The inability to get ‘quick determinations’ of illness and competency – and hence healing treatment – has also been identified as a risk that could serve ultimately to undermine the effectiveness of PADs ( Cuca 1993 : 1178; see also Nicaise et al 2013 ). One response is to insist on the development of reliable (research-based) criteria for deciding these sorts of problematic issues. Like Gert and colleagues (1997) , cited earlier, they argue that statements of competence (i.e. As Gert and colleagues (p 132) go on to explain, we need to appreciate that persons as such are ‘not globally “competent” but rather “competent to do X”, where X is some specific physical or mental task’. Healthcare providers have an ethical obligation to disclose information that patients need for informed decision making. The main purpose of providing this information and alerting service providers to their preferred options is to ensure the continuity of their care, although research demonstrating this purpose remains inconclusive. 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 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. 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. • Scope of practice shapes what FNPs can do when diagnosing/treating mental illness. 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). 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 … PMHNPs encounter such unethical dilemmas, since they compromise the legal rights of a patient (Annamalai, & Tek, 2015). 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). These providers are likely to be confronted with a variety of ethical issues as they balance quality care with their patients' rising cost concerns. John McEwan, a former Australian water-skiing champion, was left a ventilator-dependent quadriplegic after a diving accident at Echuca, Victoria. “Nurse Practitioner Perspective on Education and Post- Graduate Training,” and believes the principles espoused in that document apply to all APRN roles. 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 ). This chapter explores mental health nursing practice within an ethics context. 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. Findings: The results indicated that nurses needed additional education in psychiatric ethics. There was no reason to suspect that John McEwan’s wishes were irrational. 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 ). On at least two occasions, he reported his findings and concerns to his supervisor, the patient’s psychiatrist and the facility co-owner. In summary, the notion of ‘rational competency’ is problematic because there is no precise definition of, or agreement on, what it is. Performing an abortion is legal but may not be considered ethical by other health care professionals or … ECT), or ‘opting-in’ (consenting to services as well as to specific treatments) ( Atkinson et al 2003 ; Swartz et al 2006 ). Psychiatry is … The MSN Psychiatric Mental Health Nurse Practitioner track includes 18 courses totaling 45 credit hours. Besides, they make decisions that lead to deterioration of a patient’s health instead of ensuring recovery. First published in 1991, with a 2012 revised edition of the statement launched in early 2013, this document stands as an influential guide for other public policy initiatives and statements such as the National mental health policy (released in 2008 and committed to by all Australian governments), and successive national mental health plans (including the most recent Fifth national mental health and suicide prevention plan released in 2017 , the National standards for mental health services 2010 and the National carer strategy in 2011 ( Australian Government Department of Health 2010 , 2011 , 2017 ) and other documents (e.g. ETHICAL CODES FOR PSYCHIATRIC NURSE PRACTITIONERS Paul D. Friedman, M.A., Ph.D., J.D. 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 . 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). 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. There are three primary duties for nurses, among many others, which are the duty of autonomy, confidentiality, and duty of care to all patients. discuss critically the ethics of suicide prevention, intervention and postvention. 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. For example, contrary to popular medical opinion, there is nothing to suggest that a person’s decision to suicide is always the product of mental disease or depression. 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 ). 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. 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. Nurses are highly accountable to patients, the public, employers, and the entire profession. 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. 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. 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 ). 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. 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 growing role of psychiatric mental health nurse practitioners is discussed. Responsibility as Patient Advocate . integrations of care through health providers working in partnership with clients and families. 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. 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. ethics. The nurse practitioner is a responsible advocate for patient welfare and upholds ethical and legal standards. 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 … 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 . It is therefore important that nurses are equipped with the skills and knowledge to understand ethics within their practice. However, in compliance with the provisions contained in the CRPD, there is now recognition that ‘persons with disabilities enjoy legal status on an equal basis with others in all aspects’ and that this requires recognition that competent persons, at least, have the right to refuse psychiatric treatment ( Maylea & Ryan 2017 : 88). Only a few countries (e.g. The objective test here is similar to that employed in law, and involves asking the question: ‘What would a reasonable person in like circumstances consider to be a reasonable outcome?’ The reliability of this measure is, of course, open to serious question – as might be objected, what one person might accept as reasonable another might equally reject. Attention will also be given to the vexed issue of the ethics of suicide prevention, suicide intervention and suicide postvention. • Scope of practice shapes what FNPs can do when diagnosing/treating mental illness. It also has obvious relevance for people admitted to mental health care facilities for psychiatric care and treatment. 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. cessation of medication, remaining out of hospital and not being the subject of an involuntary admission to a psychiatric facility) ( Sellars et al 2017 ). 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 claim of a moral right usually entails that another person has a corresponding duty to respect that right. It teases out the ethical challenges that mental health nurses can face on a daily basis. This annual award was established in 2019 in recognition of … Ethical Concerns For the nurse in a traditional medical setting, ethical decisions occur occasionally and at times the nurse may face ethical dilemmas. The test of ability to understand , on the other hand, asks whether the patient is able to comprehend the risks, benefits and alternatives to a proposed medical procedure, as well as the implications of giving consent. The scope of nursing has evolved from the early role of a nurse carrying out orders at a doctor’s bidding. Moreover, the nurse practitioner suffered emotional distress and anxiety from the entire matter and was eager to settle the claim without further legal action. Ulysses further ordered his sailors not to release him from the mast until they were safely past the Sirens. Email: email@example.com, 1100 Virginia Dr., Ste. Depending on the state, FNPs could face legal implications for prescribing to family and friends. This case study involves a nurse practitioner in an in-patient alcohol/drug treatment setting. This is because there is no substantial agreement on the characteristics of a ‘competent person’ or on how ‘competency’ should be measured. The issue of patients’ rights to and in health care, discussed in the previous chapter, has obvious relevance and application for people with mental illness admitted to hospital for the care and treatment of non-psychiatric conditions (e.g. Patients will be offered new services from highly skilled advanced nurse practitioners. 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. 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. Health care professionals practice in an environment that is complex, with many regulations, laws and standards of practice. 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. community treatment order (CTO) contexts) ( Corring et al 2017 ; Nagra et al 2016 ; Molodynski et al 2014 ). 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. #Nurse Practitioners ethics. Ethical code or nursing care -related problems included (a) neglect, (b) rude/careless behavior, (c) disrespect of patient rights and human dignity, (d) … Rights and responsibilities of the community – encompassing the responsibility of communities to be adequately informed and educated about mental health issues, and to uphold the rights of mental health consumers and their carers. Conclusions A proposal for a code of ethics for NPs is presented. 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’. Currently almost two-thirds of the states in the USA have legal processes in place for allowing and managing PADs (Zelle et al 2015b). with patients. 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. For many, the answer lies in the systematic development and formal adoption of psychiatric advance directives (PADs). 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. 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’. This case study involves a nurse practitioner in an in-patient alcohol/drug treatment setting. 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. There is, however, still work to be done, noting that provisions for PADs have not yet been incorporated in the mental health legislation of all Australian jurisdictions and that, even where it has been (e.g. Historically the critical issue in developing tests of competency is how to strike a contented balance between serving a rationally incompetent person’s autonomy and also serving that person’s health care, nursing care and medical treatment needs . Violation of ethical principle and law. 300 W. Clarendon, Suite 400 Phoenix, Arizona 85013-3424 (602) 252-8888 WWW.EXPERTETHICS.COM firstname.lastname@example.org 2. Prior to 2014 there seemed to be little optimism that PADs will be formally adopted in Australian jurisdictions as a legal mechanism for promoting and protecting the rights of mentally ill people to participate effectively in decision-making concerning their psychiatric care and treatment. 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). This framework is expressed diagrammatically in Fig. 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. 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. 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. Psychiatry is no exception. These providers are likely to be confronted with a variety of ethical issues … 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. Such nurses need guidance direction and information to assist them in their new roles. a. 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. Besides, they make decisions that lead to deterioration of a patient’s health instead of ensuring recovery. Attention will also be given to the vexed issue … 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. 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. 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. • FNPs should be aware of treating outside the scope of practice for mental illness. 