LEGAL & ETHICAL ISSUES

IN PSYCHIATRIC NURSING

Dr. Rubilyn A. Bulquerin-Sumaylo

RN, MSN, LPT
INTRODUCTION
• Nurses are constantly
faced with the
challenge of making
difficult decisions
regarding good and
evil or life and death.

• Nurses must know the

legal and ethical
issues regarding care
of the mentally ill.
 RIGHTS OF MENTALLY ILL
• RIGHT TO TREATMENT
• How treatment must be given
– By adequate staff
– In least restrictive setting
– In privacy
– In facility that provides comfortable
bed, adequate diet, and recreational
facilities
– With patient's informed consent
before unusual treatment
– With payment for work done in
facility, outside of program activities
– According to individual treatment
plan
 Nurses have a duty to ensure that
the patient knows what treatment
he needs and how he'll get it, to help
prepare him for eventual discharge.
 RIGHTS OF MENTALLY ILL
• RIGHT TO REFUSE TREATMENT
– A patient can't be kept in a hospital against
his will, nor can he be denied the right to
refuse treatment.
– CRITERIA FOR COURT-ORDERED
TREATMENT
• Need has been clearly established
• Patient poses danger to himself or others
• Physician and treatment team demonstrate need
for continued inpatient treatment
 RIGHTS OF MENTALLY ILL
• RIGHT OF MINORS
– legal responsibility must be established
immediately (Parent)
– CONSERVATORSHIP

• RIGHT TO INFORMED CONSENT

– Admitting provider's responsibility
– The nurse should refuse to participate in
procedures for which informed consent
hasn't been obtained.
 RIGHTS OF MENTALLY ILL
• RIGHT TO PRIVACY
– CIRCUMSTANCES FOR DISCLOSURE OF
CONFIDENTIAL INFROMATION
• Suspected drug abuse
• Criminal cases
• Government requests
• When public has a right to know
• Is patient is imminent risk to himself or others
 Duty to Warn Third Parties
• Is the client dangerous
to others?
• Is the danger the result
of mental illness?
• Is the danger serious?
• Are the means to carry
out the threat available?
• Is the danger targeted
at identifiable victims?
• Is the victim accessible?
 RIGHTS OF MENTALLY ILL
• REPRODUCTIVE AND SEXUAL RIGHTS
– Right to marry
– Right to have children
– Right to use contraception or sterilization,
if desired
– Right to follow lifestyle of their own
choosing
 TYPES OF ADMISSION
• Voluntary Admission
The client willingly enters and consents to
treatment.
Clients retain all of their civil rights and may
discontinue treatment whenever they choose.
If the treatment team disagrees with a
client’s decision treatment, the client signs a
form acknowledging that he has been
discharged AMA, or the treatment team may
decide to seek involuntary commitment of the
client.
• Involuntary Inpatient Commitment
The client is institutionalized against
his will.
Conditions:
a. Those who pose a threat to self or
others.
b. Those who lack the capacity for
meeting basic needs
c. Those who are seriously mentally ill
but fail to seek treatment.
• Involuntary/Mandatory Outpatient
Treatment
Involves treatment mandated by a
court order.
This option has been used as
DEINSTITUTIONALIZATION has
progressed.
Conditions:
a. Substance-impaired individuals
b. Homeless mentally ill persons
c. Sex offenders
 KEY LEGAL CONCEPTS
• CONFIDENTIALITY
Client information is considered
privileged.

• INFORMED CONSENT
Ensures that he received adequate
information about his care and treatment
prior to his consenting to treatment.
• RIGHT TO REFUSE TREATMENT
All clients (including those committed
involuntarily)
In emergency situations, a client can be
given medication or confined by
seclusion or restraints.
• CLIENT INCOMPETENCE
The inability to legally make decisions
regarding one’s health care, finance, and
property.
A legal guardian is appointed by the
court to make decisions for him.
• SECLUSION & RESTRAINT
Methods of preventing a client from
harming himself or others during a violent
outburst
Both methods are regulated by specific
legal and ethical guidelines.

*** The guiding principle of managing client

acting-out behavior is the use of LEAST
RESTRICTIVE MEASURES.
CRITERIA FOR USING RESTRAINTS
✔ Examination of patient
by physician to
determine need
✔ Written physician's
order that's placed in
patient's medical
record before
restraints are applied
✔ Application of
restraints for specified
duration
Nursing Implications
• Monitored 1:1 for the first
hour
• Monitors & documents the
client's skin condition, blood
circulation in hands & feet,
and emotional well-being
• Monitors for side-effects of
medications
• Implements & documents
offers of food, fluids, and also
opportunities to use the
bathroom
 LEAST RESTRICTIVE
MEASURES
• The nurse attempts to calm the client before
advancing to interventions that require
seclusion or restraint.
• LIMIT SETTING, VERBAL
INTERVENTIONS, OFFERING
MEDICATIONS.
• When initial measures fail or are
inappropriate  client may be involuntarily
confined (secluded) in a room/area to
prevent him from physically leaving.
 M'Naghten Rule
(Defense of Insanity)
• The person accused of the
crime is NOT GUILTY
because the person cannot
control his/her actions or
cannot understand the
wrongfulness of the act.
• Used only 0.9% (9 in 1000)
of all criminal cases and is
successful in 20% of those
cases.
 ETHICAL PRINCIPLES
• AUTONOMY
• BENEFICIENCE
• NONMALIFICIENCE
• VERACITY
• CONFIDENTIALITY
• JUSTICE
• FIDELITY
• AUTONOMY
The client’s freedom to make choices about
his life.
E.g. Making decision for himself
• BENEFICIENCE
Acting in ways that benefit the client.
“To do the most good for the patient”
E.g. Resuscitating a drowning victim
• NONMALIFICIENCE
Acting in manner to avoid causing harm to
the client. “Do no harm”
E.g. avoiding negligent care of a patient
• CONFIDENTIALITY
Nondisclosure of information with which
one is entrusted.
• JUSTICE
Acting out in a fair, equitable, and
appropriate manner.
• FIDELITY
Faithfulness and the practice of keeping
promises.
• VERACITY
nurses must not withhold the whole
truth from clients even when it may lead
to patient distress
 ASSIGNMENT
Look for:
•Case on Confidentiality in Mental Health
•Case on Legal Issues in Mental Health