ Judge present, is a legal proceeding on unit
◦ Sworn in for testimony
•Attendees
Administrative Law Judge –from the state of Maryland
Public Defender –Md. (goal is to release client)
Treatment Team Members
Family and/or friends
Client
 Outcomes of Hearing
Retained (dangerous to self/others)
May APPEAL (within 30 days) x 1
Another Hearing then scheduled

Released
NOT dangerous
Sometimes paperwork not done correctly
Public defender pleads and wins case
Client agrees to switch to voluntary status before hearing

Hearing cancelled
 IF retained as involuntary
May appeal within 30 days
Another hearing scheduled (NOH given)
Another decision made whether client is still involuntary, or may be released
If is retained as INVOLUNTARY 2nd time, now is on a more long-term Involuntary
Hospitalization
STILL can refuse medication throughout this whole process
Medicating a client against the client’s will
During an emergency, may give a one-time prn to reduce aggression
Scheduled medications may be refused by client, whether voluntary or involuntary
MUST HAVE ANOTHER HEARING
 MED Panel hearing
Given another NOH (notice of hearing)
At this hearing (must be declared involuntary first) will now determine whether client
will have forced medications
May also be appealed x 1
If so ruled, immediately after the hearing, client is given medication
◦ Often begins with IM
◦ Soon transitions to PO
Involuntary
Admission
 Insanity Defense
Not Criminally Responsible (NCR) or Not Guilty by reason of insanity (NGRI)
◦ Not Given a Defined Sentence
◦ Court Ordered Meds and Treatment
◦ Conditional Release

Legal meaning but no medical definition

Client is determined incompetent to stand trial due to mental illness

Person unable to control his or her actions or understand the difference between right and wrong at time of crime (M’Naghten Rule)

The public perception is that the person accused of the crime “gets off” and is free immediately.

Three states (Montana, Idaho, and Utah) that do not allow the insanity defense
Whether Admitted as a voluntary or involuntary
admission

Client brought to Inpatient Unit

Belongings searched

Admission completed

Admission orders obtained

At first, on Close Observations or 15-minute checks

Client rights during psychiatric
hospitalization
◦ Receive telephone calls
◦ Phone specifically for client use only
◦ Visitors –
◦ during published visiting hours (unless disruptive)
◦ Vote
◦ Receive and send mail (unopened)
◦ Clergy
◦ Lawyer
◦ Interpreter
◦ Client Representative/Advocate
 Client’s Rights in Hospital
•Treatment Rights
◦Treated at Appropriate Level of Care
◦Least Restrictive Environment
◦Participate in the Treatment Planning
◦Give their Informed Consent
◦Know their Diagnosis
Right to Treatment O’Connor v. Donaldson 1975

Must be ACTIVE treatment, not custodial

 Client’s Treatment Rights
Confidentiality (HIPAA) within the treatment
team
Release of Information ONLY with client’s
permission
No photographs
VERY IMPORTANT!!!!!
Exception to
confidentiality
Duty to warn (Tarasoff v.
Regents of U.Cal. 1976)
◦ Client makes a threat
against specific person(s),
treatment team must
notify person(s)
Client rights:
Minors
For children and adolescents,
parents or guardian must give
permission for treatment
◦ For medications
◦ For ECT
◦ For hospitalization

Exception: emancipated
minors
 Competency

Competent: able to make informed decisions

To be declared incompetent, two doctors must evaluate that incompetency exists.

◦ Incompetent is a legal term indicating that a client is unable to “manage his/her own affairs
◦ Can no longer enter into legal contracts, vote or drive

If incompetent, a guardian decision-maker must be appointed

VERY RARE for clients to be declared incompetent unless

◦ Mental retardation
◦ Brain damage
◦ Dementia
Temporarily….Under influence of anesthesia, sedation
 Nursing Interventions
Based on right to least restrictive environment
◦ Help person regain behavior control
◦ When client is dangerous to self or others
◦ When clients’ behaviors are disruptive to the milieu
All interventions require MD orders
◦ Zoning
◦ Be in Staff Eye-Sight
◦ One to One
◦ Close observations
◦ Chemical restraints (medications)
 Physical/Mechanical Restraints
Rarely used in psychiatric units) (primarily when harmful
to self
◦Out of restraints q2 hours
◦Offered hydration, food, restroom
◦Range of motion (ROM), skin check
◦Types
◦Mittens
◦Wrist/Legs (2-point, 4-point)
◦Geri-chair
◦Papoose
 Seclusion

Try to use alternatives first IF POSSIBLE

Only when imminently harmful to others
◦Physician Order after seclusion
◦PRN medications given
◦Short Duration (no more than 4 hours)
◦Monitored continually for first hour
◦Monitored q 15 minutes after
◦Nothing in room except mattress on floor
◦Window in door and camera

◦Potentially very dangerous

◦Completely INAPPROPRIATE for suicidal clients
Involuntary Outpatient commitment
Usually requires proof of mental illness and dangerousness

Not available in all states (not in Md.)

Issue debated
◦ Need to protect society
◦ Individual rights

Often used after mentally ill offenders are released from jail
Psychiatric Advance Directives
“PAD”

Legal document

Able to indicate preferences for mental health care

Register refusal of certain psychiatric interventions…i.e. specific medication

Appoints a surrogate decision maker, give consent on behalf of client

Liability in Psychiatric Nursing
Civil law
Tort is a civil wrong made against person or property
Can be intentional or unintentional
Intentional
◦ Assault
◦ Battery

◦ False imprisonment

Unintentional
◦ Negligence
 Civil torts : Intentional
Assault is the intentional threat to bring about harmful or offensive
contact. No actual contact is necessary
Battery intentional touching without consent, which may cause
injury
False imprisonment

So, a nurse who threatens a client or gives treatment without

consent can be charged with what?
Unintentional Torts
Negligence is conduct that falls below the standards of care

Examples of negligence include:

◦ Medication and IV errors that result in injury
◦ Malpractice
Preventing Liability
 Ethical Principles

Autonomy” independence and the ability to be self directed”

◦ Clients' choices available
◦ Involuntary commitment and forced medication must be absolutely justified to
protect client
◦ Informed consent & ability to understand

Beneficence: promote good, second prevent harm , and third remove evil or harm
Non-maleficence
◦ Is the treatment causing more harm than good? Weigh the risks /benefits
Ethical Principles continued
Justice
◦ Fair and equal treatment
◦ What about the uninsured?

Fidelity
◦ Faithful to your promises

Veracity
◦ Be truthful
◦ Maintains trust
◦ Shows respect for client

Confidentiality
Stigma and ethics
Clients are not a DIAGNOSIS

Diagnosis is not absolute

Nursing diagnoses focus more on symptoms and needs

Psychiatric nurses have for years tailored interventions to symptoms

Diagnosis in Psychiatry is inexact, and changes

Confidentiality and ethics
Nurses must maintain confidentiality at a very high level in psychiatric/mental health settings

DO NOT EVER talk about the clients’ names, experiences, jobs, crimes, or any other identifying
information with anyone other than your clinical instructor, course instructor or the treatment
team

This includes friends, significant others, and family

Confidentiality standards are to prevent discrimination and stigma

Standards of Care
ANA Code of Ethics for Nurses :
◦ practice with compassion and respect, primary commitment is to the client, promotes nurses to be
advocates to protect health, safety, and rights of the client. Nurses are to be responsible and
accountable, collaborate with other health care professionals, and maintain competence in their field
of practice

ANA Standards of Professional Performance