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. 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. “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. 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 ). 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. 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 ). A review of the literature has found that the information and options most frequently cited by users when preparing a PAD are: contact details of the user, the consultant, the general practitioner, the psychiatric nurse and the nominee (trusted person nominated by the user). Here very practical questions arise of what, if anything, can be done to strike a balance between respecting the patient’s autonomous wishes and constraining their freedom where its exercise could be harmful to themselves and / or to others? 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. during a moment of restored competency to decide) that the fiduciary nature of the professional–client relationship has been violated. Ethical Codes for Psychiatric Nurse Practitioners [Compatibility Mode] 1. 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). The fifth and final competency test is that of actual understanding . 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. 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. Nevertheless, as Buchanan and Brock’s highly cited work Deciding for others: the ethics of surrogate decision-making (1989) has shown, it is possible to devise at least a prima-facie working framework to guide professional ethical decision-making in this sensitive, complex and problematic area. 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). 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. 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 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 ). 300 W. Clarendon, Suite 400 Phoenix, Arizona 85013-3424 (602) 252-8888 WWW.EXPERTETHICS.COM [email protected] 2. 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). Before his accident he had been a committed sportsman and for him the life of a helpless quadriplegic was intolerable. 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). 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 ). discuss critically the possible risks and benefits of psychiatric advance directives. 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 ). 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 … • Recommendations to ensure best practices and avoid legal issues are suggested. 3 An estimated 77 percent of U. S. counties are reporting a significant shortage of professionals who can prescribe and manage medications. At four o’clock in the morning on 3 April 1986, John McEwan was found dead by his nursing attendant. 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 ). Underpinning the selection of this model is the view that ‘all people have fundamental human rights’ and that people with mental health problems or mental illness should not be precluded from having or exercising these rights just because of their mental health difficulties. 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. 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. She was treated with pain medication and antidepressants. 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). 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. The insured was not working on the day of the suicide attempt. Here objections can be raised concerning just how sophisticated a patient’s understanding needs to be. In response to the insured, the psychiatrist indicated that the patient’s diagnosis was his responsibility and he would manage her care. 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. 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. 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). Relevant state law imposed a limitation on noneconomic damage awards in medical malpractice claims for physicians (psychiatric) and limits attorney fees. 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’. Other barriers that have been identified include: concerns about the ‘legal and ethical issues relating to the liability for implementing or overriding (PAD) statements’. A 23-year old woman with no significant prior medical history presented to the emergency room with complaints of generalized body ache of two weeks duration and a fever of 102.6. 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. Being a patient advocate and acting ethically is one of the foundations of nursing (Kalb & O’Connor-Von, 2007). 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. Ethical Concerns For the nurse in a traditional medical setting, ethical decisions occur occasionally and at times the nurse may face ethical dilemmas. 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. Insufficient personnel, excessive workload, working conditions, lack of supervision, and in-service training were identified as leading to unethical behaviors. Whereas most clinicians believed that New Zealand’s mental health legislation should be able to override a user’s preferences outlined in a PAD, in contrast most mental health service users disagreed that legislation should enable their preference to be overridden ( Thom et al 2015 ). In defence of their position, they argue that the patient’s complaints are justified – the adverse side effects of his psychotropic drugs have indeed been ‘awful’, and are commonly experienced by other patients as well; and that he has experienced a decline in his psychiatric condition before, and hence knows what to expect. The nurse maintains competence in nursing. 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. This article will examine some of the ethical and legal issues correctional nurses must address in their practice. 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 ). [emphasis original]. 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. Discuss critically the notions of ‘surrogate / substitute decision-making’ and ‘supported decision-making’ in the case of people deemed to be rationally incompetent. 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. For example, an elderly demented resident may be deemed competent to eat his / her evening meal alone, but deemed not competent to refuse treatment – for example, surgery for a fractured hip. 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). 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. 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. The plaintiff’s experts valued her future care expenses at $4-6 million. patient autonomy. Insufficient personnel, excessive workload, working conditions, lack of supervision, and in-service training were identified as leading to unethical behaviors. Conclusions A proposal for a code of ethics for NPs is presented. 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. To date, however, the anticipated benefits of PADs have yet to be realised. Insufficient personnel, excessive workload, working conditions, lack of supervision, and in-service training were identified as leading to unethical behaviors. 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. 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 happen when choices need to be made, the answers may not be clear and the options are not ideal. 4 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 … Earlier in this chapter, under the discussion of competency to decide, the case was given of an involuntary psychiatric patient who was held down and given an intramuscular injection of psychotropic medication against his will (see pp 213–14 ). 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). He believed that an alcohol and drug program was not appropriate for the patient, who needed psychiatric inpatient treatment. This, in turn, may be counter-therapeutic because of the harmful emotional effects of the dehumanisation and dignity violation that are sometimes experienced as well as the undermining of trust in the professional–client relationship ( Belcher et al 2017 ; Borckardt et al 2007 ; Cusack et al 2018 ; Gustafsson et al 2014 ). 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. Moreover, there is little evidence showing that PADs have, in fact, achieved their intended purpose ( Campbell & Kisely 2009 ). 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. A second consideration is that many people with mental illness have experienced high rates of trauma during their lifetime. This case study involves a nurse practitioner working in a medical clinical environment. 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. 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). Nursing staff of many specialities are taking on and developing their roles in new and advanced practice areas. 4 In either case, timely and effective psychiatric treatment and care are imperative. Although practised under the rubric of benevolent paternalism, the tenets of involuntary treatment have nonetheless seriously challenged and, in many instances, infringed the rights of mentally ill persons – particularly those whose decision-making capacity has been seriously compromised by their illness – to make informed and self-determining decisions about their care and treatment. 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. 8.1 . Significantly the issue of competency rarely arises in contexts where the patient agrees with and consents to a doctor’s recommended or prescribed treatment. 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. 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… 3 An estimated 77 percent of U. S. counties are reporting a significant shortage of professionals who can prescribe and manage medications. Progress has been slow, however. 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). The patient was a 59-year old female who had undergone inpatient bilateral salpingo-oophorectomy three days before being discharged to home care. These providers are likely to be confronted with a variety of ethical issues … Attempts were made to offer a reasonable settlement, but the plaintiff’s demands greatly exceeded the nurse practitioner’s policy limits. Phone: 1-800-247-1500 In short, those who did not support PADs placed more importance on clinical outcomes than on upholding patient autonomy. • Liability risks for psychiatric mental health nurse practitioners are reviewed. 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). During such periods, the mentally ill can also be at risk of harming themselves and / or others. 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? 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.. In many instances, people with serious mental illnesses might not comply with, and might even refuse altogether to accept, recommended psychiatric treatment (e.g. 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 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. 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. 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 ). ETHICAL ISSUES IN ADVANCED PRACTICE NURSING. 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 . 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 ). The American Psychiatric Nurses Association (APNA) is your resource for psychiatric-mental health nursing. This paradigm shift in mental health is challenging traditional evaluation criteria and conventional justifications for involuntary treatment. irrevocability during a crisis (also known as a ‘Ulysses contract’ – see below) ( Swartz et al 2006 : 67). 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’). 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. 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 ). Comparable studies conducted in Australia and new Zealand survey of 110 mental health of. 2017 ) discharge orders included a home care referral for wound care and treatment ordered his sailors not release... How well the patient was a 59-year old female who had received special in... 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